Thank you for your recent appeal regarding the denial of coverage for your emergency room visit on December 5, 2024. We have carefully reviewed the additional information you provided, including the attending physician’s notes, photographic evidence of your gunshot wound, and the security footage of the event.
After a thorough re-evaluation of your case, we regret to inform you that the original denial decision has been upheld. Our reasons for this decision are outlined below:
Insufficient Documentation Supporting Medical Necessity:
While we acknowledge the physician’s statement that your “life was in immediate danger,” we remain unconvinced that the treatment you received in the emergency room was the only appropriate course of action. Specifically, we find the decision to intubate and transfuse blood unnecessarily aggressive when other cost-effective options, such as applying firm pressure to the wound with a clean cloth, could have been attempted first.
Failure to Contact Prior Authorization Hotline:
Your appeal asserts that you were “unable to call” due to being “unconscious” after sustaining the gunshot wound. While we empathize with your condition, we remind you that our Prior Authorization Hotline is available 24/7 and can be contacted by a friend, family member, or even a concerned bystander. The failure to delegate this responsibility during your medical emergency further substantiates our denial.
Out-of-Network Services:
As stated previously, City General Emergency Department is not part of our network. While we understand that DiscountCare Clinic is 25 miles away and does not operate ambulances, the choice to seek care at a non-network facility remains inconsistent with your plan’s cost-saving guidelines. Our analysis indicates that driving oneself, despite injury, or calling a rideshare service might have provided a viable and more affordable alternative.
Policy Exclusions on Firearm-Related Injuries:
Your plan explicitly excludes coverage for injuries resulting from “unapproved use of firearms.” As no evidence was provided to confirm the shooting was accidental or unavoidable, we are unable to overturn this aspect of the denial.
Next Steps:
This decision is final. You may choose to escalate your appeal to the Independent Medical Review Board (IMRB) at your own expense. If the IMRB overturns our decision, you may be eligible for partial reimbursement minus a $5,000 “Claim Reconsideration Fee.”
We encourage you to consult our Member Handbook to better understand your plan benefits and avoid similar misunderstandings in the future. Should you find your current coverage unsatisfactory, we invite you to explore our new UHC UltraBasic plan, which offers even fewer benefits at an even lower premium.
Sincerely and in good health,
UnitedHealthCare
P.S. Please note: Our appeals process is designed to promote proactive healthcare decision-making. While this unfortunate incident did not meet policy requirements, we commend your efforts to stay alive and wish you a speedy recovery.
