17- year-old girl needs liver transplant, CIGNA denies

Wsmith16, ADN, BSN · Dec 20, 2007

This is an all new low. Even if this were "experimental" as CIGNA calls it. Isn't it worth it to possibly save a life. Shouldn't all measures be taken? I wonder if the folks who denied the liver transplant how they would feel if this were their mom, dad, or child? This is SICK, SICK, SICK on the part of CIGNA.

Nathalie & her parents ( I can't imagine what they have been going through) will be in my prayers. Something has to be done with some of these insurance companies, one day it could be one of us in this situation. I hope I am never or anyone close to me will ever be in this situation.

Katnip, RN · Dec 20, 2007

I know a 2-year-old who died because his insurance denied him a bone marrow transplant. This was in the late '80s and the insurance company also used the "experimental" tag to justify their denial.

People say that Canada's health system is bad because people have to wait or are denied. Insurance companies here are no better.

pickledpepperRN · Dec 21, 2007

This was called a "victory".

I pray it is. Thank you to all who prayed!

CIGNA CAPITULATES TO PATIENT REVOLT - Following Massive Protest, Insurer Authorizes Transplant for 17-year-old Nataline Sarkisyan
...In a Dec. 11 letter to CIGNA's transplant department, four UCLA physicians said that Nataline "currently meets criteria to be listed as Status 1A" for a transplant and urged the company to "urgently re-review her case" and their denial.
CIGNA said it denied the care because their benefit plan "does not cover experimental, investigational and unproven services," to which the doctors replied, "Nataline's case is in fact none of the above."
On Dec. 14, Hilda Sarkisyan was told by the hospital that a healthy liver was available, but because CIGNA had refused authorization, the family would have had to make an immediate down payment of $75,000 to proceed, an amount the family could not afford....
http://www.calnurses.org/media-center/press-releases/2007/december/cigna-capitulates-to-patient-revolt-following-massive-protest-insurer-authorizes-transplant-for-17-year-old-nataline-sarkisyan.html?print=t

tencat · Dec 21, 2007

Ummm...if she has active cancer, isn't she a really poor candidate for a liver transplant? It's not right that CIGNA denied the claim, but is this person the best candidate for those precious and rare organs? If her cancer is cured, then by all means she's a good candidate, and it should happen right away. But if it's not, then......wouldn't it be better to give the liver to someone who is more likely to survive for a while?

pickledpepperRN · Dec 21, 2007

I am not an oncology nurse. A transplant RN from UC San Diego spoke today. She said she has seen patients with nearly the same clinical situation recover after receiving a liver.

I am not qualified to second guess the team of physicians who wrote that she had a chance and asked Cigna to reconsider.

I am so sad but thankful that so many are praying.

From the UCLA web site and posted by an Armenian American organization.

…Nataline Sarkisyan, 17 year old girl who underwent bone marrow transplant developed a complication which caused her liver to fail. Doctors feel she has a reasonable chance of survival with a liver transplant. Without one, she has no chance….
http://www.armeniancalendar.com/Documents/NatalineInformation.pdf

Bone marrow transplantation can cure severe inherited disorders such as thalassemia and disorders of the immune system as well as leukemia and aplastic anemia. –

http://nobelprize.org/nobel_prizes/medicine/laureates/1990/press.html

dmrph · Dec 21, 2007

Ok here is my question -

if she did not have insurance, what would UCLA do?

pickledpepperRN · Dec 21, 2007

CIGNA, In Switch, To Fund Transplant

Courant Staff Report

December 21, 2007

...California nurses, family of the patient, and others gathered Thursday outside CIGNA's Glendale, Calif., office to demand that the company reverse its denial. CIGNA says a company representative informed the family there that a liver transplant would be covered.

In a public statement Thursday, CIGNA said it decided "to make an exception in this rare and unusual case" based on the "unique circumstances of this situation, and although it is outside the scope of the plan's coverage, and despite the lack of medical evidence regarding the effectiveness of such treatment."

CIGNA also said, "Our hearts go out to Nataline and her family, as they endure this terrible ordeal."

Asked whether the mounting bad publicity had changed the company's mind, CIGNA spokesman Wendell Potter would only say, "When you have a request for coverage for something like this, there is an appeal process, and the appeal process was under way."

http://www.courant.com/business/hc-cigna1221.artdec21,0,5238485,print.story

jeolsz · Dec 21, 2007

We all like to blame the insurance company, probably because it is face less and represents what we see as money oriented and less than human. The truth is, if this proceedure was needed in the doctor's eyes as life saving, why wasn't the procedure done? And did they have a liver that matched? What other disease processes and complications were going on that might have made this procedure more risky? I work for an "evil" insurance company and have seen members wait in the surgery suite for needed surgery, while doctor's offices call and await approvals. Next time take a close look at the doctor who is complaining about the insurance company.. What kind of car does he drive? Where does he live? How many vacations did he go on last year? And how much money did he waste last year in your hospital on needless tests, delays in service( especially on weekends) and unnecessay hospital days, especiallly with his Medicare patients? There are 2 sides to every story, unfortunately the doctors, who we often give Godlike attributes to come out smelling like a rose instead of a rat. And often the patients and family are in the middle.

