Mountain_Fig_9253
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1d ago
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Thank you for choosing United Healthcare for your healthcare needs. After a careful review of the claim submitted for emergency services on December 4, 2024, we regret to inform you that your request for coverage has been denied.
Our denial is based on the following findings:
Lack of Prior Authorization:
Our records indicate that you failed to obtain prior authorization before seeking care for the gunshot wound to your chest. While we acknowledge the emergent nature of the situation, our policy requires that all non-preventative services, including “unexpected chest injuries,” be pre-approved through our 24/7 Prior Authorization Hotline. Unfortunately, our hotline received no such call during your ambulance transport or at any point before your admission to the emergency room.
2. Failure to Prove Medical Necessity:
The submitted documentation does not sufficiently demonstrate that treatment for a penetrating chest wound meets the definition of “medically necessary.” Our guidelines specify that life-threatening conditions must be substantiated with a second opinion from a network provider, preferably before care is rendered.
3. Alternative Options Not Explored:
Based on our retrospective analysis, alternative, more cost-effective treatment options—such as a virtual telehealth consult or at-home first aid—were not attempted prior to your emergency room visit. We understand that you were actively “bleeding out,” but this does not exempt you from exploring lower-cost care pathways.
4. Out-of-Network Care:
The emergency room where you received treatment is not within our network. While City General is geographically closer to the location of your shooting, our network partner, DiscountCare Clinic, is only 25 miles away and equipped with staplers and gauze for such injuries.
Next Steps: You may file an appeal within 30 days if you believe this decision is incorrect. Appeals must include:
A notarized letter from the attending physician, explaining why you thought you were entitled to not bleed to death while waiting for approval.
Evidence that your injuries were, in fact, serious enough to merit immediate attention, such as photos, videos, or live reenactments.
We encourage you to familiarize yourself with your plan benefits and utilize in-network providers for future incidents. Please do not hesitate to reach out to our customer support team if you have questions about this
Sincerely and in good health, United Healthcare
P.S. Remember: Preventative care is the best care! If you’d like, we can help you schedule your annual physical or connect you to a mindfulness seminar to prevent future traumatic injuries.
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Mountain_Fig_9253
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1d ago
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Thank you for your recent appeal regarding the denial of coverage for your emergency room visit on December 5, 2024. We have carefully reviewed the additional information you provided, including the attending physician’s notes, photographic evidence of your gunshot wound, and the security footage of the event.
After a thorough re-evaluation of your case, we regret to inform you that the original denial decision has been upheld. Our reasons for this decision are outlined below:
Insufficient Documentation Supporting Medical Necessity:
While we acknowledge the physician’s statement that your “life was in immediate danger,” we remain unconvinced that the treatment you received in the emergency room was the only appropriate course of action. Specifically, we find the decision to intubate and transfuse blood unnecessarily aggressive when other cost-effective options, such as applying firm pressure to the wound with a clean cloth, could have been attempted first.
2. Failure to Contact Prior Authorization Hotline: Your appeal asserts that you were “unable to call” due to being “unconscious” after sustaining the gunshot wound. While we empathize with your condition, we remind you that our Prior Authorization Hotline is available 24/7 and can be contacted by a friend, family member, or even a concerned bystander. The failure to delegate this responsibility during your medical emergency further substantiates our denial.
3. Out-of-Network Services: As stated previously, City General Emergency Department is not part of our network. While we understand that DiscountCare Clinic is 25 miles away and does not operate ambulances, the choice to seek care at a non-network facility remains inconsistent with your plan’s cost-saving guidelines. Our analysis indicates that driving oneself, despite injury, or calling a rideshare service might have provided a viable and more affordable alternative.
4. Policy Exclusions on Firearm-Related Injuries: Your plan explicitly excludes coverage for injuries resulting from “unapproved use of firearms.” As no evidence was provided to confirm the shooting was accidental or unavoidable, we are unable to overturn this aspect of the denial.
Next Steps: This decision is final. You may choose to escalate your appeal to the Independent Medical Review Board (IMRB) at your own expense. If the IMRB overturns our decision, you may be eligible for partial reimbursement minus a $5,000 “Claim Reconsideration Fee.”
We encourage you to consult our Member Handbook to better understand your plan benefits and avoid similar misunderstandings in the future. Should you find your current coverage unsatisfactory, we invite you to explore our new UNH UltraBasic plan, which offers even fewer benefits at an even lower premium.
Sincerely and in good health,
United Healthcare
P.S. Please note: Our appeals process is designed to promote proactive healthcare decision-making. While this unfortunate incident did not meet policy requirements, we commend your efforts to stay alive and wish you a speedy recovery.
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