Orthopedic patient's death highlights potential dangers of prior authorization

Alan Condon -  

A negligence and medical malpractice lawsuit against an insurer has been picked up by the family of a patient who died during the litigation process. 

The case relates to Kathleen Valentini, 47, a North Carolina woman who was denied coverage for an MRI that the lawsuit argues could have avoided amputation and potentially death following the discovery of sarcoma in her right hip, Medscape reported July 1.

Seven details:

1. Ms. Valentini was referred to orthopedic surgeon Steven Bauer, MD, after experiencing pain in her hip. Dr. Bauer ordered an MRI after an X-ray failed to reveal the cause of her pain. 

2. Group Health Inc. allegedly denied coverage of the MRI, claiming it would be "medically necessary" only if Ms. Valentini failed to improve after six weeks of physical therapy, according to court documents filed June 15 in the U.S. District Court for the Southern District of New York.

3. Dr. Bauer appealed the denial, arguing the MRI was medically necessary and that Ms. Valentini had just finished a full course of physical therapy, which Group Health paid for. 

4. The payer reversed its decision almost 40 days later and on March 14, 2019, an MRI revealed a sarcoma in the patient's hip. "Had you come to us a month sooner, we could have used chemotherapy. Now we can't; we have to amputate before we treat with chemo,” physicians at Memorial Sloan Kettering Cancer Center in New York City told Ms. Valentini, according to court documents. 

5. Ms. Valentini's leg, hip and pelvis were amputated. Further testing found cancer nodules in her right lung and she died two years later. The lawsuit argues Group Health's denial and prolonged prior authorization delayed Ms. Valentini's treatment, which led to her amputations and long-term prognosis.

6. In 2021, a judge sided with Group Health on the negligence and medical malpractice charges, stating the insurer had no duty of care nor a physician-patient relationship with Ms. Valentini, according to court documents.

7. However, Ms. Valentini's family appealed to the U.S. Appeals Court for the Second Circuit, which is expected to hear the case later this year.

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