Dental appeal (orthodontics)in year 2023

Our current plan began 01-Jan-2023. It is a Gold Plan provided by Health First Health Plans and includes both children with Dental insurance from HFHP but provided by Liberty Dental.

Initially, Liberty said in February, neither of the children could receive treatment until either children will be eligible for a simple 6-month cleaning unless I have already paid HFHP $8750.

Subsequently, I was hospitalized for 18 days; I mentioned it only because I exceeded the $8750.

I also filed an appeal, but the appeal coordinator wasn’t able to reach a decision in the 30-day window and they asked for an agreed extension.

In the process of waiting for a decision, we needed to seek pediatric treatment and it resulted into a referral to an orthodontist. Prior to allowing my son to receive orthodontic treatment, I confirmed that HFHP still hadn’t made a decision on the appeal.

The orthodontist said that I would have to pay $5550 out of pocket.

After the work (braces) was done, HFHP finally decided that Liberty was wrong to have denied the treatment.

When I contacted Liberty, they declared that there would be no coverage since the work was performed outside of network, even though Liberty wrongfully denied the treatment.

Had Liberty not denied the coverage, we would have obviously sought treatment in network;

A second appeal to HFHP led to the following response: The Appeals and Grievance coordinator decided to uphold the original decision of Liberty.

Based upon the facts outlined above, what course of action, (including legal) would provide the best outcome for an attempt at reimbursement?