UnitedHealthcare Appeal Success Stories

Sarah's $127,000 Cancer Treatment Victory

The Denial

Sarah, 51, was diagnosed with stage III breast cancer. Her oncologist recommended immunotherapy (pembrolizumab/Keytruda) in combination with chemotherapy—a treatment FDA-approved and recommended by NCCN guidelines for her specific cancer type.

UnitedHealthcare denied the claim as "experimental and investigational," claiming the combination therapy wasn't proven for her cancer subtype.

Why This Was Wrong

• FDA approved pembrolizumab for triple-negative breast cancer in 2020
• NCCN guidelines listed it as Category 1 (highest level of evidence)
• Peer-reviewed studies showed significant survival benefit
• UHC's own medical policy supported coverage when NCCN recommends treatment

Sarah's Strategy

1. Day 1-5: Requested UHC's specific medical policy on immunotherapy
2. Day 6-15: Oncologist wrote detailed letter citing:
   • FDA approval date and indication
   • NCCN Category 1 recommendation
   • Three peer-reviewed studies from major journals
   • Sarah's specific tumor characteristics making her ideal candidate
3. Day 16: Filed internal appeal with:
   • Oncologist's letter
   • Copies of FDA approval documents
   • NCCN guidelines excerpt
   • Peer-reviewed studies
   • UHC's own policy showing they cover NCCN-recommended treatments
4. Day 17-30: Internal appeal pending
5. Day 31: Internal appeal denied with same reasoning
6. Day 32: Immediately requested external review through state Department of Insurance
7. Day 33-52: External review process
   • Independent oncologist reviewed case
   • Reviewer agreed treatment met medical necessity
8. Day 52: APPROVED by external reviewer ✓

Key Takeaways

• ✅ Don't accept "experimental" label without checking FDA approval and clinical guidelines
• ✅ Use UHC's own medical policies against them
• ✅ External review overturned what UHC wouldn't reverse internally
• ✅ Detailed physician documentation with evidence was crucial

Outcome: Sarah completed her immunotherapy treatment. She is now in remission, 18 months cancer-free.

James' $43,000 Emergency Surgery Reversal

The Denial

James, 38, experienced severe abdominal pain while traveling. He went to the nearest ER, which happened to be out-of-network. Diagnosis: acute appendicitis requiring emergency surgery.

UHC denied the $43,000 claim, stating:

• Hospital was out-of-network
• Claim they weren't notified (impossible during emergency)
• Alleged appendicitis "wasn't a true emergency" because it could have been monitored

Why This Was Wrong

• Federal law requires emergency coverage regardless of network
• Prudent Layperson Standard: severe abdominal pain warrants ER visit
• ER physician documented emergency condition
• Surgery was performed same day due to medical necessity

James' Strategy

1. Day 1-3: Gathered all ER records showing:
   • Triage notes documenting severe pain
   • CT scan showing acute appendicitis
   • Surgeon's note indicating emergency surgery needed
   • Pathology report confirming inflamed appendix
2. Day 4: Filed internal appeal citing:
   • Prudent Layperson Standard (what reasonable person would consider emergency)
   • Federal emergency coverage requirements
   • State law prohibiting out-of-network emergency denials
3. Day 5: Simultaneously filed complaint with state Department of Insurance
4. Day 6-19: Internal appeal and state investigation pending
5. Day 20: State DOI contacted UHC about complaint
6. Day 21: UHC reversed denial and approved full $43,000 ✓

Key Takeaways

• ✅ Emergency care must be covered regardless of network—federal law
• ✅ Use Prudent Layperson Standard: what you knew at time of ER visit, not final diagnosis
• ✅ State DOI complaint created regulatory pressure
• ✅ UHC reversed quickly when regulator got involved

Outcome: James paid $0 out-of-pocket. Claim processed as in-network emergency.

Maria's $31,000 Mental Health Parity Win

The Denial

Maria, 29, needed residential mental health treatment for severe depression and suicidal ideation. Her psychiatrist recommended 30 days residential treatment.

