Cleft Advocate - First Insurance Appeal Letter

XXXXXXX XXXXXX

XXXX XXXXXX XXXXX

XXX XXXXX, XX XXXXX

(XXX) XXX-XXXX

VIA FAX (XXX) XXX-XXXX

Date

(Insurance Company/HMO)

XXXX XXXXX

XXXX XXXX XXXXX

XXX XXXXX, XX XXXXX

Provider Name:

Patient Name:

Patient Number:

Group Number:

Procedure: Midface Reconstruction and Oral Surgical Splint

To whom it may concern:

Please accept this letter as XXXX XXXXX's appeal to your decision to deny coverage for the above-mentioned procedure. It is my understanding based on your letter dated November 1, 2001 that this procedure has been denied due to an "exclusion per your Evidence of Coverage".

After reviewing Section 8--Exclusions, Paragraph 8.5, I believe that this procedure should be covered.

While Section 8.5 concludes with "when determined by HPN to relate to a dental condition", XXXX's treatment is a necessary medical procedure--not a dental one.

My daughter should have been in surgery at 7:30 AM today. The surgical wires and hooks were ready; impressions were taken. She was checked out of school and had collected over a week's worth of

schoolwork and homework in anticipation of her big day. XXXX is well-aware that this procedure is necessary to improve the function of her abnormal facial structure. Breathing, chewing, swallowing, talking...all these things will improve with this operation. Furthermore, the surgery will provide the bone structure...the foundation...the stepping stone she needs to come closer to leading a normal life despite the incredible facial deformity she was born with. Future treatment depends on it.

XXXX doesn't like needles; she doesn't like hospitals. It probably doesn't seem likely that a child would be disappointed by the prospect of not having her jaw broken, but she cried when I told her the request had been denied. Your letter arrived to her father's house a mere 12 hours before she was to check in at the hospital this morning.

I truly believe it is too much to ask of her that she simply live with her deformity and its complications when there is a proven medical procedure available to correct it.

Utilization Management Department/Appeals Specialist

November 7, 2001

Page 2

Based of Section 8.5, I am requesting on my daughter's behalf that you reconsider your previous decision and allow coverage for the procedure Dr. XXXXXX has outlined in his request. Should you require additional information, please do not hesitate to contact me at (XXX) XXX-XXXX or (cell) (XXX) XXX-XXXX.

XXXX and I look forward to hearing from you in the near future.

Sincerely,

Deborah Oliver

Enc: