Writer’s choice
PA Jones has several patients in his practice with chronic low back pain. Several have recurrent spasm issues that do not respond to oral muscle relaxants.Recently, he attended a conference which advocated for using Botox injections to relieve chronic back spasms. He would like to use this on his patients to see if they get relief. He makes the requests to the patient’s insurance companies, and submits literature advocating for this treatment. After a few weeks, two of the five patients receive a denial for this “investigational treatment” citing explicit policies prohibiting coverage for experimental treatments. The others are pending but PA Jones believes they will offer a similar response.While attempting to purchase the Botox from an approved distributor, he finds the cost prohibitive. When discussing this with some colleagues, they offer him their supplier, who obtains it from “somewhere overseas”. He proceeds to purchase the vials through this vendor, at a favorable price.In the ensuing week, he brings three patients in for back injections. After injections, he submits a bill to the insurance company for Botox migraine scalp injections, although the patients do not have a history of intractable migraines. The claims go through.A few days later, he receives a call from the local hospital. Two of his three patients are on ventilators with acute Botulism toxicity.What is the correct administrative law legal procedure for fighting insurance claims denials? What sort of cause of action might a patient pursue?What laws regulate the jurisdictional bounds of insurance regulation?What issues present here, and what aspects of this case would be state based, and which might be federal?