State Agency Must Decide Whether HMO Should Pay for Hepatitis C-, HIV-Infected Woman’s Liver Transplant, Judge Says

The Massachusetts Office of Patient Protection will decide today whether Neighborhood Health Plan must pay for the liver transplant of a woman infected with HIV and hepatitis C, the Boston Globe reports. Yesterday, the AIDS Action Committee of Massachusetts asked a federal judge for an emergency order to "force" the health insurer to cover Belynda Dunn's transplant, but the judge "deferred" that decision to the state agency (Ellement, Boston Globe, 7/19). The Gay and Lesbian Advocates and Defenders first filed suit against the health plan on behalf of Dunn, who had initially requested the transplant four months ago. NHP denied that request, and its internal appeals board has rejected two subsequent requests. Physicians say that Dunn, who would receive a portion of her brother's liver, will die before the end of the year if she does not receive the transplant. Bennett Klein, a GLAD attorney, said that NHP's decision to reject the transplant was "based on outdated notions about HIV," namely that "liver transplants should not be done" for people infected with HIV. Klein added that "[a]t least" 20 health plans "routinely" cover liver transplants for individuals with HIV and hepatitis C (Belkin, Boston Globe, 7/18). NHP has said that it will not cover the surgery because liver transplants for people with HIV are considered "experimental," and experimental surgeries are not covered under the HMO contract Dunn signed. But Dunn is exercising a new state patients' rights law, which took effect in January, that allows patients to appeal denials of care by a health plan after first going through an internal appeals process. U.S. District Court Judge Robert Keeton denied the request for an emergency order because he "wanted to first see" Dunn go through an appeals process at the Office of Patient Protection. Keeton added that because decisions by the agency are "binding," he might not have the authority to "help Dunn if the ... agency rules against her." Richard Riley, an attorney for NHP, said that the agency is expected to complete its review today, adding that NHP will comply with its decision (Boston Globe, 7/19).