The much-publicized death of a 17-year-old California girl has put her insurance company, Philadelphia's Cigna Corp., in the national spotlight and again raised questions about the role insurers play in deciding the medical care Americans receive.

Nataline Sarkisyan died last week, less than an hour after Cigna reversed its decision and approved coverage for a liver transplant. Mark Geragos, her family's attorney, blames the insurance company for her death and plans to sue.

For its part, Cigna said yesterday that two independent experts had concluded that a transplant in this case "would not have been an effective or appropriate treatment."

Geragos said he also would ask the Los Angeles County District Attorney's Office to consider a manslaughter or murder charge against Cigna.

"Right now, the person who is clearly responsible for this mess and this tragedy is Cigna," Geragos said. The insurer, he said, signed the girl's "death warrant" by delaying approval for a transplant.

Geragos said Sarkisyan was diagnosed with leukemia two years ago. Her liver failed after she received a bone-marrow transplant from her older brother. She was placed on UCLA Medical Center's transplant list Dec. 6. Geragos said she had been "in and out" of a vegetative state but was conscious when Cigna initially denied approval of a transplant.

In a letter protesting the Cigna decision, UCLA doctors estimated Sarkisyan's chance of surviving six months with a transplant at 65 percent. Nationally, the average one-year survival rate for pediatric liver transplants is about 87 percent.

The teen's case sparked protests by nurses in California. Since her death, presidential candidate John Edwards and filmmaker Michael Moore have both weighed in.

Chuck Idelson, communications director for the California Nurses Association, said the broader issue was that insurance companies profited by denying care. "It's not just Nataline. We're all Nataline," he said. "Our view is that we need a health-care system that takes these decisions out of the hands of insurance companies."

But Karen Ignagni, president of America's Health Insurance Plans, an industry lobbying group, said most employers do not buy insurance that covers experimental procedures. People who are desperately ill often want such care, and the country needs to start thinking about how to make it available to them, perhaps with public funding, she said. Her organization has been studying the issue for several months, she said.

Meanwhile, representatives of UCLA and Cigna said they were hamstrung because the family had not signed a statement waiving privacy protections. Without the signature, they say, they cannot answer specific questions about the girl's treatment.

Geragos said he would not approach the Sarkisyans for permission before Nataline's funeral on Friday.

Hospital spokeswoman Roxanne Moster said she could not address why UCLA did not go ahead with a transplant - Geragos said two donor livers were offered for Sarkisyan during her first week on the waiting list - and haggle over money later. She said the hospital had performed transplants on uninsured patients in the past.

Cigna yesterday released a message it had sent to its employees. "Due to patient confidentiality, it is currently not possible for us to comment on specific accusations, many of which have mischaracterized our decisions and intentions," the statement said.

Geragos said he suspected Cigna addressed its memo to employees, rather than the public, because of employee unrest. He said he had been inundated with e-mails from current and former Cigna workers who say it was part of their corporate culture to deny expensive claims.

In a written response yesterday, Cigna's chief medical officer, Jeffrey Kang, said the company approved 99 percent of services physicians recommend and 90 percent of liver transplants. "Coverage decisions are always made without consideration of cost," he said.

Abraham Shaked, a liver-transplant surgeon and director of Penn Transplant Institute, said insurance companies had generally been reasonable about transplant coverage. Cigna has denied coverage twice, he said, but paid after his hospital appealed.

There is scientific evidence that leukemia patients whose livers fail after a bone-marrow transplant can do well with a liver transplant, Shaked said. He worked at UCLA for six years and described it as a "very responsible center and very good center."

Whether or not to go ahead with a transplant should be the doctor's decision, he said. Insurance companies do not have any right to intervene, he said.

Shaked also said he did not think the University of Pennsylvania Health System would refuse to do a transplant because of an insurance denial. "I don't think that we've faced a case where we did not have insurance coverage and we said we are not going to do it because we're not going to get money for it," he said.

Contact staff writer Stacey Burling at 215-854-4944 or sburling@phillynews.com.