Posted and filed under Business, Payers.

If you haven’t heard the name Dr. Jay Ken Iinuma before, you’re about to get acquainted. Iinuma is the former Medical Director of health insurance giant Aetna, and he might just be the reason yet another Aetna deal flatlines.

During a recent deposition in a lawsuit between Aetna and Gillen Washington, a young adult with common variable immune deficiency (CVID) who was denied coverage for an IV immunoglobulin treatment, Iinuma admitted that did not review medical records before making coverage determinations. In fact, the Medical Director never reviewed patient medical records, and instead listened to the recommendations of staff nurse reviewers. Perhaps what’s even more troubling is the lack of medical knowledge Iinuma possesses on the conditions he routinely denies coverage for.

“Do I know what happens? […] Again, I’m not sure…I don’t treat it.”

According to the deposition, Iinuma was following standard Aetna policy and protocol in his delegation of responsibility. When asked by Gillen Washington’s attorney if he routinely examined medical records as a part of his decision-making process, he went on the record stating that it was not. This particular case is of public interest because it suggests that Aetna, among other health insurers, are not as forthcoming or fair with their coverage determinations as they let the public believe. Complex medical conditions and their associated treatments should require examination by a knowledgeable physician or Medical Director. This lack of oversight from Aetna’s Medical Director will force Aetna to not only reassess their training, but hopefully make necessary revisions.

Aetna responded to CNN’s breaking report with, “we…look forward to explaining our clinical review process,” but they must answer to more than just CNN now that the State of California has announced that they are launching an investigation into Aetna.

The Aetna and CVS acquisition depends upon approval from the Federal Trade Commission and the United States Justice Department. Judging by CA Insurance Commissioner Dave Jones’ expressed concerns over Iinuma’s testimony, the deal could be slowed down or squashed completely. While CVS refused to comment on matters at this time, Dave Jones will not slow down until more information is released. Insurance laws and corporate policies can be a convoluted web, but when an insurer is making coverage decisions without requiring a physician to review the medical records, there’s a chance that such policies are a direct violation of the law.