(Insurance Company/HMO)
(Date)
XXXX XXXXX
XXXX XXXX XXXXX
XXX XXXXX, XX XXXXX
Member Name:
Member Number:
Provider Name:
Service: Midface Reconstruction and Oral Surgical Splint
Claim Number: XXXXXXXXXXXX. XXXXXXXXXXXX
Dear XXXX:
Thank you for your patience and cooperation during our review process. Your request for reconsideration of the services referenced above has been reviewed. The decision reached was to uphold the original denial of the prior authorization as Midface Reconstruction and Oral Surgical Splint are an exclusion per your Evidence of Coverage. Please refer to Page 20, Section 8, Exclusions, Paragraph 8.5 which states:
"Dental or orthodontic splints or dental prostheses, or any treatment on or to teeth, gums, or jaws and other services customarily provided by a dentist. Treatment of pain or infection known or thought to be due to a dental condition and in close proximity to the teeth or jaw; surgical correction of malocclusion; maxillofacial orthognathic surgery, oral surgery (except as provided uner the Covered Services Section), orthodontia treatment, pre-prosthetic surgery and any procedure involving osteotomy of the jaw. Including outpatient Hospital or ambulatory surgical services, anesthesia and related costs when determined by (Insurance Company/HMO) to relate to dental condition. Charges for dental services in connection with temporomandibular joint dysfunction are also not covered unless they are determined to be Medically Necessary. Such dental-related service are subject to the limitation shown in the Benefit Schedule."
If you disagree, you have the right to request a grievance within 30 days. Should you choose this avenue, your options are to submit your request in writing to:
(Insurance Company/HMO Information)
Or, you may call a Member Services Representative at (XXX) XXX-XXXX. If you are outside the XXX XXXX area, please call our toll-free number (800) XXX-XXXX. A Member Services Representative will assist you if you have any questions.
Sincerely,
CR&R Coordinator/Appeals
Customer Response and Resolution Department
cc: Doctor
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Sample Second Denial Letter
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This cleftAdvocate page was last updated March 25, 2014
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