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

Nurses Activism

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Life Denied: Nurses, Family of Sick Teen March on Health Insurance Company Thursday - 17- year-old girl needs liver transplant, CIGNA denies...

The family and the nurses are urgently appealing to the public to call CIGNA at 818-500-6262 and demand they provide the care Nataline needs.

http://www.calnurses.org/media-center/press-releases/2007/december/life-denied-nurses-family-of-sick-teen-march-on-health-insurance-company-thursday-17-year-old-girl-needs-liver-transplant-cigna-denies.html?print=t

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Specializes in Maternal - Child Health.
Jolie, from what I have seen of documentation of policies where I worked, they are pretty much screwed. Benefits are either experimental or not: new procedures are typically deemed experimental and if there is medical necessity as viewed by her doctors in this case, then the insurance needs to approve as the procedure of giving a transplant is no longer considered experimental in the US. They could have denied it for being not medically necessary, but in this case it was, as NMN criteria is typically met when a doctor bills open heart surgery with a diagnosis of acne.

That will have to be decided in court. From what I've read, transplantation in an otherwise stable patient would be the standard of care, and not considered experimental.

Transplanting a liver in a patient with active leukemia and pneumonia is not the normal standard of care, and that is where the determination of "experimental" comes into play. To prove that it is not experimental, the family's attorneys would have to find cases where livers were successfully transplanted into patients with the same complications this girl was experiencing. According to the U of W transplant surgeon quoted earlier in this thread, it doesn't sound likely that they will be able to do so.

Why did Cigna approve it after it was too late?

Specializes in Family Practice, Primary Care.

Transplanting a liver in a patient with active leukemia and pneumonia is not the normal standard of care, and that is where the determination of "experimental" comes into play. To prove that it is not experimental, the family's attorneys would have to find cases where livers were successfully transplanted into patients with the same complications this girl was experiencing. According to the U of W transplant surgeon quoted earlier in this thread, it doesn't sound likely that they will be able to do so.

I think the problem CIGNA is going to come into is that they later approved it during protests. They pretty much screwed themselves. If it were truly experimental, they would not have changed their ruling.

Specializes in Maternal - Child Health.
Why did Cigna approve it after it was too late?

I think the obvious answer is that they caved to public pressure in a (misguided) effort to avoid negative press.

Much like malpractice carriers who settle bad baby cases in which the doctor is not at fault, because emotions run high and the public wants to make someone responsible for unfortunate circumstances that could not be prevented or fixed.

Of course we will not know the reason unless the case goes to trial since privacy laws prevent the insurance company from openly discussing the case, and it would harm their image even more if they were viewed as "attacking" the family.

I find it difficult to defend the actions of a multibillion dollar company given the apparent timeline of events.

I find it difficult to defend the actions of a multibillion dollar company given the apparent timeline of events.

Agreed.

But I also find it difficult to defend the actions of the doctors who gave this family false hope by offering them a rarely-used procedure for a girl who was very likely going to die regardless of how many organs they wasted on her.

Am I the only one who wonders if this offer of a transplant was a cynical attempt to avoid having the family sue them after the girl developed life-threatening complications from their original treatment?

I feel like this was a deeply tragic situation where everyone involved behaved very badly.

Am I the only one who wonders if this offer of a transplant was a cynical attempt to avoid having the family sue them after the girl developed life-threatening complications from their original treatment?

I feel like this was a deeply tragic situation where everyone involved behaved very badly.

I hadn't thought of that, in part because I know of a family where their child had cancer (histiocytosis X) and the treatment cured her cancer but led to liver failure, and she rejected her first liver but as far as I know is still doing well with liver #2 more than 15 years later.

But she was not receiving cancer treatment when her liver failed! That was long over - when the second nightmare began. She did not leave the PICU for three months, since she rejected the first liver right away and it took that long to find another since kids' livers can't be selected from a vending machine (nor, contrary to popular belief, can adults') and split-liver transplants weren't being done at the time.

Specializes in Dialysis, Nephrology & Cosmetic Surgery.

i have watched this thread since it was first started and would like to play devils advocate here.

lets say i am the mother of a 16 year old lying in an icu bed with liver failure and in desperate need of a liver transplant. he hasn't got any other medical problems and is not receiving any other treatment that may interfear with a newly transplanted organ.

i am called into the hospital as there is a good chance my son is going to theatre tonight as an organ has become available and they are now doing that bloods to see if it is a match.

hours later i am told that he won't be going after all and the organ has been given to someone else. i later find out that the person it has been given to was someone who was actively recieving a treatment that caused her own liver to fail and could also cause her newly transplanted liver to fail.

my son dies because another organ does not become available - the one that was transplanted into the young lady was a perfect match to my son.

what are you going to tell me that will help me understand the reason for your decision.

thankfully this is not my experience, but i do work in an area were my patients are waiting for kidney transplants - some actually gey a transplant and wish they never had.

some of our patients have had liver transplants in the past for ald but the anti-rejetion therapy has caused their kidneys to fail.

i have seen people in desperate need of heart transplants - some die while waiting others get a their transplant and are transformed, but at the end of the day it is rationed and some people will never get an offer of an organ - thats just the way it is.

please take a moment to consider the person who did receive the liver that would have been a match for this young lady. imagine in a few years time that this recipient, may be getting interviewed on the tv as he has achieved great things and is the picture of health - would you still be thinking it should have been given to the other person??

