Denials of Care by UnitedHealth Group...Of The Damned

If you can imagine a conversation that would make Sisyphus blush.

I just had a conversation with “United Healthcare's Medical Director,” Dr X. She just identified herself as the medical director of behavioral health at United Healthcare, which isn't particularly helpful, given how large that organization is. This conversation followed an initial prior authorization, which was denied, and this was, at least in theory, the appeal. If anyone thinks this is an appropriate level of education or training for a theoretical “peer-to-peer review” with a medical director, feel free to let me know, but I'm editing this only to protect the patient's identity. The level of seriousness of the reviewer is frankly horrifying.

If anyone's wondering why the population has a murderous rage for United Healthcare, what you're about to read is precisely that. I had a patient, a child, who had failed previous treatment, and the family was going to have to pay out-of-pocket for the treatment she was scheduled to receive. We have effective treatments in medicine, many of which have evidence, and some are beyond the limits of large-scale evidence bases. To be clear, if I were running a managed healthcare company, I might have criteria for what gets covered and what doesn't because we must have some degree of rigor in addressing payment and healthcare. But we shouldn't settle for utter unwillingness to have a conversation and an absurd lack of familiarity with the actual evidence for the treatments we are providing or asking for permission to provide appropriate coverage.

Again, what follows is a lightly edited transcript to protect the patient's privacy. I have also removed the name of the medical director, because I don't want her to get murdered. That having been said, I can understand why someone would feel, very angry. Don't murder people, that's my advice. It's also my advice to not have no idea what your job is, when you're working for an insurance company, because honestly, it's getting bad out there.

And the reason it's so bad for insurance executives is because, well, they act in a way that makes us want to scream. This call happened just an hour ago… Paging Andrew Witty!

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OM: It's a pleasure to speak with you. Can you please identify yourself?

UHC: Yeah. Hi, my name is Dr. X. I'm calling from United Healthcare about an urgent appeal for [patient].

That's correct. Um, if this was sent for urgent appeal, it was initially denied from peer review, and the reason why is for TMS, correct?

OM: It is for TMS. That is correct.

UHC: Yeah, the reason being, is the member nine years old?

OM: The member is nine years old. That's correct.

UHC: Um, because, and then it's being, um, asked for OCD, obsessive-compulsive disorder?

OM: That's correct.

UHC: Okay. The reason why it was denied was that United Healthcare will not approve of those under the age of 18.

OM: Yes.

UHC: And they will not approve for TMS for the diagnosis of OCD.

OM: I am aware of both of those things.

UHC: So that's the reason that it was denied.

OM: And so can you please tell me what is your licensure, your training, and your experience with TMS?

UHC: I do not have any direct, um, experience with TMS. I've never done it. I'm a child psychiatrist.

OM: Where did you train?

UHC: Um, so that's in New York. Well, in New York, but why is that relevant to this conversation?

OM: Because I want to understand who I'm talking to.

UHC: Okay. Well, I trained in New York many years ago.

OM: Where in New York did you train?

UHC: I don't feel comfortable giving that information. All I can tell you is what the policy is.

OM: We're having a peer to peer review, and this is not a review. You're telling me what a policy is. I'm aware of what the policy is. I have issues with what your policy is when it comes to the coverage of this patient. So, I want to establish the understanding you have of the evidence and practice we're discussing to understand if you have the relevant expertise even to be a meaningful peer reviewer.

UHC: Okay, I do not have any expertise in TMS.

OM: So, are you a board-certified child psychiatrist?

UHC: I am a board-certified child psychiatrist but cannot approve this because of the United Health Care policy.

OM: And what is your understanding as to the evidence base for the use of transcanialmagnetic stimulation in those under 18?

UHC: I do not have…If there's any evidence about that… I can’t tell you, I can only tell you what the policy for UnitedHealthcare.

OM: that's not a review. You're only calling me to tell me what the first reviewer already told me. And I'm appealing that decision based on the specifics of this case. That's not a review. That's just you telling me the same thing they did.

UHC: Okay.

OM: So, what evidence supports your decision?

UHC: I do not, I do not have any evidence other than what UnitedHealthcare's policy is.

OM: And what is UnitedHealthcare's policy? What evidence is it based on?

UHC: I do, I would not know. All I can tell you is that they will not approve for under the age of 18, and they will not approve for OCD.

OM: spell your name for me.

UHC: [spells name]

OM: So, Dr. X, you are calling me as a physician, as an M. D., for a peer review on behalf of UnitedHealthcare, the third-party administrator for this patient. And you're telling me you can only tell me what the policy says, not what evidence the policy is based on. Is that understanding correct?

UHC: I cannot [tell you the evidence] at this time.

OM: And why are you doing this peer review? If you're unfamiliar with the evidence?

UHC: they asked me to do the peer review.

OM: What is your job at United Healthcare?

UHC: The medical director.

OM: You're the medical director of what?

UHC: Is there anything else you'd like?

OM: Yes. You're the medical director of what?

UHC: For behavioral health.

OM: Uh, for what?

UHC: For behavioral health.

OM: For what part of the company? It's a very large company.

UHC: You know, doctor, I am ending this phone call.

OM: For what part of the company?

UHC: Do you have any other information or any other questions that I can answer?

OM: [paraphrase], I requested an appeal to a senior medical director.

UHC: Okay, then I will let them know. You always have the right to appeal this decision.

OM: And I am appealing it yet again.

[UHC hangs up]

OM: This was not a meaningful appeal.

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For what it's worth, transcranial magnetic stimulation is approved in pediatrics down to age 15, at least for major depressive disorder, and has FDA clearance for OCD, at least in adults. Still, for a “Behavioral Health Medical Director,” on an appeal, to have no experience with the treatment, to have no experience with the evidence, and to only be familiar with the United coverage policy does not, at least to me, appear to be a physician using her medical judgment to adjudicate a claim. It appears to be the very definition of the corporate practice of medicine, which is, of course, forbidden in the state of New York.