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Non-CPAP Forum 21
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UHC pre-authorization strategy

Posted by DarkStranger on July 31, 2007 at 05:19:13:

As I mentioned in a previous post, I have received pre-authorization for my MMA on August 9th, but not for my GA.

I received the denial letter for the GA from UHC yesterday.

The most relevant paragraphs of there form-letter denial:
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Upon reviewing the submitted information, I have determined that at this time SLIDING GENIOPLASTY is/are not a covered benefit under the benefit plan. This determination is based on the following plan language, found in Intranet Benefits at a Glance in the section entitled "COSMETIC":

"COSMETIC PROCEDURES ARE EXCLUDED FROM COVERAGE"

THERE IS A LACK OF DOCUMENTATION OF AN IMPROVEMENT IN PHYSIOLOGIC FUNCTION EXPECTED FROM THE PLANNED GENIOPLASTY.
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I am trying to get my doctor to send an urgent appeal letter. In the meantime, the doctor's office wants me to pay out of pocket ($5100.00) for the GA portion of my procedure.

A couple of questions for the board:

1 - What's the best way to get a pre-authorization appeal in less than 9 days? What tactics, resources and strategies can I employ?

2 - Should I pay the out-of-pocket? Is this normal/reasonable? It should be covered, so why wouldn't they submit a claim rather than ask me to pay up front?

Thanks for your help,

-DS

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