HM2VikingRN, RN · Dec 21, 2007

The point is that given her age there is no real doubt that she should have been given the "benefit of the doubt" for transplantation. Liver transplants aren't really experimental anymore. As I recall from my peds course last summer the prognosis for leukemia patients in adolescence is actually quite good.

I think this is one of those cases that can be used to talk about how to rationally allocate medical procedures. A 17 year old with a reasonable chance of survival should automatically be given a liver transplant. But should a 75 yo be given the same services? Probably not. In that case it should probably be after all other candidates were ruled out. Hypothetically a transplant priority system could look like this: (I have no transplant experience so this is a thought experiment.)

0-21 excellent chance of survival-AAA

0-21 moderate chance-AA

0-21-good- A

0-21 fair B

0-21 poor C

22-50 excellent chance (with dependent children)- AAA

22-50 excellent chance (without dependents) -AA

22-50 Moderate Chance (with dependents)- AA

22-50 moderate without dependents- A

22-50 good chance with dependents- A

22-50 good chance without dependents- B

22-50 fair chance with dependents- BB

22-50 fair chance without dependents- B

22-50 poor chance with dependents- B

22-50 poor chance without dependents- C

This is one possible way to allocate precious transplant resources for maximum benefit of individuals and society. The priority goes to children first (because they are the future) and then next to parents of dependent children (because they raise the future). Other adults would be eligible but at a lower priority. Rationing on ability to pay seems wrong to me. The impact of not treating a parent is much higher to society as a whole than not treating a non-parent Cigna was wrong to deny coverage for this procedure.

I don't know the answer but I think an honest ethical discussion about how to use precious resources for the maximum benefit of individuals and society needs to be held.

I sincerely hope that this girl survives and recovers from her liver failure.

UM Review RN, ASN, RN · Dec 21, 2007

We all like to blame the insurance company, probably because it is face less and represents what we see as money oriented and less than human. The truth is, if this proceedure was needed in the doctor's eyes as life saving, why wasn't the procedure done? And did they have a liver that matched? What other disease processes and complications were going on that might have made this procedure more risky? I work for an "evil" insurance company and have seen members wait in the surgery suite for needed surgery, while doctor's offices call and await approvals. Next time take a close look at the doctor who is complaining about the insurance company.. What kind of car does he drive? Where does he live? How many vacations did he go on last year? And how much money did he waste last year in your hospital on needless tests, delays in service( especially on weekends) and unnecessay hospital days, especiallly with his Medicare patients? There are 2 sides to every story, unfortunately the doctors, who we often give Godlike attributes to come out smelling like a rose instead of a rat. And often the patients and family are in the middle.

I disagree. Healthcare has been changing ever since the advent of DRGs and has slowly been taken over in the US by insurance companies.

The insurance companies only seem to want to insure healthy people and cover a minimum of procedures and medications. My family deductible last year was $3000. That didn't even cover the ambulance.

What kind of insurance do we have that doesn't even cover the ambulance in an emergency?

Do you know how many patients I have seen that are stroke or heart attack victims who are coming to the hospital by neighbors and friends because they literally do not have the $600 for the ambulance ride?

Do you know that it practically took an act of God for my friend to get breast reconstruction after a radical mastectomy back in the 80s because the insurance company actually called it "cosmetic" surgery?

The docs are not the villains here. The patients are not the villains here. The insurance companies, who reward medical professionals for denying procedures, are.

jeolsz · Dec 21, 2007

I feel I have to respond back to Angie.. Take a good look around you where you work.. Want to know why your premiums are so high?.. Do you realize the waste and lack of continuing education towards the lastest medical trends that goes on in most acute care facilities? Why should a patient wait from Friday until Monday for a test that could have been done on Saturday? Why should a patient stay in an acute care facility such as a hospital when maybe a subacute facility may be a better fit? I myself felt the pinch of the rising cost of insurance and felt cheated, however when I opened my eyes and saw both sides of the argument things became much clearer. I have to say I have never worked with better educated and healthcare motivated people as I have with the health insurance Co I now work with.. And I've been working as an RN for more than 25 years.. The Dr's and nurses who work with these companies have many years of bedside experience and believe it or not truely care about the welfare of the members they are responsible for. Insurance co's get a really bad rap for being uncaring and money grubbing.. but look around you.. can't the same be said for the Dr's and nurses working at the bedside?

pickledpepperRN · Dec 21, 2007

Her Mother knows her daughter is in heaven. My heart is broken for this family.

On local TV this morning they said that on December 11th the doctors gave her a 65% chance for a full recovery with the transplant.

…A Northridge teenager awaiting a liver transplant died Thursday after she was pulled off of life support….
http://abclocal.go.com/kabc/story?section=news/local&id=5848163

I was in one of many buildings owned by insurance companies yesterday. No one working in any of them provides any healthcare at all.

If they have doctors and nurses working there those professionals are not caring for patients.

I do not believe direct care nurses are the problem in healthcare.