Vorster v. Bowen

Ola Vorster (plaintiff) received 17 chiropractic manipulations to treat subluxation of the spine, a painful misalignment of the vertebrae. Chiropractic manipulation was covered by Medicare to treat subluxation. Transamerica Occidental Life (defendant), the insurance company administering Vorster’s Medicare Part B plan, denied coverage for all 17 treatments. The Explanation of Medicare Benefits (EOMB) Transamerica issued stated that coverage was denied because (1) Medicare did not cover the service and (2) the frequency of service was not covered. Vorster petitioned for independent review of the denial and submitted a letter from her chiropractor stating the treatments were medically necessary. After conducting the independent review, Transamerica issued a review determination letter again denying all 17 claims. The review determination letter did not inform Vorster that a utilization screen had been used to review her claims or that her claims were denied because the utilization screen found the frequency of service Vorster received was excessive. Vorster sued Transamerica and Otis Bowen (defendant), the Secretary of Health and Human Services, in federal district court, arguing that (1) Transamerica’s use of a utilization screen was improper and (2) Transamerica’s review determination letter violated her due-process rights because it did not contain sufficient notice regarding the reasons her claims were denied after review.