Nelson Hardiman Convinces U.S. Office of Personnel Management to Reverse Blue Shield’s Determination of Lack of Medical Necessity

Nelson Hardiman attorneys, John A. Mills and Claire Marblestone, successfully represented a pharmaceutical provider and its patient in a claim for health care benefits under a Federal Employee Health Benefit (FEHB) plan. The provider had administered IVIG treatments to the patient over the course of several years based on the patient’s physician’s determination of medical necessity. However, Blue Shield of California denied the claims for benefits submitted by the provider on the grounds that the treatments were not medically necessary. Blue Shield acted as the administrator of the plan. Because of Blue Shield’s intransigence, Nelson Hardiman filed a lawsuit in federal court against Blue Shield and the United States Office of Personnel Management (“OPM”), which is the federal agency that acts as the actual payor of FEHB benefits. Nelson Hardiman was able to have the court order OPM to conduct independent medical necessity review of the IVIG treatment. OPM determined that the treatments were in fact medically necessary, and therefore directed Blue Shield to pay the claims.