BRIEFSUMMARY文档格式.docx

BRIEFSUMMARY文档格式.docx

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RespondentBCBSM,underlawsuitfromtheDepartmentofJustice,hasrefusedtopayfortheprudent,lifesaving,andqualityoflifeextendingmedicaltreatmentofPetitioner.ThisdespitethefactthatPetitionerhassurvivedforfifteenyears,withrelativelyreasonablequalityoflife,duetothemedicalcareandtreatmentprovidedbyEdwardLichtenMD.

SaidtreatmentswerepaidwhenDr.Lichtenwasa“participatingphysician”,andwerepaidtoanotherparticipatingphysician,butnottoDr.LichtenafterDr.Lichtenwasnolongeraparticipatingphysician.

Dr.Lichten'

smedicalcareisappropriate,i.e.“medicallynecessary”underthecriteriaRespondentBCBSMwasOrderedtoapplytoitsexistingcontracts,inaccordancewitha2008consentJudgmentandOrderintheLove,etal.v.BlueCrossBlueShieldAss’n,etal.,（formerlyThomas,etal.v.BlueCrossBlueShieldAss’n,etal.）,CaseNo.03-21296-CIV-MORENO/SIMONTON（SeeExhibit1）.

However,RespondentOFIR,improperlydismissedPetitioner'

srequestthatthelegallycorrectdefinitionof“medicalnecessity”beapplied,andinsteadappliedanillegaldefinitionof“medicalnecessity”,onethatwaslegallysupersededbythedefinitionOrderedandconsentedtobyRespondentBCBSM,inaccordancewiththeLoveOrder,andthereforethedecisionofOFIR,denyingpaymentforDr.Lichten'

sservices,mustbereversed,andPetitionermustbecompensatedforsuchmedicalcare.

BACKGROUNDFACTSANDPROCEDURALHISTORY

PetitionerJamesAntonisa55yearoldmalethatiscurrentlybeingtreatedforanumberofmedicalconditions,includingbutnotlimitedto,mitochondrialcardiomyopathy,duetoageneticmitochondrialdefectcausingcongestiveheartfailure.Healsosuffersfromprogressivekidneydisease,priorkidneystones,liverabnormality,chronicbackpain,hyperlipidemiaandpolycythemia,amongothermedicalconditions.Mitochondrialcardiomyopathyisanextremelyraremedicalcondition“anorphandisease”thatissubstantiallydifferentfromotherformsofcardiomyopathyincludingtheprognosis,etiologyandtreatment（SeeAdministrativeRecord,pg4,“raredisease”,andAdministrativeRecord,pg146-149）.

Thediagnosisofmitochondrialcardiomyopathywasmadein1995,attheUniversityofMichiganHospital,andatthetimeaccordingtoPetitioner,Petitionerwastoldbythetreatingcardiologist,thatthePetitionerhadtenmonthstolivewithvirtuallynochanceofsurvivalbeyondthattime（SeeAdministrativeRecordpg.7,letterfromPetitionerfootnotes）.

PetitionerbegantreatmentwithDr.EdwardLichtenin1996,andhishealthimprovedsignificantly.DuringthecourseofPetitioner'

streatmentwithDr.Lichten,hisheartfunctionimprovedgreatly,withtheleftventricularejectionfractionimprovingfrom15%to40%,animprovementofover250%（SeeAdministrativeRecordpg.15,letterfromDr.LichtentoValerieGlosson）.

ThesetreatmentsofPetitionerbyDr.EdwardLichtenwerepartofaprudent,comprehensiveandindividualizedcourseoftherapythatrequiredconstantmonitoringandfine-tuninginadditiontoroutinemedicalcare.ThemedicationsandprocedureswithintheindividualizedcourseoftherapyforPetitionerincludedgrowthhormone,testosterone,nandrolone,stanazolol,oxandrin,humanchorionicgonadotropin,carnitorliquid,armourthyroid,chromagen,coenzymeq10,andintravenousinfusionsandphlebotomy.TheabovemedicalcarebyDr.LichtenistheonlyexplanationfortheremarkableimprovementinthePetitioner’shealth:

Frombeingbedriddenandtotallydisabledandliterallydyingtolivingamorenormalizedindependentlifewithanextendedlife-expectancy.

BCBSMhadpaidfortheabovetreatmentbyDr.LichtendirectlytoDr.Lichtenasaparticipatingphysicianfrom1996,untilDecember2003.BCBSMplacedDr.LichteninPre-PaymentUtilizationReview（PPUR）inJanuary2004andvirtuallystoppedallreimbursementstoLichten’spatientsthereafter.BCBSMcontinuedtoreimbursePetitionerforsomeservicesin2004.

WhenPetitionerwenttoanewparticipatingphysicianMarkHertzbergMD,shortlythereafter,BCBSMpaidforHGH,testosterone,andnadorlone,thesametreatmentsBCBSMrefusedtopayDr.Lichtenfor.

PetitionerthenresumedtreatmentwithDr.Lichten.AtissuearetreatmentsprovidedbyDr.LichtenfromJuly6,2005untilthepresentdate.BCBSMdeniedhand-deliveredmultiplesubmissionsofPetitioner’sclaimswithaccompanyingmedicalrecordsforreimbursementofmedicalservicesandmedicationsdispensed,administeredorprescribedbyDr.Lichten（SeeAdministrativeRecordpg.5,letterfrompetitionerstatingentirerecordsweresubmitted“sixtimes”）.

