Michigan Plastic Surgery Lawyers

The Surgeon Recommended A Positron-Emission Tomography  Scan Be Performed

Petitioner is a Physicians Health Plan of Mid-Michigan (PHPMM) member. He has a history of coronary artery disease including myocardial infarction, quadruple coronary artery by-pass, congestive heart disease, irregular heartbeat, and ventricular arrhythmia. In , Petitioner was admitted for recurrent and repeat ventricular tachycardia. He has recurrent episodes of congestive heart failure. Dr.X, his cardio-thoracic surgeon, had no convincing evidence Petitioner’s myocardium was viable or if there was evidence of reversible ischemia. The surgeon recommended a positron-emission tomography (PET) scan be performed as soon as possible. The test was crucial for making a management decision. The surgeon advised Petitioner the test could be performed. The Petitioner elected to have the test performed at  an out-of-network hospital is in- network.

Petitioner believes the services should be covered because 1) time was critical, and 2) the test was crucial to his physician’s management decisions. Petitioner filed a grievance with PHPMM and exhausted PHPMM’s internal grievance process. PHPMM issued its final adverse determination on March 13, 2003.

Did Physicians Health Plan of Mid-Michigan appropriately deny retro-authorization and coverage for medical services provided out-of-network?

Contact Michigan Plastic Surgery Attorneys

Contact a Plastic Surgery Lawyer now for a free case review.