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Irwin Law
Irwin Law, Attorney
Category: Personal Injury Law
Satisfied Customers: 7415
Experience:  Partnered in a personal injury law firm for approximately 30 years.
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I am having to appeal a surgical denial of a

Customer Question

I am having to appeal a surgical denial of a predetermination sent in to United HealthCare for Bi-Lateral Jaw Replacements due to severe results from what originally began as TMJ. I had surgery on 10/30/2012 where it was arthroscopy tempromandilur on both sides in hopes it would provide relief for a while. It did but my relief has ended and the pain is excruciating ! I visited my surgeon again, he ordered a CT and found severe bone deformity that is causing the severe pain. I received a second opinion from a surgeon that came highly recommended by another specialist. He ordered another CT and the same results were found. I will definitely have to have a Bi-Lateral Jaw Replacement ASAP. It will require custom joints to be made. I am only able to open my jaw/mouth 16mm. Therefore, I have had to move to soft foods only at all times due to the severity of the pain. I am having to take pain medicine and muscle relaxers daily just to make it until my surgery date. My surgery date is not until October 20 because it takes 8-10 weeks to build the custom joints. I simply pray I can survive until Oct 20. I have never felt this kind of pain. I have had United HealthCare Insurance through my job since March 26, 2007, same plan, same employer-they are self insured, same PPO (Choice Plus). My question is when I had the surgery on Oct 30, 2012 I received my pre-determination letter back for the diagnosis & procedures codes and the letter states this procedure is covered by your medical benefits and will be covered by your plan. Absolutely NOTHING has changed since Oct 30, 2012 as far as my United HealthCare benefits but yet on my pre-determination letter submitted by my surgeon stating it was definitely medically necessary, all the new procedure codes, diagnosis, CT results, clinical exam measurements, etc. I received the pre-determination letter from United HealthCare and they denied the surgery saying TMJ is an exclusion with my policy. I am not understanding since NOTHING changed benefit wise or insurance company wise between 2012 & 2017, I did not pay one single penny for the surgery in 2012 but yet the surgery in 2017 the same insurance company is saying isn't a covered benefit so I would have to pay for the entire surgery myself. I have 2 entire files of physician, hospital, radiologist, etc. receipts where United HealthCare paid 100% of my surgery in 2012. I have been doing some research with a health advocate and they told me with "larger group insurance plans are required to cover TMJ in the state of Texas if the group plan is underwritten in Texas", is this correct?
JA: Because employment law varies from place to place, can you tell me what state this is in?
Customer: Texas
JA: Has anything been filed or reported?
Customer: Filed or Reported for what?
JA: Anything else you want the lawyer to know before I connect you?
Customer: How do I find out what state an insurance plan is underwritten in? Also, How many people are required for it to be a larger group insurance plan? How to I go about getting an attorney to just write a letter on my behalf to submit to United HealthCare for my appeal in conjunction with my surgeon's information?
Submitted: 1 month ago.
Category: Personal Injury Law
Expert:  Irwin Law replied 1 month ago.

Good morning. Thanks for using JUST ANSWER. I'm sorry to hear that you are undergoing such pain and stress. While a letter from a local lawyer might be helpful, a formal complaint filed with the Texas insurance department (http://www.tdi.texas.gov/consumer/complfrm.html) usually gets quicker action out of the insurance company, and you won't have to pay for it. Save the legal action for later.

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