A Duval County, Florida resident diagnosed with gastroesophageal reflux disease (GERD) alleges Blue Cross and Blue Shield of Florida, Inc. (BCBSF) wrongfully denied insurance coverage for a “widely performed” corrective procedure that in no light can be classified as “experimental and investigative.”
The eight-page lawsuit claims the plaintiff’s request for insurance coverage for what’s known as the LINX System procedure was improperly turned down by BCBSF, who characterized the procedure as “experimental and investigative” and then reviewed only “self-serving, internal documents” in denying an appeal.
Filed in Duval County Court on September 14, the lawsuit says GERD is a digestive disorder that affects the lower esophageal sphincter, causing the reflux of gastric contents into a person’s esophagus. Those diagnosed with GERD may experience heartburn or acid indigestion or, in more serious cases, pathological changes in the esophagus or esophageal cancer, according to the complaint.
Many individuals diagnosed with GERD are advised to have surgery to minimize acid reflux, the case says. The plaintiff, who the suit says suffers from severe GERD, was advised by her doctor that a surgery to receive a magnetic sphincter augmentation device, called the LINX Gastroesophageal Management System (the LINX System), would be medically necessary to cut down on acid reflux, the lawsuit relays.
According to the complaint, the LINX System—composed of miniature titanium beads, each with a magnetic core, connected together to form a ring shape and implanted at the lower esophageal sphincter to block the backward flow of stomach acid or contents—is rated a Category I CPT code by the American Medical Association, indicating it’s consistent with contemporary medical practice, widely performed, and documented in medical literature. Despite this, however, BCBSF denied insurance coverage for the plaintiff’s LINX System procedure, the case alleges.
Though the plaintiff appealed the defendant’s decision, a family medicine hospice and palliative care physician who reviewed the plaintiff’s file at BCBSF’s request found the LINX System procedure was, pursuant to the woman’s policy, “experimental and investigative,” the suit says. After the plaintiff requested copies of all the records reviewed by the physician, the defendant responded by producing “a handful of papers” the doctor allegedly reviewed, per the lawsuit.
These papers, the case alleges, were merely internal BCBSF documents stating the LINX procedure is “experimental and investigative,” the complaint alleges.
“In other words, BCBS assigned a physician to review [the plaintiff’s] appeal and the only records they reviewed were internal BCBS documents providing the conclusion that the procedure was excluded under the Policy,” the lawsuit reads. “There is no evidence of independent investigation or of review of any documents which are not self-serving, internal documents.”
The lawsuit was removed to federal court in Florida’s Middle District on October 14.
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