Cleft Advocate - Second Insurance Appeal Letter/Request A Hearing

XXXXXXX XXXXXX

XXXX XXXXXX XXXXX

XXX XXXXX, XX XXXXX

(XXX) XXX-XXXX

VIA FAX (XXX) XXX-XXXX

Date

(Insurance Company/HMO)

XXXX XXXXX, Supervisor

XXXX XXXX XXXXX

XXX XXXXX, XX XXXXX

Provider Name:

Patient Name:

Patient Number:

Group Number:

Procedure: Midface Reconstruction and Oral Surgical Splint

Claim Numbers: XXXXXXXXXXXX, XXXXXXXXXXXX

To whom it may concern:

It has come to my attention that XXX has yet again chosen to deny the above-mentioned medical procedure for my daughter, XXXX XXXXX. My initial appeal was forwarded to your office November 7, 2001 via fax.

I cannot express in words my disappointment, dissatisfaction and utter amazement! Your letter of November 19 simply reiterates what I pointed out to you in my previous request for review. Did anyone even read my letter?

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

Sometimes it is difficult for people, even some medical rofessionals, to understand the cleft defect, the medical procedures involved in correcting it, and my child's needs. This is NOT a dental procedure, nor is it related to a dental condition. XXXX's upper jaw is severely underdeveloped as a result of her bilateral cleft. This condition was not caused by any previous surgery; it was present at birth.

Her jaw is not of normal size. It will not grow or "correct itself". According to the March of Dimes, one in every approximately 700 births is affected with a cleft. I find it difficult to believe that no one on your review board or in your organization is familiar with this medically-necessary procedure. We're talking about one of the most common types of congenital facial deformities. This medical procedure is not experimental by any means. And my daughter is a child who waits for this medically necessary procedure as part of a staged repair, necessary for the proper functions that most of us, myself included, take for granted.

XXXXXXX XXXXXXXXXXX, continued

November 26, 2001

Page 2

Perhaps if you were to watch my daughter eat a meal...

Unlike someone with an overbite, XXXX cannot simply reposition her jaw at will to make her front teeth meet. It is impossible, and even painful to attempt.

Can you imagine biting into a burger and having the food positioned inside your bottom lip and in front of your bottom teeth? Do you hold your hand in front of your mouth when you chew, fearing food may fall

to the table? Do you chew your food normally, or do you cut it in small pieces and almost swallow it whole because your teeth don't meet in the back, making it difficult to chew and grind as molars are designed to do? Do you break off each part of a sandwich and place it toward the back of your mouth because you are unable to take a normal bite?

My daughter cannot eat fresh fruit unless it is cut up. Biting into an apple is impossible...actually, she has told me it hurts tremendously to even try. On the rare occasion we let her have a candy bar, she has to break it apart, piece by piece. I wonder sometimes if this also affects the way she tastes food, since she is limited to the areas she can actually hold and maneuver her food.

And that simply describes how she gets food into her mouth and attempts to chew it. Swallowing that food is a whole other problem. In fact, she is underweight. One summer she was under constant care by her pediatrician because she could barely put on a pound.

If you watched XXXX eat, you would surely notice that she severely forces her chin down and back to swallow even the softest, smallest foods. This action alone is something she has had to perfect over her lifetime to avoid choking, which still happens now and then. While swallowing should be a subconscious act, it is something XXXX has to think about at every meal. Even the rice krispies she just finished...I watched as her chin pressed toward her chest to get the spoonful down. A simple meal--turned into an event of sorts.

And there's more...

Imagine speech therapists telling you that your daughter doesn't have the physical means to advance any further. The silver lining? They tell you that after the appropriate medically-necessary procedures are performed, speech therapy can resume.

In fourth grade XXXX asked us if she could play the flute in the school band. Imagine the difficulty in telling her that she just "didn't have the equipment" to play the flute...how about the drums?

XXXXXXX XXXXXXXXXXX, continued

November 26, 2001

Page 3

XXXX is a wonderful young lady. She's bright and funny and smart. She never has a pity-party about her condition, and she carries no chip on her shoulder...no "why-me attitude". Since her fate was determined during the first trimester of my pregnancy, the only life she knows is one of medical procedures, speech therapy, recoveries, scarring, testing, etc. She takes on each new challenge like a champ. While we cannot turn back time, I can certainly fight the hard battles for her, such as this has become. Yet again, 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.

Should those reviewing XXXX's file not be familiar with this congenital anomaly, I insist that you have one of your reconstructive or oral/maxillofacial surgeons review this request....someone familiar with bilateral cleft lip/palate as well as someone familiar with the staged correction of this repairable congenital birthdefect.

Unless this can be resolved quickly by your office, you can consider this letter my request for an audience with the proper (Insurance Company/HMO) review board and/or directors to resolve this issue. Time is of the essence. Please contact me by phone to my residence at your earliest possible convenience with a date, time and venue for such a review.

If this request is yet again rejected by (Insurane Company/HMO), I feel I will have no other choice but to contact the Nevada State Insurance Commissioner and/or an attorney.

XXXX and I look forward to your approval for this procedure in the immediate future.

Sincerely,

Deborah Oliver

Enc: