Help! My 4yo son’s kidney transplant is not covered at our local Children’s hospital
My youngest son was diagnosed with Chronic Kidney Failure in Jan 2023 at the age of 3. We spent about 6 weeks at Oregon Health Sciences University, in particular the Doernbecher Children's Hospital. Since then, we have our regular nephrologist on speed dial and go in for routine labs and visits. He is now 4 and his kidneys are worsening so we had a case worker at OHSU contact United Healthcare on our behalf to initiate the transplant process. We just learned that the claim was denied. They are asking us to go to SFO or Seattle Children's Hospital (which is closer so I'm assuming that is where we would go worst case). Here was the main reason for the denial per the paperwork:
"Transplant Services- Grid pg 29- For Network Benefits, transplantation services must be received at a Designated Provider."
So essentially OHSU is not a United Healthcare designated provider for transplant services. Now, I have the option to appeal. I have a few questions. Please bear with me and if I'm asking the wrong group, let me know.
1) We are definitely going to appeal no matter what, but how likely is it that they will heed our appeal accept the claim?
2) If #1 is feasible, do you have any advice on how to sway them? My husband is self-employed and can't leave the area. I have two sons 6 and 11 that will most likely be in school during the transplant/after-care. I work remotely, fortunately. But it would still be a hardship when we have a great facility 30 minutes away that my son is comfortable with.
3) We have HSA and have hit our deductible but still have a ways to hit our out-of-pocket deductible. Should we plan to pay more on top of that? Let's pretend my HSA would pay the rest of the out-of-pocket.
Thank you (TIA is what my oldest son told me to write, lol)!
submitted by /u/Ok_Mathematician6075
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