Case I
Kathleen Valentini
Waxhaw, North Carolina · GHI / EmblemHealth · eviCore
Kathleen Valentini with husband Val and son Matthew. Kathleen died in November 2020 at age 50.
The Story
Kathleen Valentini was, by every account, an ideal patient — diligent, proactive, and attentive to her health. When she developed worsening hip pain that physical therapy wasn't resolving, her orthopedic surgeon did what doctors are trained to do: he ordered an MRI.
Her insurer, Group Health Inc. (GHI), a subsidiary of EmblemHealth — operating through a third-party denial contractor called eviCore — said the MRI was "not medically necessary." The stated reason: she needed to complete six weeks of physical therapy first. GHI had already approved and paid for that physical therapy. The denial was issued against a medical history the insurer already possessed.
The doctor appealed. Forty-one days after the original MRI request, GHI reversed its denial. By then it was March 14, 2019. The MRI revealed an aggressive sarcoma in Kathleen's right hip.
The Timeline
Orthopedic surgeon orders MRI for worsening hip pain after physical therapy fails to help.
GHI/eviCore denies MRI as "not medically necessary" — requiring six weeks of physical therapy first. GHI had already approved and paid for that physical therapy. The history was in the medical record.
The doctor appeals. Forty-one days pass. Kathleen waits while the cancer grows.
MRI finally performed. Aggressive sarcoma confirmed in right hip. Kathleen travels to Memorial Sloan Kettering Cancer Center.
Sloan Kettering doctors deliver the prognosis. "Had you come to us a month sooner, we could have used chemotherapy. Now we can't. We have to amputate before we treat with chemo." Kathleen's leg, hip, and pelvis are amputated in a 20-hour surgery. While she is still in the hospital recovering, GHI continues denying tests.
Val and Kathleen Valentini file suit against GHI and eviCore, alleging negligence, medical malpractice, fraud, breach of contract, and conspiracy. The suit alleges GHI is "engaged in a systemic effort to delay or block necessary medical treatments."
Kathleen Valentini dies at age 50, leaving behind her husband Val and their teenage son Matthew. "I'm convinced that the delay caused her death. They deny and delay and hope you go away." — Val Valentini
US District Judge John P. Cronan dismisses the lawsuit. Finding: GHI had no duty of care to Kathleen. The insurance policy gives GHI the right to determine medical necessity. No physician-patient relationship existed with eviCore.
The 2nd U.S. Circuit Court of Appeals affirms the dismissal. The court rules that prior authorization review "is not a service that subjects the general public to possible physical harm when performed without care." The judge calls the outcome "a travesty" — and upholds the dismissal anyway.
What the Court Said It Could Not Do
"Preauthorization utilization review is not a service that subjects the general public to possible physical harm when performed without care — it is rather a service that ensures financial reimbursement of individual insureds for contractually covered medical services."
— 2nd U.S. Circuit Court of Appeals, 2023
The court acknowledged the harm was real. It ruled there was no law under which the insurer could be held liable for it. The AMA, the Vermont Medical Society, the Connecticut State Medical Society, and the Medical Society of the State of New York all filed amicus briefs arguing the opposite — and lost.
The Clinical Integrity Amendment addresses exactly this gap: by mandating that the physician who signs the denial is personally accountable for the clinical judgment they render — not shielded by the insurer's contractual structure. eviCore's own website promised it would "put patients' needs first." The 2nd Circuit said that promise was not legally enforceable. The Amendment makes the clinical standard legally enforceable.
Who Is eviCore?
eviCore is a "medical benefits management company" that insurers hire to deny claims. One source cited in the Problem Room notes that eviCore advertises a 3-to-1 return on investment to insurers who contract with them. Kathleen Valentini's denial was issued by eviCore on behalf of GHI — a third party with no physician-patient relationship to her, no personal liability for the outcome, and a financial incentive to deny. The Clinical Integrity Amendment's specialty matching requirement (§ 2) would require that any reviewing physician be board-certified in the relevant specialty. It does not currently specify the reviewing physician's name, credentials, or specialty at the time of denial.
Sources
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