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Medical Records Before Denying Care - Merlin
Former Aetna Medical Director Admits To Never Reviewing
Mon Feb 12, 2018 9:33am

Is this the exception or the rule?

In an eye-opening exclusive reported by CNN, it was revealed that former Aetna Medical Director, Dr. Jay Ken Iinuma, admitted under oath that “he never looked at patients’ records when deciding whether to approve or deny care.”

This admission was made during a deposition in a lawsuit brought against Aetna by Gillen Washington, a 23 year old with common variable immune deficiency (CVID) who was denied coverage for an infusion of intravenous immunoglobulin (IVIG) four years ago.

California’s insurance commissioner, Dave Jones, is now looking into Aetna’s relevant protocols.

In his deposition, Iinuma, as reported by CNN, “said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.”

In this particular case, Iinuma admitted that he had minimal if any knowledge of the medical condition, common variable immune deficiency (CVID), that Washington suffered from. He was also not clear about what the most effective drug would be to treat the patients’s condition, the symptoms of CVID, or even the consequences of the abrupt discontinuation of therapy for the condition.

“Do I know what happens?" Iinuma said. “Again, I’m not sure…I don’t treat it,” according to the deposition, as reported by CNN.

Further, when asked by Washington's attorney if it was his general practice to look at medical records as part of his decision making process, he replied that it was not.

This opens up the obvious question of just how transparent health insurers are being with the public regarding their process for approval or denial of coverage, especially for complex medical care and procedures.

Aren’t we to expect that an experienced and knowledgeable physician review a person’s medical records before approving or denying a potentially disease-modifying therapy or treatment?

In Aetna’s response to CNN’s inquiry, the company said “we…look forward to explaining our clinical review process.”

And we, the public, certainly look forward to learning more about it.

This is an unconscionable practice on the part of Aetna.

And Dr. Jay Ken Iinuma knows better. If he does not he should have his medical license revoked and his medical degree rescinded.

1. A physician unfamiliar with a disorder making life and death decisions based upon the recommendations of nurses is malpractice.

2. Immune disorders are esoteric, some more so than others, and diagnosis and treatment decisions should be made by a specialist, one who has knowledge and experience with the specific disorder.

3. Infusion of intravenous immunoglobulin (IVIG) is a very expensive treatment, and the results are mixed depending on the individual. So I can understand why Aetna would be eager to disallow the therapeutic procedure. But a physician can not allow Aetna's financial motivations to override his medical professionalism and ethics.

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