Bills after TBI Advice for Appeal
My brother wrecked on a motorcycle and as a result received several surgeries. This was a double craniotomy, a brain shunt, surgery to drain fluid from the brain to reduce swelling, and another surgery to put everything back together. I am his brother and guardian/conservator through all this and I received 2 different letters from his health insurance provider United Healthcare. These were not actual bills in either letter.
The first letter on 8/25 was a notice of denial of service for 5 days staying at the hospital while he was being tended to after his surgeries with acute care while he began intense recovery. "You were admitted to the hospital on 7/29/23. The diagnosis was bleeding on the brain. We reviewed the medical information made available to us. We reviewed the health plan criteria for your continued stay. You could have safely discharged on 8/18/23. Continued stay is not covered starting that day. The reason is that there was no new symptoms. There were no abnormal test results."
The second letter on 9/5 was a notice of denial of service for 2 days while he was admitted to a different hospital while in acute rehabilitation for acute observation due to extreme symptoms from hydrocephalus (cerebral spinal fluid accumulating in dangerous amounts on the brain, not draining properly causing brain damage due to swelling) which could cause have caused a need for emergency surgery at any point in time and this hospital admittance was recommended by the primary neurosurgeon. The denial was stated by UHC in similar terms in this letter, only they want to deny the claim because "increased brain fluid" does not meat the guidelines. "You did not have a severe illness. You were stable." This was for his stay directly prior to the surgery to implant a shunt in his brain to his stomach to drain the cerebral spinal fluid safely.
In both cases these hospitals and stays were in network and covered by his UHC policy according to the policy documentation from UHC. I plan to internally appeal these denials for him and then externally appeal them if that doesn't work and possibly seek help from a lawyer after that if they still deny the claim. Can anyone please help me understand what kind of paperwork and documents and attestations I will need to include with the appeal to best appeal these denials of claims from UHC?
Thank you thank you thank you in advance. My brother is 29 and was making about 50000 per year and is on disability now. I am 32 and make about 85000 per year. I am moving to his town in 68847 but I currently reside in 15211.
submitted by /u/Heavy_Recipe5478
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