Class Action Claims Anthem Refused to Cover Cost of Sacroiliac Joint Fusion Surgery

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A proposed class action lawsuit claims that Anthem, Inc. and Anthem UM Services, Inc. ran afoul of the Employee Retirement Income Securities Act by denying coverage of a widely approved medical procedure to members of its insurance plans.

The procedure in question is known as minimally invasive sacroiliac joint fusion surgery (MISIJF), the case explains, and is designed to relieve low back pain by fusing the sacrum and the ilium. The procedure is recognized as safe and effective by the International Society for the Advancement of Spine Surgery, is regularly performed by surgeons nationwide and is approved by Medicare as an effective treatment for sacroiliac joint pain, the suit states.

Despite MISIJF being widely recognized as safe and effective within the medical community, Anthem categorically refused to approve the procedure for members of its health plans, according to the case. From the complaint:

“Despite this evidence, [Anthem’s medical coverage policy] nonetheless categorically denies all requests for MISIJF. It states, ‘Minimally invasive sacroiliac joint fusion and percutaneous sacroiliac joint fusion procedures are considered investigational and not medically necessary.’”

The lead plaintiff in the case says he is covered by the Catholic Health Initiatives Medical Plan, an employee welfare benefit plan administered by the defendants. According to the complaint, the plaintiff suffers from sacroiliac joint pain and received a recommendation from his doctor for MISIJF surgery in July 2018. The plaintiff allegedly contacted the defendants seeking authorization for the treatment but was denied in November 2018.

The lawsuit says Anthem UM responded to the plaintiff’s appeal the following month, informing him that Anthem considers the surgery “investigational and not medically necessary” in that it would not be an effective treatment for his pain. The case claims the plaintiff made additional requests for authorization of the surgery yet was denied each time.

The suit, originally filed in Kentucky’s Franklin County Circuit Court, has since been removed to the District Court for the Eastern District of Kentucky.