UHC approved only 10 days, claiming:

• "Medical necessity" only supported 10 days
• Outpatient treatment would be sufficient after 10 days
• Additional days not "appropriate level of care"

Why This Was Wrong

• UHC was applying stricter criteria to mental health than physical health
• Psychiatrist documented why 30 days medically necessary
• Equivalent physical health condition (e.g., cardiac rehab) would get full 30 days
• Violated Mental Health Parity and Addiction Equity Act (MHPAEA)

Maria's Strategy

1. Day 1-7: Psychiatrist wrote detailed letter:
   • Documented suicide risk requiring monitored environment
   • Explained why 10 days insufficient for stabilization
   • Treatment plan showing 30-day program structure
   • Evidence of failed outpatient treatment attempts
2. Day 8: Maria's attorney sent MHPAEA demand letter to UHC:
   • Requested documentation of how UHC applies same standards to physical health
   • Cited federal parity law violations
   • Threatened DOL complaint and litigation
3. Day 9-30: Filed internal appeal with parity violation allegations
4. Day 31: Internal appeal denied
5. Day 32: Requested external review
6. Day 33: Filed complaints with:
   • Department of Labor (ERISA/parity violation)
   • State Department of Insurance
7. Day 34-60: External review process ongoing
8. Day 61: Before external review decision, UHC reversed denial and approved full 30 days ✓

Key Takeaways

• ✅ Mental Health Parity Act is powerful—use it
• ✅ Ask how UHC would treat equivalent physical health condition
• ✅ DOL complaints for parity violations get UHC's attention
• ✅ Legal representation helped but isn't always necessary

Outcome: Maria completed 30-day residential treatment. She's now stable and thriving in outpatient therapy.

Robert's $28,000 NaviHealth Reversal

The Denial

Robert, 76, had hip replacement surgery. Hospital discharge planner recommended 21 days skilled nursing for rehabilitation.

UHC's NaviHealth AI system approved only 7 days, claiming:

• Algorithm predicted Robert could do therapy at home after 7 days
• "Recovery timeline" for hip replacement was 7-10 days
• Skilled nursing "not medically necessary" beyond 7 days

Why This Was Wrong

• Robert lived alone in two-story home with stairs
• No family nearby to assist with care
• PT/OT notes showed need for continued skilled therapy
• NaviHealth algorithm ignored individual circumstances
• Medicare SNF coverage criteria met for 21 days

Robert's Strategy

1. Day 1: Received denial on Day 7 of SNF stay
   • Immediately requested expedited appeal (continuing services)
   • Requested continuation of benefits during appeal
2. Day 2-3: Gathered documentation:
   • Surgeon's letter explaining 21-day recommendation
   • PT/OT notes showing ongoing progress but continued need
   • Documentation of home environment (stairs, no caregiver)
   • Functional assessment showing ADL dependencies
3. Day 4: Submitted appeal specifically challenging NaviHealth:
   • Requested physician review, not AI
   • Cited NaviHealth lawsuits and known over-denial issues
   • Provided individualized clinical justification
   • Referenced Medicare SNF coverage requirements
4. Day 5-7: UHC physician reviewer (not algorithm) examined case
5. Day 8: UHC approved additional 14 days (total 21 days) ✓

Key Takeaways

• ✅ NaviHealth denials can be reversed—demand physician review
• ✅ Document your individual circumstances (home environment, support system)
• ✅ Expedited appeal kept Robert in SNF during appeal
• ✅ Citing NaviHealth problems helped discredit the AI denial
• ✅ Functional assessments and therapy notes were crucial evidence

Outcome: Robert completed 21 days skilled nursing and returned home safely. He's now independent with ADLs.

Linda's $89,000 Spinal Surgery Authorization

The Denial

Linda, 54, needed spinal fusion surgery for severe degenerative disc disease causing debilitating pain and neurological symptoms.