Transplant decisions are heartbreaking and difficult. I could not serve on the committee.

I believe a for-profit corporation must not make that decision.

...As California and the nation debate how to institute universal health insurance coverage for citizens, the Sarkisyan case indicates that more must be done than simply covering everyone with a policy. All too frequently, insurance company bureaucrats are making medical judgments that should be left in the hands of a patient's physician

If the staff at the UCLA transplant unit approved Nataline's procedure, that should have been the end of the discussion.

For universal health coverage to be meaningful, such decisions must be taken out of the hands of insurance adjustors and placed with an impartial arbiter whose interest is the welfare of the patient rather than a corporation's balance sheet....

http://www.chron.com/disp/story.mpl/editorial/5402763.html

...UCLA doctors put her on a list for a liver transplant Dec. 6 and a liver became available four days later, the family said. Her doctors told Cigna in a letter that patients in similar situations had a 65% chance of living six months if they received a liver transplant.

But the transplant was not done because Cigna deemed it experimental in Nataline's case and refused to pay for it....

http://www.latimes.com/features/health/la-fi-cigna25dec25,1,7386134.story?coll=la-headlines-health&track=crosspromo

Chuck Idelson, communications director for the California Nurses Association, said the broader issue was that insurance companies profited by denying care. "It's not just Nataline. We're all Nataline," he said. "Our view is that we need a health-care system that takes these decisions out of the hands of insurance companies."

But Karen Ignagni, president of America's Health Insurance Plans, an industry lobbying group, said most employers do not buy insurance that covers experimental procedures. People who are desperately ill often want such care, and the country needs to start thinking about how to make it available to them, perhaps with public funding, she said. Her organization has been studying the issue for several months, she said.

Meanwhile, representatives of UCLA and Cigna said they were hamstrung because the family had not signed a statement waiving privacy protections. Without the signature, they say, they cannot answer specific questions about the girl's treatment.

Geragos said he would not approach the Sarkisyans for permission before Nataline's funeral on Friday.

Hospital spokeswoman Roxanne Moster said she could not address why UCLA did not go ahead with a transplant - Geragos said two donor livers were offered for Sarkisyan during her first week on the waiting list - and haggle over money later. She said the hospital had performed transplants on uninsured patients in the past.

http://www.philly.com/inquirer/business/20071225_Questions_over_role_of_insurer.html

UCLA Transplant Center - http://www2.healthcare.ucla.edu/transplant/liverhome.html

UCLA pediatric center - http://www2.healthcare.ucla.edu/transplant/liverpeds.html

I base my statement of knowledge of the law.

I actually mis-spoke in my previous post. CIGNA, like any defendant in civil court doesn't have to prove anything. The burden of proof in a civil case is entirely on the plaintiff.

The family will have to prove a number of things in order to prevail in a wrongful death lawsuit against CIGNA, including the following:

That their insurance policy covered non-experimental transplants.

That the liver transplant proposed for the girl was non experimental, given her condition.

That a viable liver was available to the girl to be transplanted in a timely manner.

That a liver transplant would have saved her life.

That she wouldn't have died of complications of her leukemia, pneumonia, or the transplant itself.

I understand that this is an emotional issue, and I share the sorrow expressed by so many that a young girl died an untimely death. I have no doubt that CIGNA will be sued, but filing a lawsuit is not the equivalent of a finding of wrongdoing. The parents' attorney will have to prove the above points, and CIGNA will have the opportunity to defend its actions, based on scientific evidence. As sad as this case is, I believe that CIGNA has science on its's side. Emotion does not equal scientific evidence.

Well, since my daughter holds a law licence ,has passed the bar and practices in this state, I choose to belief her take on this case over yours.You hold other posters feet to the fire to prove their statements, yet YOUR "knowledge of the law" should make me believe your statements as fact? Hmmmm.....
Specializes in Maternal - Child Health.
Well, since my daughter holds a law licence ,has passed the bar and practices in this state, I choose to belief her take on this case over yours.You hold other posters feet to the fire to prove their statements, yet YOUR "knowledge of the law" should make me believe your statements as fact? Hmmmm.....

ingelin,

I truly don't understand your hostility. I'm not asking you to believe my statements as fact. You are free to believe anything you like, whether it is accurate or not. While not an attorney, I have some legal training and practical experience in healthcare law, and am not simply spouting emotions, but calmly stating fact. I think you mistake my postings for lack of compassion for this family, which could not be further from the truth. But courts of law have well-established procedures intended to uncover facts, not to rule based on emotion and passion.

I wish you a peaceful Christmas.

Jolie, I do not mean to BE hostile, but when you continue to post erroneous info about what may happen legally in this case, I felt compelled to call you on it. IT IS CHRISTMAS and if I hurt your feelings , I am truly sorry, wasnt meant to.This IS a forum and we have the chance to have discussions that can get heated, we are BOTH passionate, even though you may not agree, about our "causes".I dont know if either YOU or I can know what this case will entail, I can only hope in my emotional kind of way, that justice does prevail in the end.

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