Class Action Claims Anthem Wrongfully Denied Coverage for FDA-Approved, Pain-Treating Electrical Nerve Stimulation Device

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Anthem, Inc. and Anthem UM Services, Inc. face a proposed class action over their allegedly wrongful denial of insurance coverage for FDA-approved percutaneous neuromodulation therapy (PNT) devices commonly used for nerve stimulation following trauma or surgery.

Filed in California’s Central District, the 16-page suit says PNT is a form of non-drug therapy that treats intractable pain through electrical nerve stimulation. Per the case, PNT with an FDA-approved device is proven to be a safe, effective treatment for those with chronic and acute pain. Overall, PNT device usage has become a standard clinical practice, the lawsuit stresses. 

The plaintiff, a San Diego County resident with chronic right knee pain, says she experienced relief that allowed her to discontinue using opioids after trying the FDA-approved Stimwave device for PNT for seven days, leading the woman to submit a claim to Anthem to approve use of the device on a permanent basis. According to the complaint, however, Anthem UM, in a January 2020 letter to the plaintiff’s physician, wrongfully denied the woman’s claim for PNT coverage on the grounds that the Stimwave device was “investigational” and therefore not covered by her health insurance. 

Though the plaintiff’s physicians chimed in on her appeal, informing Anthem that the woman had in fact experienced substantial pain relief and was able to stop using opioids thanks to the Stimwave device and including clinical studies supporting PNT as safe and effective, Anthem UM in February denied the appeal, again claiming PNT devices are “experimental/investigational” treatments. 

According to the lawsuit, PNT with an FDA-approved device is not investigational as the devices have been shown to be safe and effective while eliminating the need for long-term drug use. Moreover, the case reiterates that clinical evidence showing that FDA-approved PNT devices are effective against chronic pain is strong, with “at least 20 randomized controlled trials” demonstrating PNT treatments work. 

The lawsuit looks to cover those with ERISA health plans, self-funded or fully insured, that are administered by Anthem and whose claims for FDA-approved percutaneous neuromodulation therapy devices were denied on the basis that the treatment was investigational. 

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