A California woman is suing Anthem Inc., claiming the Indianapolis-based health insurer is improperly denying her claims to use electrical stimulation to treat her pain.
Marie Fortier of San Diego County filed suit Thursday in U.S. District Court in Central California. She is seeking class action status on behalf of others whose similar claims to Anthem have been denied.
Anthem spokesman Tony Felts said the company does not comment on litigation.
According to the complaint, Fortier has a history of osteoarthritis in her right knee and has undergone surgeries, starting with a knee replacement and reconstruction in 2014, a revision in 2015, then another in 2016.
As a result of the conditions, she has experienced chronic right knee pain for which she has received treatment at the University of Southern California Chronic Pain Center. Physicians there provided various forms of treatment, including the prescription of opioids.
Doctors there also recommended that Fortier undergo a seven-day trial of a treatment known as percutaneous neuromodulation therapy, known as PNT. The treatment uses electrical stimulation to deep tissues.
Fortier underwent a seven-day trial with the device and experienced relief that allowed her to discontinue the use of opioids during that time, the complaint said.
She then requested Anthem to approve PNT use on a permanent basis, claiming that it is approved by the Food and Drug Administration for such uses.
On Jan. 22, Anthem sent a letter denying coverage for the device, calling it “investigational”–or still the subject of clinical studies designed to evaluate effectiveness.
Fortier appealed the decision. In connection with her appeal, physicians at the USC Chronic Pain Center advised Anthem that Fortier had, in fact, experienced substantial pain relief with the device that allowed her to stop the use of opioids. The physicians further advised Anthem of clinical studies that had found such devices to be safe and effective.
On Feb. 24, Anthem denied the appeal. “This service is considered an experimental/investigational treatment for your condition (knee pain),” Anthem’s letter said. “This service has not yet been proven to be safe and effective for the treatment of your symptoms in comparison to standard therapy in accord with the medical studies reviewed in the approval criteria for your plan.”
Fortier’s lawyers argued in the complaint that clinical evidence is strong in support of PNT devices. “There are at least 20 randomized controlled trials demonstrating that PNT treatments for musculoskeletal pain are safe and effective. PNT devices are currently in use as a standard clinical practice in treating chronic pain,” the complaint said.
Fortier is claiming denial of plan benefits and breach of fiduciary duty and equitable relief under ERISA plan. She is asking the court to order Anthem to pay for the treatments.
“Plaintiff has been unable to afford the treatment, so she lives in constant pain while requiring the use of drugs for temporary relief,” the complaint said.