Duringtherelevanttimeperiodandcontinuingtopresent,Dr.Lichtensubmitted:

1）paperclaimswithmedicaldocumentation;

2）copiesofallpaperclaimsonCD-ROMtotheBCBSMattorney,Mr.LeoNouhan;

and3）attemptsatelectronictransmissionthroughathirdparty,Capario.

TheelectronictransmissionswereblockedbyaBCBSMemployee,StaceySartin,whostatedtoDr.LichtenthattheEDIkeywasremovedonorderofBCBSMPPUR.

Alloftheseflagrant,willfulandillegalactionsbyBCBSMresultedinnopaymentsbeingmadetoPetitionertothedetrimentofhisphysicalandmentalhealthdespitetheclearlegalobligationofBCBSMtothemakesuchpaymentsinatimelyfashionasarguedbelow.

Itcannotbeoverstressed,anditisPetitioner'

sposition,thattheseactionswereinnosmallpartduetoBCBSMunwarrantedandillegalanimustowardDr.Lichtenforreasonsincludingbutnotlimitedtohisvigorousadvocacyforhispatients’necessary,cost-effectiveandlife-savingtreatments.ThetreatmentsatissuearelistedintheAdministrativeRecord,pg.95-98.

PetitionerfiledarequestforexternalreviewonNovember23,2009inaccordancewiththePatient'

sRighttoIndependentReviewAct（PRIRA）,MCL550.1901etseq.,AccordingtoOFIR,therequestforexternalreviewwasnotacceptedbecausePetitionerhadnotcompletedBCBSM'

sinternalgrievanceprocess.However,therecordclearlyshows,andasstatedabove,thatthePetitionerrequestedinternalreviewbyBCBSMonnumerousoccasions.ItwasonlyafterOFIRbecameinvolvedandPetitionerresubmittedallmedicalrecordsandclaimsfortheseventhtimethatBCBSMinitiatedtheinternalreviewprocess（SeeAdministrativeRecord,pg.26,requestforOFIRreview）.OnFebruary22,2010,BCBSMagreedtorespondtotheinternalgrievancereviewprocess.

PetitionerarguedthattheservicesprovidedbyDr.Lichtenweremedicallynecessary,andtheysavedJamesAnton'

slife,andthattheserviceswerebeingdeniedforother,illegalreasons,directedbyBCBSMagainstDr.Lichten.PetitioneralsoarguedthattheCommissionerwasboundtoanalyzetheissueofmedicalnecessityinaccordancewithLove,etal.v.BlueCrossBlueShieldAss’n,etal.,（formerlyThomas,etal.v.BlueCrossBlueShieldAss’n,etal.）,CaseNo.03-21296-CIV-MORENO/SIMONTON（SeeAdministrativeRecord,pg.160-162,OFIR'

sORDER）.

AfterreceivingPetitioner’srequestforreview,BCBSMrespondedonMarch18,2009,afteranewrequestforexternalreviewbyOFIRwasfiledandacceptedinMarch2010.TheCommissionerassignedthecasetoanIndependentReviewOrganization,MAXIMUS,inaccordancewithPRIRA,sincemedicalissueswereinvolved.

MAXIMUSprovideditsrecommendationsandanalysistotheCommissioneronMarch24,2010.MAXIMUSapprovedsomeoftheservicesandtreatment,providedbyDr.Lichten,thatwererejectedbyBCBSM,butdeniedothersasnot“MedicallyNecessary”（SeeAdministrativeRecord,pg.163-165,OFIR'

sORDER）:

[Petitioner]hascardiomyopathythatisnotbeingtreatedwithstandardprovenmedicationsduetointoleranceand/orhisrefusal.The…medicationswithwhichthe[Petitioner][isbeingtreatedhavenotbeenshowninrigorousscientificstudiestoimproveoutcomesinpatientswithcardiomyopathyandarenotpartofthestandardacceptedtreatmentofcardiomyopathyinthemedicalcommunity…[N]oneofthesemedicationsarerecommendedforthetreatmentofchronicheartfailureaccordingtoexpertguidelinesendorsedbyseveralnationalorganizations.[Citationomitted]

[T]hereferenceregardinggrowthhormonetreatmentintheNewEnglandJournalofMedicinewhichwasreferredtobythe[Petitioner’s]treatingphysiciandidnotassessoutcomesandwasnotcontrolled

[M]orerecentdataevaluatingtestosteronetreatmentforpatientswithchronicheartfailuredemonstratelittleornoeffectoncardiacfunctionwithnooutcomesdataandnodataonthesafetyofchronicuseinthispopulation.[Citationomitted]

Theuseofadiuretic,suchasDemadex,torelievecongestivesystemsandaBetablocker,suchasInderal,arestandardacceptedtreatmentsforcardiomyopathy…Ifglucoseintoleranceispresent,treatmentwithagentssuchasMetforminisindicatedandofprovenvalue…Ifafungalinfectionispresent,thentreatmentwithDiflucanwouldalsobeappropriate…Thevariablecoursethatpatientswithcardiomyopathyoftendisplaycanresultintheneedforpe