Blue Cross ordered to cover cancer therapy Judge: Insurer must pay women it denied.

February 27, 1991|By Kelly Gilbert | Kelly Gilbert,Evening Sun Staff

U.S. District Judge Marvin J. Garbis ruled today that Blue Cross and Blue Shield of Maryland wrongly denied expensive breast cancer treatment to two women on grounds that it was "experimental."

In a decision filed in U.S. District Court in Baltimore, Garbis ruled that Blue Cross and Blue Shield must pay for the therapy, called "high dose chemotherapy with autologous bone marrow transplants," at an estimated cost of $100,000 each.

The plaintiffs, Alexandra Adams, 34, and Kelly Whittington, 29, both mothers with two children, challenged the Blue Cross and Blue Shield denials in a lawsuit filed last summer. They claimed their physicians specifically recommended the treatments after they had undergone breast removal surgery, and that the treatments were "accepted medical practice."

Blue Cross and Blue Shield claimed that the treatments, known as HDCT-ABMT, were "experimental or investigative in nature" and thus were not covered by the patients' health insurance policies.

Garbis ruled that Maryland oncologists "generally acknowledged [the HDC-ABMT treatments] as accepted medical practice" at the time Adams and Whittington applied for coverage. The judge said his decision hinged on that acceptance.

Garbis also chided Dr. Arthur Keefe, Blue Cross' corporate medical director, for failing to contact nine Maryland oncologists on recommendations from Whittington's attorney regarding the acceptability of the treatments, and for failing to contact any experts recommended by Adams' physician.

The judge noted that experts who testified at a trial last December said the treatments yield "a significant benefit in disease-free survival."

"The court considers it highly unreasonable for Blue Cross to ignore the benefits of disease-free survival in favor of concentrating only on long-term survival rates," Garbis said.

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