NCAR Visitor Center - One-Day Closure - Saturday 10/25 more info>

Insurance Providers

Q

On the radio, I recently heard the story of Thomas Concannon, who suffers
from a rare cancer called multiple myeloma. His physician, a professor of
medicine at Tufts University and director of the bone marrow transplant
unit at Tufts-New England Medical Center, recommended that he receive a
bone marrow transplant from his sister. Concannon's insurance company,
CIGNA, informed him that since the treatment was experimental it was not
covered by his insurance, even though his physician states that a
bone-marrow transplant is the preferred form of treatment for this
condition. Concannon has just had an appeal upheld that requires CIGNA to
pay for the $200,000 treatment.

UCAR has just changed healthcare providers to CIGNA. This story has me
wondering about what would happen to a UCAR employee under similar
circumstances. I also understand that CIGNA declines to cover the
rehabilitation of stroke victims.

I would like to know if a similar situation could arise with the plan
provided by CIGNA. Furthermore, I would like you to indicate what help and
assistance UCAR would provide to employees should they have the misfortune
to find themselves in a similar dispute with their healthcare provider.

Answered on June 19, 2002

A

Both the CIGNA HMO and PPO plans offered through UCAR cover autologous bone
marrow/stem cell transplants. As with any transplant, each case must be
reviewed thoroughly, and a transplant case manager would be assigned.

All the specifics relating to Concannon‚s case are not available to the
general public. Because each case is different and we do not know about the
CIGNA contract in this case, it‚s difficult to speculate about the reasons
for denial.

If a transplant is approved for a UCAR employee, the services include the
recipient‚s medical, surgical, and hospital services; inpatient
immunosuppressive medications; and the costs for organ procurement. These
services are only covered when they are required to perform any of the
following human-to-human organ or tissue transplants: allogeneic bone
marrow/stem cell, autologous bone marrow/stem cell, cornea, heart,
heart/lung, kidney, kidney/pancreas, liver, lung, pancreas, or small
bowel/liver. The HMO plan charges $200 per admission to the hospital and
pays 100% thereafter. The PPO plan has certain other limitations. The
lifetime maximum for a bone marrow transplant is $130,000. Other issues
addressing travel to a transplant facility and donation are covered in the
plan documents.

Like many other health insurance plans, the UCAR CIGNA plan does exclude
experimental procedures. In general, experimental, investigational, or
unproven services are excluded if they are

* not approved by the U.S. Food and Drug Administration to be lawfully
marketed for the proposed use and not recognized for the treatment of the
particular indication in one of the standard reference compendia or in
medical literature; or

* not demonstrated, through peer-reviewed literature, to be safe and
effective for treating or diagnosing the condition or illness for which its
use is proposed; or

* the subject of an ongoing clinical trial as set forth in the FDA
regulations, regardless of whether the trial is subject to FDA oversight.
On occasion, a person needing a transplant might not meet the medical
criteria for transplant (e.g., other treatments might be more effective;
the person might not be able to withstand the procedure).

Both CIGNA plans have a formal appeal process if a proposed transplant
should be denied. UCAR encourages employees to pursue the formal appeal
process in the event of a denial.

The questioner also mentioned rehabilitation for stroke survivors. Once
again, each case is different and would be thoroughly evaluated. In
general, medically necessary physical therapy, occupational therapy, speech
therapy, and feeding therapy would be covered. Each type of coverage has
certain limitations.

This response offers general information about the issues raised. Please
address specific questions regarding transplant issues to me or to CIGNA
directly. The CIGNA plan documents are in the process of being prepared and
made available on the Web. If you have more specific questions about the
issues raised in this Delphi question, please contact me at ext. 8702 or
lcarr@ucar.edu.

-Laurie Carr, Manager, Human Resources