Medical Director Under Investigation For Denying Care Without Reviewing Patient Records

A CNN report revealed that during a deposition for a case against Aetna, a former medical director stated that he did not look at patient records before making health care treatment approval or denial decisions.

Jay Ken Iinuma, MD, MBA, a former medical director for Aetna between 2012 and 2015, was in charge of making treatment decisions for patients during his time with the company. According to a lawsuit filed by Gillen Washington, a 23-year-old whose infusion of intravenous immunoglobulin—for a life-threatening condition known as common variable immune deficiency—was abruptly denied by Aetna.

In a deposition transcript, reported by CNN, Dr Iinuma explained that he did not look at patient records when making health care decisions, and instead relied on the recommendations made by nurses who reviewed patients’ medical records. Dr Iinuma also admitted that he rarely called these nurses for more information regarding their recommendations.

Dr Iinuma claims that this process was in line with the training at Aetna.

In court papers, Aetna stood by Dr Iinuma’s treatment decision in the case of Mr Washington. According to Aetna, the need for treatment with intravenous immunoglobulin infusions was based on outdated blood work. Instead of getting new blood work to obtain approval for additional treatments, Mr Washington ended up hospitalized after going months without an infusion.

Aetna also reiterated that its clinical review process is sound.

“In addition to applying their clinical judgment, the Aetna doctors and nurses use Aetna's Clinical Policy Bulletins ('CPBs') to determine what medical records to request, and whether those records satisfy medical necessity criteria to support coverage,” Aetna said. “These CPBs reflect the current standard of care in the medical community. They are frequently updated, and are publicly available for any treating physician to review."

However, California insurance commissioner Dave Jones has opened an investigation into Aetna as a result of Dr Iinuma’s testimony. Mr Jones told CNN that his investigation will review every denial made by Dr Iinuma to determine whether or not the decisions were clinically appropriate.

In his deposition, Dr Iinuma also admitted that he was unfamiliar with common variable immune deficiency, and the proper treatments for the condition. He also stated that he was unfamiliar with the adverse events associated with ceasing treatment, according to CNN.

Expert Insight

We spoke with Larry Hsu, MD, medical director for the Hawaii Medical Service Association, and a First Report Managed Care Editorial Advisory Board member about the seriousness and implications of these claims against Aetna.

“To not review medical records as a medical director before issuing a decision, particularly to deny is a serious issue,” Dr Hsu said.

He explained that through the NCQA’s recognition process, insurers are required to meet a certain set of standards in order to maintain their accreditation as a health plan.

“It is very clear from NCQA that accredits health plans like Aetna, that under their utilization management standards , that ‘The organization's utilization management program has clearly defined structures and processes, and assigns responsibility to appropriate individuals,’” he said. “As part of this process  ‘patient records [and] conversations with appropriate physicians’ at a minimum have to be reviewed by the medical director.

He further explained that the description of Aetna’s practices in the case of Dr Iinuma, were therefore not adequate.

“It would not be sufficient or acceptable to only have as written in the [CNN] article that ‘nurses reviewed the records and made recommendations,’” Dr Hsu said. “The medical director is ultimately responsible for that decision and needs to review all of the information presented in the request, ask pertinent question, do the needed research to understand the request and condition, and obtain consults as needed to make the appropriate decision.”

—David Costill

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