Case and Commentary
Jul 2001

Is It Covered or Not? Health Plans and Experimental Procedures

Kayhan Parsi, JD, PhD
Virtual Mentor. 2001;3(7):224-225. doi: 10.1001/virtualmentor.2001.3.7.hlaw1-0107.


Ms. Evans was diagnosed with stage II, node positive breast cancer. The primary tumor was 3 centimeters when diagnosed, and 14 of her 23 axillary lymph nodes were involved with the tumor. Ms. Evans underwent a lumpectomy, lymphadenectomy, and several months of standard-dose chemotherapy, all of which her health plan covered. Her physician, Dr. Bookman, discussed another possible follow-up treatment for her breast cancer. He believed that Ms. Evans' best chance for long-term survival required the administration of a procedure called high-dose chemotherapy/peripheral blood stem cell rescue (HDC/PBSCR). This is a three-step process. First, blood stem cells are harvested from the patient's circulating, or peripheral, blood and placed in temporary storage. Next, the patient undergoes a cycle of high dose chemotherapy in hopes of killing the cancer cells. After administration of the HDC, the stored blood stem cells, which also would have been attacked by the chemotherapy had they not been removed, are reinfused into the patient's bloodstream to relieve the toxic effects of the HDC.

Dr. Bookman requested that the health plan pre-approve payment of expenses for Ms. Evans' treatment. Part of the charge was for stem cell rescue procedure, but no CPT code existed for such a procedure. Moreover, the health plan determined that the HDC/PBSCR procedure was experimental and investigational in nature and should not be covered. This decision was made by a patient care committee composed of physicians employed by the health plan.

Questions for Discussion

  1. Ms. Evans cannot afford the HDC/PBSCR treatment without reimbursement. Should Dr. Bookman use the code of a therapy that is listed on the CPT so that Ms. Evans can receive the therapy he thinks offers her the best chance of long-term survival?
  2. Should physicians who are employed by the health plan serve on the patient care committee that makes reimbursement decisions?
  3. "Mis-coding" for the procedure aside, does Dr. Bookman have any ethical or professional responsibility for attempting to help Ms. Evans receive payment for the HDC/PBSCR procedure that he believes will benefit her?

See AMA Code of Medical Ethics in Opinion 8.13 regarding Managed care. Code of Medical Ethics 1998-1999 Edition. Chicago, IL: American Medical Association; 1998.


Virtual Mentor. 2001;3(7):224-225.



The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.