Monica Blumenfield, a longtime employee of the Long Beach Unified School District, is such a person. She was turned down for coverage of physical therapy for work-related nerve damage and for an MRI scan related to earlier treatment for breast cancer.
Her insurer, Blue Shield, said the decisions were reviewed by the company's medical director. But this wasn't a doctor experienced in either physical therapy or oncology. It was a Northern California osteopathic physician who lists his specialty as pulmonary disorders such as bronchitis and asthma.
"The doctor who reviewed my case wasn't qualified to make these decisions," Blumenfield, 50, told me. "Basically, Blue Shield tried to deceive me."
Blue Shield said the treatment had been reviewed "by an independent physical therapy specialist."
A separate letter to Blumenfield's clinic, Movement Works Physical Therapy Inc., stated that the treatment was "reviewed for medical necessity by Alan Brooker, D.O., medical director for Blue Shield of California."
Brooker is not a member of the American Medical Assn., according to the organization's website. But the site lists him as a nonmember and identifies his specialty as pulmonary disease, or lung-related disorders.
About a month after Blue Shield rejected Blumenfield's physical-therapy appeal, she received another letter from the insurance company saying it wouldn't cover MRIs related to her breast cancer, even though it had done so without apparent difficulty for the previous three years.
The letter said the scans were considered "investigational or experimental" and as such were "not in accord with Blue Shield of California medical policy." The letter was signed by Brooker.
Dr. Alan Sokolow, the company's chief medical officer, said doctors who sign off on denials of coverage typically consulted first with specialists.
"We employ a lot of medical directors who have a variety of medical expertise but who rely on the expertise of others trained in a specific area," he said.
