Health Insurers' Assessment of Medical Necessity

One can hardly imagine a more difficult choice than that faced by the district court in Rollo v. Blue Cross/Blue Shield.'In the judge's own words: I was called upon to decide whether eight year old Tishna Rollo could live or whether she must die, a humbling and sobering decision.Tishna, I was told, had virtually no chance of surviving the relapsed Wilms' tumor [of the kidney] from which she is suffering and Blue Cross/Blue Shield had denied coverage for autologous bone marrow transplant ("ABMT") with accompanying high dose chemotherapy, a treatment which could well prolong and quite possibly save her life and which, concededly, provided her only realistic hope of either.The University of Nebraska Medical Center ... would not admit her without coverage, her parents could not afford to pay the projected $130,000-$140,000 costs of the treatment, and there was simply no time to wait, for Tishna's "window of opportunity" would soon close.The coverage issue had to be litigated and litigated quickly. 2