Appealing Denial of Coverage Decision

[sarahfelldown]

Hi there, found this board while researching my appeal. My situation is similar to the one in this post (viewtopic.php?t=39646), Mandibular hyerplasia diagnosis, Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation and Reconstruction midface, LeFort 1; 3 or more pieces, segment movement in any direction, without bone graft.

However United Healthcare's determination was not that it was not medically necessary but that orthognathic surgery is specifically excluded in UnitedHealthcare's policies except for a handful of exceptions. It's likely a long shot that I will get UHC to cover me here (even my surgeon's office said so...which is why I'M filing the appeal and not them) but I'm going to go through the motions anyway. (At the very least I can tell myself I tried everything before getting into $20k worth of debt for the surgery.)

Does anyone have any experience going through the appeal process that could offer some advice? I noticed in the thread above the user Reosity seemed to have success with their appeal, but I couldn't find any follow up posts.

Thanks in advance!

-Sarah Martin

[PierreDeFermat]

Very sorry to hear that Sarah, unfortunately if you don't meet the exact exceptions put forth by UHC (which are mandated at the federal level) there's almost no chance you will be covered.

But there is hope!

I know many people on the forums who have decided to get out of pocket insurance with an insurance provider which covers orthognathic surgery (Kaiser, BC/BS, etc.) and were approved quite quickly. I'm not quite sure on the specifics but I recommend you do your research here on the forums and via the insurer's own benefit guidelines and see if switching might be worth it.

Best of luck

[sarahfelldown]

Thanks for the reply! That's what I've heard will likely be my course of action. I'll do some research here to see what forum users have found helpful. Thanks!