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Retired firefighter—s denied treatment draws scrutiny; SFHSS director cites Medicare rules, Blue Shield pledges review
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Summary
Public comment and the SFHSS director's report focused on retired firefighter Ken Jones—s prior‑authorization denials by Blue Shield. Director Ray Guillen said Medicare/ CMS rules and an independent review upheld the denials; callers and unions urged further investigation and data collection.
Ray Guillen, executive director of the San Francisco Health Service System, addressed public concern over a retired firefighter—s denied prior authorization during his director—s report, telling the board that "at the heart of this matter is actually Medicare rules" and that an independent review entity, Maximus, upheld Blue Shield—s denial because some treatments were not FDA‑approved for the requested off‑label use.
Family members and firefighter advocates disputed that characterization during public comment. Helen Horvath, the caller who identified herself as the wife of Ken Jones, said the family had raised private funds for his initial immunotherapy and later received care under traditional Medicare; she called the director—s memorandum—which upheld the denial—"outrageous" and cited a February 3, 2026 Office of Inspector General guidance on Medicare Advantage denials, arguing the plan may have used automated decisioning rather than individualized review.
Adam Wood, vice president of the San Francisco Firefighters Cancer Prevention Foundation, urged the board to allow a citywide collection of member reports to proceed and to act if a pattern of denials emerges. "The top priority for this board should be making sure that the people represented by it get life‑saving treatment in a timely fashion," Wood said.
Blue Shield—s regional representative, Amy DeHart, told the board she watched recent media coverage and said Blue Shield has "reached out to Mister Jones when he was a member" and that the plan—s clinical teams contacted the provider while reviewing treatment options that would be consistent with CMS and FDA rules. She added Blue Shield is "absolutely committed to providing the best quality care" and is examining whether additional support is appropriate.
Guillen and his staff told the board that, because Mr. Jones is enrolled in a Medicare Advantage prescription drug plan administered by Blue Shield, SFHSS had to follow Medicare rules; he said seven of the ten requested medications were approved while three were denied because they were not FDA‑approved for the specific off‑label use. He also described the appeal pathway and noted that Maximus, the signed independent review entity, upheld the denials.
The board did not take a formal action on the case at the meeting. Staff said they provided a written response to the offices of Supervisors Dorsey and Chan and that the city—s outreach to retirees to collect similar stories is underway. Director Guillen said the department will continue to support members and that the administrative appeal and independent review processes remain available.
Next steps: the board received public comment and media inquiries asking for documentation of who SFHSS consulted during its investigation; staff said they submitted materials to the clerk of the board and will continue to communicate with members and supervisors.
