Insurance Medical Director Denied Care without Review

Last week it was reported in an exclusive by CNN, that former Aetna Medical Director, Dr. Jay Ken Iinuma, testified during a deposition that “he never looked at patients’ records when deciding whether to approve or deny care.”

This deposition was in response to a lawsuit filed against Aetna by Gillen Washington who suffers from a rare disease and was denied coverage for a medically necessary treatment related to his diagnosis.

The additionally disturbing revelation from his testimony is that Dr. Iinuma admitted that “he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.” He also acknowledged that he had very little knowledge of Mr. Washington’s diagnosis, common variable immune deficiency (CVID), nor did he know which drug would be best suited to treat him.

Likewise, when asked by Mr. Washington’s attorney as to his typical decision-making process, Dr. Iinuma responded that he did not typically review medical records when making decisions.

Aetna responded that their practice of having nurses collect and prepare Aetna’s Clinical Policy Bulletins (CPB’s) to present to the medical director for review and final decision.

Will this open up additional investigations into how private insurers define and declare medical necessity? Based on recent reports, California’s Insurance Commissioner, Dave Jones, is launching an investigation into Aetna. He plans to review every denial of coverage or pre-authorization during Dr. Iinuma’s time with Aetna (he is no longer employed there). If it is determinations that there were violations, hefty fines could be placed against the payor.


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