Mother says PEIA refused treatment to son

CHARLESTON -- A woman is suing Public Employees Insurance Agency after she claims the company refused to authorize a treatment for her son.

Express Scripts, Inc. and MCMC, LLC were also named as defendants in the suit.

E.M. was born on June 18, 2008, and was diagnosed with central precocious puberty as a result of a hypothalamic hamartoma and has had to undergo various treatments in an effort to prevent progression of his condition, according to a complaint filed July 20 in Kanawha Circuit Court.

W.M., E.M.'s mother, claims one of E.M.'s physicians determined that E.M.'s conditions should be treated with injections of a growth hormone called Tev-Propin, which the physician determined was the best hope for E.M. to achieve a reasonable final adult height.

W.M. claims the defendants refused to authorize a treatment for E.M. because it was not "medically necessary."

PEIA refused to authorize the treatment solely on the basis that it was not "medically necessary," according to the suit.

W.M. claims the Tev-Tropin injections are medically necessary for treatment of E.M.'s condition as determined by his treating physician and are covered under the PEIA insurance program.

Despite being provided information sufficient for the defendants to comply with the language of the PEIA insurance policy and authorize payment for the Tev-Tropin injection, they failed to do so, according to the suit.

W.M. claims the defendants' delay in authorizing payment for the medically-necessary Tev-Tropin injections has harmed E.M. and will continue to harm him in the future if they are not provided.

The Tev-Tropin prescription costs $1,523.88 per month and W.M. cannot afford to pay for the medically-necessary Tev-Tropin injections prescribed by E.M.'s physician, according to the suit.

W.M. is seeking compensatory damages with pre- and post-judgment interest. She is being represented by John Andrew Smith.

The case has been assigned to Circuit Judge Paul Zakaib Jr.

Kanawha Circuit Court case number: 12-C-1425

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