UHC denied prior authorization claiming:

• "Not medically necessary"
• Conservative treatment not adequately tried
• Insufficient documentation of failed alternatives

Why This Was Wrong

• Linda had 18 months of conservative treatment (PT, injections, medications)
• MRI showed severe disc degeneration with nerve compression
• Neurologist documented progressive neurological deficits
• Met all criteria in UHC's spinal surgery coverage policy

Linda's Strategy

1. Day 1-5: Requested UHC's spinal surgery medical policy
2. Day 6-10: Neurosurgeon compiled comprehensive documentation:
   • Timeline of conservative treatments (18 months)
   • Records of failed PT, epidural injections, medications
   • MRI reports showing disc herniation and stenosis
   • Neurological exam findings
   • EMG/nerve conduction studies
3. Day 11: Filed appeal with comparison chart:
   • Column 1: UHC's coverage criteria
   • Column 2: How Linda met each criterion
   • Column 3: Supporting documentation reference
4. Day 12-30: Internal appeal review
5. Day 31: UHC requested additional information (pain diary, functional limitations)
6. Day 32-35: Linda submitted:
   • 3-month pain diary
   • Employer letter about work limitations
   • Spouse's letter about ADL assistance needed
7. Day 40: UHC physician reviewer requested peer-to-peer call with neurosurgeon
8. Day 42: Neurosurgeon and UHC reviewer discussed case
9. Day 45: APPROVED ✓

Key Takeaways

• ✅ Create comparison chart: UHC criteria vs. your evidence
• ✅ Document conservative treatment thoroughly (dates, providers, outcomes)
• ✅ Include objective findings (imaging, nerve studies) not just pain reports
• ✅ Functional impact evidence (work, ADLs) strengthens case
• ✅ Peer-to-peer physician call can be turning point

Outcome: Linda had successful spinal fusion. Six months post-op, she's pain-free and back to work full-time.

David's $156,000 Transplant Coverage Win

The Denial

David, 48, needed kidney transplant. His doctors recommended a specific transplant center with expertise in his complex case (he had prior abdominal surgeries complicating transplant).

UHC denied coverage because:

• Transplant center was out-of-network
• Claimed in-network centers were "equally qualified"
• Refused to grant gap exception

Why This Was Wrong

• Recommended center had specific expertise David needed
• In-network centers declined to take David's case due to complexity
• Network inadequacy: no in-network center with required expertise
• Life-saving procedure should be covered at in-network rates when network inadequate

David's Strategy

1. Day 1-10: Documented network inadequacy:
   • Letters from 3 in-network transplant centers declining case
   • Each letter cited complexity as reason for decline
   • Nephrologist letter explaining why specific center needed
2. Day 11: Requested gap exception (out-of-network coverage at in-network rates)
3. Day 12-25: UHC denied gap exception
4. Day 26: Filed internal appeal with network adequacy argument:
   • State law requires adequate provider networks
   • No in-network center willing/able to perform surgery
   • UHC must cover at in-network rates when network inadequate
5. Day 27: Filed complaint with state Department of Insurance for network adequacy violation
6. Day 28-60: Internal appeal pending
7. Day 61: Internal appeal denied
8. Day 62: Requested external review AND continued pursuing state DOI investigation
9. Day 63-85: External review process
10. Day 75: State DOI contacted UHC about network adequacy complaint
11. Day 86: Before external review decision, UHC approved gap exception ✓
12. Day 89: Formal approval letter: out-of-network center covered at in-network rates

Key Takeaways

• ✅ Network adequacy exceptions available when no in-network provider can treat you
• ✅ Get written documentation from in-network providers declining care
• ✅ State DOI network adequacy complaints create regulatory pressure
• ✅ File external review AND state complaint simultaneously
• ✅ For complex/rare conditions, specialist expertise argument is strong

Outcome: David had successful kidney transplant at specialized center. All costs covered at in-network rates. He's thriving with new kidney.