Need braces but United Healthcare denied coverage? You might need a “Sample Letter To United Healthcare Requesting Medically Necessary Orthodontia.” This letter explains why braces aren’t just cosmetic for you. It argues that they are essential for your health.
Writing this letter can feel daunting. You need to clearly state your case. You also need to use the right language. Don’t worry, we’ve got you covered.
We’re sharing templates and examples. These samples will make writing your letter easier. Get ready to build a strong appeal!
Sample Letter To United Healthcare Requesting Medically Necessary Orthodontia
[Your Name]
[Your Address]
[Your Phone Number]
[Your Email Address]
[Date]
United Healthcare
[Insurance Company Address]
**Subject: Request for Medically Necessary Orthodontia – [Patient Name] – [Policy Number]**
Dear United Healthcare,
I am writing to request pre-authorization for orthodontic treatment for my [son/daughter], [Patient Name], policy number [Policy Number].
[Patient Name] suffers from a severe malocclusion that significantly impacts their oral health and overall well-being. Specifically, [he/she] experiences [List specific problems, e.g., difficulty chewing, pain in the jaw, speech impediments, chronic mouth breathing, etc.].
Dr. [Orthodontist’s Name], a qualified orthodontist, has evaluated [Patient Name] and recommends orthodontic treatment to correct this condition. Dr. [Orthodontist’s Name]’s report, attached to this letter, details the diagnosis, proposed treatment plan, and explains why this treatment is medically necessary.
The proposed treatment is not solely for cosmetic purposes. It is essential to alleviate [Patient Name]’s current symptoms and prevent further complications, such as [List potential complications, e.g., temporomandibular joint (TMJ) disorder, increased risk of tooth decay, gum disease, etc.].
I have enclosed the following documents for your review:
* Orthodontist’s report from Dr. [Orthodontist’s Name]
* Photographs of [Patient Name]’s teeth
* [Any other relevant medical records]
I urge you to consider this request carefully. Medically necessary orthodontia will significantly improve [Patient Name]’s quality of life.
Thank you for your time and attention to this matter. I look forward to your positive response.
Sincerely,
[Your Name]
How to Write Letter To United Healthcare Requesting Medically Necessary Orthodontia
Subject Line: Concision is Key
The subject line acts as the initial beacon, guiding your correspondence through the administrative labyrinth. It must be succinct yet informative, laying the foundation for a prompt and favorable review.
- Be specific: “Prior Authorization Request for Medically Necessary Orthodontia – [Patient Name], [Member ID]”
- Avoid vagueness; eschew generic terms like “Dental Claim” alone.
Salutation: Establishing Rapport
While formality is paramount, injecting a modicum of affability can subtly influence the tone of your appeal. Address the recipient appropriately to foster a sense of professional respect.
- Prefer “Dear United Healthcare Medical Director” if the specific name of the medical director isn’t available.
- If a contact person is known, use “Dear Mr./Ms. [Last Name].”
- Avoid overly casual greetings.
Introduction: Setting the Stage
Your introductory paragraph should immediately establish the purpose of your correspondence and provide a concise overview of the situation. Clarity here is indispensable.
- State the patient’s name, date of birth, and member ID number.
- Clearly assert that you are requesting prior authorization for medically necessary orthodontic treatment.
- Briefly describe the patient’s malocclusion (e.g., severe overbite, crossbite) and its impact on oral health.
Body Paragraphs: Articulating Medical Necessity
This is the nucleus of your appeal. Meticulously detail the medical ramifications of the patient’s orthodontic condition. Employ persuasive prose, underpinned by concrete evidence, to substantiate your claim.
- Elaborate on the functional impairments caused by the malocclusion, such as difficulty chewing (mastication), speech impediments, or temporomandibular joint (TMJ) dysfunction.
- Cite specific clinical findings from the orthodontic evaluation, including measurements of overjet, overbite, and crowding.
- Include diagnostic codes (ICD-10) that correlate with the patient’s condition.
- Explain how orthodontic treatment will alleviate these medical issues and improve the patient’s overall health.
- If applicable, mention any previous treatments attempted and their outcomes.
Supporting Documentation: Fortifying Your Case
A well-documented appeal is invariably more compelling. Enclose all pertinent records to provide a holistic understanding of the patient’s orthodontic needs. Scrupulous attention to detail can be determinative.
- Include a comprehensive orthodontic evaluation report, signed and dated by the orthodontist.
- Attach pretreatment photographs and radiographs (panoramic and cephalometric) to visually demonstrate the malocclusion.
- Provide a detailed treatment plan outlining the proposed orthodontic procedures, including expected duration and cost.
- Enclose letters of recommendation from other healthcare professionals, such as the patient’s dentist or physician, if applicable.
Anticipating Objections: Proactive Defense
Consider potential counterarguments United Healthcare might raise and proactively address them in your letter. Forewarned is forearmed.
- Acknowledge any policy limitations regarding orthodontic coverage, but emphasize the medical necessity exception.
- If the plan covers only specific types of malocclusions, explicitly demonstrate how the patient’s condition meets those criteria.
- Reiterate that the requested treatment is not solely for cosmetic purposes but is essential to address significant health concerns.
Closing: A Lasting Impression
Conclude your letter by reiterating your request and expressing your willingness to provide additional information. A polished and professional closing can leave a lasting positive impression.
- Reiterate your request for prior authorization for medically necessary orthodontic treatment.
- Express your availability to discuss the case further or provide additional documentation.
- Thank the recipient for their time and consideration.
- Use a formal closing such as “Sincerely” or “Best Regards,” followed by your name and contact information.
Frequently Asked Questions: Sample Letter for United Healthcare Orthodontia Coverage
This section provides answers to common questions regarding sample letters used to request coverage for medically necessary orthodontia from United Healthcare.
Understanding this process can help streamline your request and improve your chances of approval.
What information should be included in a medically necessary orthodontia request to United Healthcare?
Your request should include the patient’s identifying information, the treating orthodontist’s details, a clear diagnosis justifying the medical necessity of the treatment, a detailed treatment plan, and supporting documentation such as X-rays and clinical photographs.
What constitutes “medically necessary” orthodontia under United Healthcare policies?
United Healthcare typically considers orthodontia medically necessary when it corrects a severe functional impairment, such as difficulty chewing, speaking, or breathing, caused by a significant malocclusion that cannot be addressed with other less intrusive treatments.
Where can I find a sample letter to request medically necessary orthodontia from United Healthcare?
While it is best to consult with your orthodontist for a personalized letter, you can find general templates online by searching for “sample letter medically necessary orthodontia United Healthcare.” Ensure any template is adapted to reflect your specific situation.
What supporting documentation is essential to include with my request letter?
Include pre-treatment records such as panoramic and cephalometric X-rays, clinical photographs demonstrating the malocclusion, a detailed narrative from your orthodontist explaining the medical necessity, and any relevant specialist referrals or consultations.
How long does it usually take to receive a response from United Healthcare regarding a request for medically necessary orthodontia?
The processing time for prior authorization requests can vary, but it typically takes United Healthcare between 15 and 30 business days to review a request. Follow up with United Healthcare if you do not receive a response within this timeframe.