Aetna has reached a deal to settle two class-action lawsuits that allege the CVS Health subsidiary violated federal law by improperly denying to cover spinal surgery for more than 230 patients, according to orders submitted in federal court this week.
The patients who sued contend that Aetna failed to uphold its fiduciary duty under the Employment Retirement Income Security Act of 1974 by systematically denying coverage of lumbar artificial disc replacement surgery, which it allegedly wrongfully classified as experimental and investigational. Filings submitted Monday and Tuesday in the U.S. District Court for the Central District of California say Aetna has agreed to settle the cases, and that the parties will agree on terms by Feb. 17.
Aetna and lawyers representing the plaintiffs did not immediately respond to interview requests.
UnitedHealthcare, Elevance Health (formerly known as Anthem) and Blue Shield of California settled similar cases in the same court. The Food and Drug Administration approved lumbar artificial disc replacement surgery as a “safe and effective” treatment for spinal disease in 2004.
Patient Andrew Howard sued Aetna in March, alleging the insurer improperly denied his requests for the procedure, which his physician recommended. Howard's claims echo those Brian Hendricks and Andrew Sagalongos, patients who sued Aetna in the same court in 2019. Hendricks and Howard underwent the procedure and paid out of pocket, while Sagalongos continues to live with degenerative spinal disease.
Aetna moved to dismiss Hendricks and Sagalongos’ case, arguing the policyholders did not follow the proper steps for appealing its denials and that the insurer never promised to pay for this surgery in the first place. Judge Cormac Carney rejected this argument in 2019, writing in his opinion that patients were not legally required to exhaust their appeals and that, even if they had, they “would have been doomed to fail.” Carney certified a class that includes 239 patients covered by employer plans Aetna administered. Aetna never formally responded to Howard’s lawsuit.
Patients in each case requested Aetna reprocess theirs and other affected individuals’ claims and end its policy of denying lumbar disc replacement surgery.