XXXXXXX XXXXXX
XXXX XXXXXX XXXXX
XXX XXXXX, XX XXXXX
(XXX) XXX-XXXX
VIA FAX (XXX) XXX-XXXX
Date
(Insurance Company/HMO)
XXXX XXXXX, Department Manager
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
Dear XXXX:
I am in receipt of your letter dated January 21, 2002 confirming my conversation with XXXXXXX XXXXX. The following are my remaining concerns regarding XXXX's case and any further treatment her doctors may deem medically necessary.
As you can imagine, I am both pleased and displeased with this correspondence. My questions are:
1. Why was the original Committee bypassed when they were due to meet on XXXX's case the day after this letter was written? Is the Committee aware of the ruling and the basis for the decision?
2. If this procedure is "not covered", what is the specific reference in the EOC and/or all supporting documents?
3. If this procedure is "not covered", on what basis was the administrative exception considered?
4. Who was the Senior Administrator who made the decision, and on what basis?
Additionally, XXXXXXX's remark to me on the phone that he can understand why we went ahead with the surgery on December 26 so that we would not be liable for another deductible after the first of the year...well, the remark was unacceptable. I told XXXXXXX that the reason we went ahead with XXXX's surgery is because, at the direction of Dr. XXXXXX and Mr. XXX XXXX, CEO of XX. XXXX XXXXXXXXX Hospital, it was high time that XXXX's necessary operation be performed, despite the insurance company complications. These gentlemen made the arrangements necessary
to ensure prompt and necessary care for my daughter, XXXX.
XXXX XXXXX, continued
January 25, 2002
Page 2
I am happy to report that the Reconstruction Midface Piece was a great success, although it will be several more weeks before the complete results are known. XXXX's breathing and swallowing
are very much improved. She is still in the healing process, so biting into anything and chewing beyond a soft food diet are prohibited right now to allow the surgical site to heal. We are grateful that the decisions made by her surgeon and the CEO of the hospital were in the best interest of our daughter.
I have received the Evidence of Coverage packet from XXXXXXX and have noted the following passages which further support XXXX's case.
Per the Benefits Schedule provided by XXXXXXX, Page 6: (attached)
Oral Surgical Physician Services Office Visits, Inpatient and Outpatient Facilities
Tier III 60/40
Furthermore, (Human Resources Representative) has provided me with additional support from her office.
Per the XXX Rider, Page 5: (attached)
Section 2.5
"Subject to all of the terms and conditions of the Plan, the following limited Dental/Oral Surgical Services will be considered Covered Services provided only in connection with the following:
Paragraph (b)
"...the correction of a non-dental, physiological condition which has resulted in a severe functional impairment."
I await the specific reference(s) in the EOC that would prevent my daughter from being covered for this and any further orthognathic and/or reconstructive treatments and surgeries. I'm sure you can recognize why this entire situation would cause confusion, even for the most savvy of consumers.
XXXX XXXXX, continued
January 25, 2002
Page 2
Additionally, I would like a complete copy of XXXX's file pertaining to this ongoing process, beginning with the first denial of coverage in 2001. I believe the file may lend insight into why this process has taken so terribly long, and perhaps provide a better understanding of the reasoning behind the repeated denials.
Sincerely,
Deborah Oliver
(XXX0 XXX-XXXX
cc:
Doctor XXXXXX
Doctor XXXXXX Human Resources Insurance Broker Hospital RepresentativeWe subscribe to the HONcode principles of The Health On Net Foundation
This cleftAdvocate page was last updated March 25, 2014
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