A settlement has been reached in the case detailed on this page after four years of “intense negotiations.”
In an October 20 motion for preliminary approval, the plaintiffs’ attorneys stated that the deal will provide “substantially all” of the relief requested in the complaint, with Anthem having revised its criteria for determining whether microprocessor-controlled lower limb prostheses are medically necessary.
According to court documents, Anthem’s policy changes have expanded its definition of medical necessity to include insureds whose medical providers attest that the microprocessor devices will likely provide better mobility and stability and who show that they need the devices for regular home or office use.
Under the terms of the settlement, Anthem will, effective May 20, 2021, evaluate claims for both knee and foot-ankle microprocessor-controlled prostheses using the new medical necessity criteria.
Certain insureds who paid for the devices out of pocket and were not reimbursed by other insurance will be eligible to have their expenses reimbursed by Anthem as if their claim had been initially approved as an in-network service. Certain Anthem insureds who have not yet paid out-of-pocket expenses for the devices will be able to submit a new request for a prosthetic device pursuant to their existing Anthem health plan.
Notice to those who will be covered by the settlement will begin to be sent only after the deal receives the judge’s stamp of preliminary approval.
Anthem, Inc. and its claims administration subsidiary, Anthem UM Services, Inc., are the defendants in a proposed class action that alleges the companies breached their duties to plan participants by unlawfully denying insurance coverage for microprocessor-controlled lower limb prostheses for individuals who’ve suffered lower limb loss. At particular issue in the 16-page lawsuit is the defendants’ coverage guideline titled “Anthem Medical Policy on Microprocessor Controlled Lower Limb Prosthesis, Policy No. OR-PR.00003” that governs knee and foot-ankle prostheses. The complaint alleges the companies have used “erroneous criteria” in the policy that denies requests for coverage for knee prostheses on the grounds that the devices are not “medically necessary.” Similarly, the policy allegedly denies coverage for foot-ankle prostheses because they are “investigational and not medically necessary for all indications,” the case continues.
The complaint notes the two named plaintiffs are amputees covered under ERISA-governed welfare benefits plans. Each alleges the defendants denied them coverage for microprocessor-controlled prostheses because their need for their respective devices was deemed to be “not medically necessary.”