What is it like to appeal a medical decision
Filing an appeal is a labor that a veteran should not have to indure.
I appealed a decision by a VA Primary Care physician denying treatment by an outside neurologist.
The neurologist is well-qualified and respected in the neurology field. He completed his Clinical Neurophysiology fellowship at Hahnemann University Hospital in Philadelphia. He is an avid researcher with many publications, abstracts, and presentations to his credit. He continues practicing neurology and conducting clinical trials.
This neurologist prescribed a device, Cala Device, that could significantly improve my quality of life by treating my essential tremor.
This device could bring hope and normalcy back into my life if approved.
The VA PCP's denial decision lacked medical support. His denial was not based on the merits of the device or my condition but on his unfamiliarity with it. This lack of medical support in such a crucial decision is deeply concerning.
Despite my persistent efforts, I was unable to sway his opinion. I initiated the appeal process, only to be informed that it would take 45 days. However, the decision was not delivered within the stipulated time and was delayed by another three months, causing further distress and uncertainty.
After enduring a three-month wait, the outcome of my appeal was a complete shock. It was denied based on a definition that was not recognized, seemingly pulled out of thin air. This decision was not based on factual evidence but on a subjective opinion.
The decision did not include a test done by the local VA pacemaker clinic. The test results showed that the device does not interfere with my pacemaker and is safe for me to use, and this is noted in my medical records.
The Hospital Director gave the response to my appeal. He is not a Doctor, but he is an attorney. His response surprisingly mirrored the VA PC comments. The response even used the definition used by the PC, but the definition is not found in medical definitions.
When I questioned the response, the Acting Deputy Chief of Staff gave an unexpected answer, adding to my bewilderment.
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"examined about the input of other clinical experts even if not fully described in the medical record. In performing that review, primary care, neurology, and cardiology were asked to review your appeal and provide their recommendation. All of them recommended against your request citing as their rationale that the requested device is not FDA approved for use by patients with an implanted electrical medical device."
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These experts commented, "All of them recommended against your request, citing as their rationale that the requested device is not FDA approved for use by patients with an implanted electrical medical device."
Veterans like myself accept the experts' comments as factual. But are they? I found out when I called the FDA.
I read the response to the FDA agent, who looked up the device. The FDA stated that the device was cleared to be marketed as low-risk. He emailed me a copy of their position.
July will mark a year of VA experts denying the device use for veterans. Denying new treatment and device advancements goes against the typical VA phase:
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While VA healthcare is widely recognized for its high quality and dedication to veteran care, stating it "provides the best medical treatment possible."
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Words do not match actions. Many medical advancements are used in the private sector that the VA does not approve. For example, veterans who are outsourced to outside providers must seek approval for the specialist treatment not used by the VA.
Denials of beneficial treatment certainly do not offer the best medical treatment possible. The VA could learn much from the private sector and medical advancements, but it goes backward and only approves outdated treatment used by the VA. The VA should embrace advancement.
The VA does not, but it should evaluate the support staff and experts annually, especially those in leadership positions.
The veterans' care should include the most current medical advancements.
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