Contract Exclusion: Unable to Appeal

Hi community, I’m struggling with an insurance issue and I need some help. For some background, I (26M) have moderate obstructive sleep apnea and have used CPAP for the past 4-5 years.

I got preapproval for sleep surgery last year with United Healthcare (UHC) before I got braces. I have been in braces for about ~1 year, which is a prerequisite to the surgery, and, in that time, my company-sponsored insurance changed to Premera. So I needed to get pre-approval again. However, I received the following message from the insurance coordinator at my surgeons office after my most recent consult:

“It looks like unfortunately orthognathic surgery is a contract exclusion from your benefits. Unfortunately, when things are a excluded benefit I am unable to appeal. Would you like to proceed with surgery as a cash pay patient?”

The OOP is $130-$180K, and the surgery is scheduled for June 22nd. I am leaving my job in May or June, depending on how insurance plays out, to take a few months off before I start my dream PhD program in the fall – it was my third year applying. Getting the surgery after that is not as much an option because of the long recovery time and the demands of the competitive program.

I am thinking I can leave my job in May to qualify for a life-changing event, purchasing individual insurance to get coverage for the surgery on June 22nd. Does this sound logical? I don’t understand these systems well and appreciate any insights you can provide.

submitted by /u/JamesAlby
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