CLEVELAND (CN) — Managed health care administrator CareSource refused to approve $3.5 million in life-saving treatments for a hemophiliac baby on the bogus claim that the commonly used drug is “experimental,” a children’s hospital claims in court.
University Hospitals-Rainbow Baby and Children’s Hospital, in suburban Shaker Heights, Ohio, sued Dayton-based CareSource on Tuesday in Cuyahoga County Court.
The hospital provided eight months of treatment for baby A.W., who has a “very rare” form of the disease resistant to clotting medication.
“This resistance requires a dosage of the clotting medication that is much higher than what is ‘normal’ or ‘standard,'” the hospital says in the complaint.
CareSource is a nonprofit corporation that administers health care services for Medicaid patients. The Children’s Hospital billed CareSource $6.3 million for the treatments, but it refused coverage, calling the treatments “experimental/investigational.”
There is nothing experimental about it, the hospital says. The only unusual thing is the size of the dose the baby needs. It told this to CareSource in “a detailed letter from A.W.’s treating physician … [that] explained why the drug was used in A.W.’s treatment and explained why the dosage was medically necessary for his treatment.”
The hospital adds: “CareSource, itself, has paid for the same or similar treatment and dosage of the clotting medication when provided and billed on an ‘Outpatient’ or ‘Home Care’ basis by University Hospitals Home Health and billed through the University Hospitals Pharmacy.”
The baby’s doctor informed CareSource in his letter that there are about 20,000 people with hemophilia A and B in the United States; that hemophilia B is one-fourth as common as hemophilia A; and that only 1 to 3 percent of people with hemophilia B — 40 to 120 nationwide — have the inhibitors, or resistance, to the clotting medication.
The hospital seeks $3.5 million in damages for breach of contract.
It is represented by John Garswood of Dreyfuss, Williams and Associates, who declined comment.
CareSource could not be reached for comment Wednesday.
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