UnitedHealthcare CPT Coding drama

There is a looong story, and this fight has been going on for literally years, but here is the Cliff's Notes and the problem.

In Sept 2021, I was fitted with a custom mouthguard for TMJ. After 2 months of discussions with UnitedHealthcare, they finally approved it, and I was reimbursed ($3500 that I had to pay out of pocket, because as soon as the doctor saw it was United Healthcare, they said they had to be paid up front.)

Apparently in March of 2022, without telling anyone, they decided to AUDIT the payment, and retroactively decided that there was something about the Diagnostic CPT codes they didn't like. So they retroactively DENIED it, and started clawing back the $3500 from every other reimbursement for any other service for anyone in my family.

It took 6 months to notice, because when I'd call to ask where the reimbursement check was, the customer service people would say they could see where it had been sent (no, because it never HAD been sent, they just applied it to my $3,500 balance owed.)

In November of 2022, when we finally figured out what had happened, after literally 8 calls to different departments, we found out there was a missing modifier code for one of the Treatment codes. So I contacted the doctor and they added the modifier code. Now 7 months later, they still haven't reapproved it. Finally I resubmitted it for the 5th time last week, and received a response now that the difficulty they were having is that one of the other CPT codes is a Deleted Code, so they can't process it.

So I googled the code they complained about, and CPT 76102 was deleted in Jan 2022, AFTER my initial claim and treatment. So it looks like United Healthcare is refusing to pay for a covered service because the code it was submitted under was changed 3 months after the initial claim went through?

Ask: If anyone is familiar with medical coding, is that legal?

submitted by /u/Richter12x2
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