Gianelli & Morris File Class Action Complaint Against Aetna for Refusal to Cover Medical Procedure

Insurer says procedure is “experimental and investigational,” despite years of FDA approval and countless successful operations

On August 7, 2019, attorney Robert Gianelli filed a class action complaint in the United States District Court for the Central District of California alleging insurance company Aetna breached a duty to its policyholders by refusing to pay for lumbar artificial disc replacement surgery when recommended by the patient’s doctor. The case is BRIAN HENDRICKS; ANDREW SAGALONGOS v. AETNA LIFE INSURANCE COMPANY, case number 2:19-cv-06840.

Aetna labels disc replacement surgery “experimental and investigational”

The plaintiffs in this case were both diagnosed by separate physicians with degenerative disc disease in the L5-S1 level of their lumbar spines, and both doctors recommended they undergo lumbar artificial disc replacement surgery (L-ADR).

Before the advent of L-ADR, spinal fusion was used to treat degenerative lumbar disc disease. This procedure is known to cause a lack of mobility at the fused disc level, put more stress on the adjacent disc levels, and create a higher risk of additional disc herniation/disease. L-ADR, in contrast, replaces the diseased disc with an artificial disc that maintains the integrity of the disc space while providing the flexibility of a natural disc.

Unfortunately, both patients had their health insurance through Aetna, which has a policy of systematically denying L-ADR. Despite having separate doctors and submitting separate requests for L-ADR surgery, both patients received nearly identical denial letters, denying the procedure on the grounds that L-ADR is “experimental and investigational.”

L-ADR is neither “experimental” nor “investigational”

Contrary to Aetna’s assertion, L-ADR is a safe, effective and often recommended procedure that has successfully treated the symptoms of lumbar disc disease in countless patients over many years.

Artificial discs have been approved by the FDA for 15 years. In fact, the FDA has approved several types of artificial discs. As Class III medical devices, artificial discs must adhere to stringent safety standards to pass the FDA premarket approval process.

In addition to the devices themselves being FDA-approved, numerous published peer-reviewed articles and controlled clinical trials have established that L-ADR with an FDA-approved device is safe and effective. L-ADR is endorsed by the North American Spine Society and is performed at leading medical centers across the country. Significantly, all other major health insurers, including Anthem, United HealthCare, Humana and Cigna, cover the surgery.

Aetna sued in federal court over its behavior

Despite the medical evidence to the contrary, Aetna systematically excludes L-ADR in all circumstances. These actions have led the law firm of Gianelli & Morris to file a class action complaint seeking recovery of plan benefits, enforcement and clarification of policyholders’ rights, and damages for Aetna’s breach of its fiduciary duty to its customers. Specifically, the lawsuit complaint demands that Aetna retract its categorical denial of L-ADR requests and reprocess all claims it has denied to-date. The lawsuit also seeks an accounting of profits the company has reaped through its unfair denials, as well as payment of benefits plus interest to policyholders who were denied this important plan benefit.

According to lead attorney Robert S. Gianelli, “this case is a prime example of the ways insurance companies wrongly deny claims as experimental and investigational.” As a leading California insurance bad faith law firm, Gianelli & Morris has successfully pursued cases against numerous health insurance companies for “experimental and investigational” denials of various procedures, including L-ADR cases against Blue Shield of California and United HealthCare.

If you have had a medical treatment denied by your insurance company on the grounds that the procedure was “investigational and experimental,” we want to hear from you. Call Gianelli & Morris for a no-cost consultation with our experienced and successful California insurance lawyers.