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Has Your Health Insurance Claim Been Denied as “Experimental” or “Investigational”?

A health insurer’s decision to approve or deny a treatment or procedure can have profound effects on the well-being of the insured.  Consider, for example, the Watchman Device. Persons who suffer from atrial fibrillation, for example, are at greater risk of stroke due to an irregular heartbeat.  When blood pools or collects in left atrial appendage of the heart, clots can form which can reduce blood flow to the brain and cause a stroke.

Research has shown that the Watchman Device, when placed inside the left atrial appendage of the heart, can significantly reduce the formation of blood clots, which in turn reduces the risk of stroke.  According to its manufacturer, the Watchman Device does not need to be replaced once it is inserted in the heart.

Some insurers have determined that the Watchman Device is experimental or investigational and therefore not covered by the health insurance policy.  This decision not to cover the Watchman Device runs contrary to the federal government’s approval of the Watchman Device for Medicare recipients. The Centers for Medicare and Medicaid Services (CMS) has established several requirements for patients to qualify for the Watchman Device.  For example, CMS requires patients first meet with a non-interventional physician to discuss oral anticoagulation medications and have a determination that the patient is not suitable for long-term usage of such medicines.

Given that the federal government has approved use of the Watchman Device, insurers will have a hard time arguing that the procedure is experimental.  Even so, some insurers continue to deny coverage for a device that could save lives and avoid serious brain injury. If your health insurer has denied coverage for the Watchman Device, or other procedures or devices it deems experimental, consider consulting with an attorney.  In some instances you may be able to bring a breach of contract or negligence action against your health insurer for the wrongful denial of a covered procedure.

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Jason Cornell is a Florida attorney who represents consumers whose insurers have wrongfully denied health insurance claims.  You can contact Jason at 561 616-3333, or jcornell@liggiolaw.com.  

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