Blue Cross reverses decision, will cover treatment for Birmingham man who had brain bleed

News23-year-old Elijah Briggs, who suffered a traumatic brain injury that nearly killed him, and his mother Samantha Briggs. Roy S. JohnsonBy Savannah Tryens-Fernandes | stryens-fernandes@al.comA young man from Birmingham will be getting medical care that his doctors say he needs after all. Blue Cross Blue Shield of Alabama has reversed its denial of coverage for a specialized brain injury rehabilitation program for Elijah Briggs.“We’re relieved and grateful to learn that BCBSAL will now cover Elijah’s rehabilitation — giving him a real chance at meaningful recovery,” the Briggs family said in a statement. Briggs was featured in an AL.com investigation on Monday that dug into the state of healthcare in Alabama and Blue Cross’s firm grip on the state’s private health insurance market. Hours after the story published, Blue Cross issued a letter saying he’d been approved for the treatment.Read more: Inside Blue Cross Blue Shield’s firm grip on Alabama: 5 things to knowBriggs, a 23-year-old recent college grad, went into a coma in July after suffering a brain bleed. He underwent multiple surgeries and began showing signs of improvement. But his doctors at UAB said his best chance at recovery was the specialized rehab at TIRR Memorial Hermann hospital in Houston.Blue Cross Blue Shield of Alabama initially denied coverage, calling the treatment “investigational.” The Briggs family appealed on Sept. 22, and got a letter from Blue Cross on the evening of Sept. 28 authorizing the treatment. The approval letter said, “this authorization is not a guarantee of payment. Benefits are dependent upon plan coverage.” But, the Briggs family told AL.com that the insurance company has said it will fully cover his rehab at Memorial Hermann. After reversing the decision, a spokesperson for Blue Cross said the company could not comment on a specific case for privacy reasons, but provided a statement.“Generally, when plan coverage is denied, we offer our members an appellate process to ensure all information is received and considered,” the company said in a statement to AL.com on Wednesday. AL.com’s reporting on Blue Cross found that the insurance giant has a firm grip on the market in Alabama. Patients in Alabama can’t get certain treatments. Doctors and hospitals argue they’re underpaid, and they say that Blue Cross’s dominance forces them to “take it” or close.Blue Cross Blue Shield of Alabama holds 84% of the state’s private insurance market, according to the American Medical Association. That’s the largest share of a statewide market by any one insurer in America. While Blue Cross of Alabama disputes the 84% figure — saying their market share is more like 67% — the company counts all Alabamians with insurance, not just those with private insurance.Doctors say the impacts can be “devastating,” with the denial of critical care for patients and physician shortages throughout the state that they blame on low pay.And the results can affect everyone, not just people with Blue Cross coverage.“The challenge is if almost 90% of the market is covered by one insurance, and that insurance decides not to cover a certain procedure or a certain device or a certain anything, then that means that essentially the state isn’t getting it,” Dr. Richard Menger, a neurosurgeon and assistant professor at the University of South Alabama, told AL.com.The treatment that Briggs’ doctors said he needed is not available in Alabama. Blue Cross initially denied authorization for him to get the treatment in Texas on an “investigational” basis. The insurance company told AL.com that that designation is given to treatments “when there is not enough medical evidence to demonstrate they are effective, safe, and improve health outcomes.” But his doctors in letters to Blue Cross said that the rehab was “medically necessary” and “time sensitive.”“Our appellate process offers an important additional level of review allowing another opportunity for review, including the consideration of any new or additional information,” the Blue Cross spokesperson told AL.com on Wednesday. “In some instances, investigational treatments do in fact get covered on appeal.” The Briggs family has launched a GoFundMe, saying they “still face out-of-pocket costs for travel and lodging in Houston for up to a month or longer.” The rehab program requires all adult household members to participate in family education, so his full caregiving team will be in Houston throughout his rehabilitation.They plan to travel to Texas within the next week. MORE BY SAVANNAH TRYENS-FERNANDESWe’re continuing to report on health insurance in Alabama. Share your story or ask a question in the form below. We read every submission.[Don’t see the form? Click here.]Savannah Tryens-Fernandes is an investigative reporter covering health and medical care in Alabama. She joined AL.com as an education reporter and Report for America corps member in 2021, covering efforts to...