May 17, 2023 by Natalie Cochran
Lone Star Legal Aid Helps 15-Year-Old Get Braces with Health Coverage Through Managed Care Organization
15-year-old Sarah’s dentist told her she needed braces. Although she had a health plan that was part of a Managed Care Organization (MCO), her orthodontic claims were denied over and over. They claimed braces are not “medically necessary.” Sarah’s mother Kathy reached out to Lone Star Legal Aid (LSLA) for assistance with an appeal.
Elizabeth Green, in our Public Benefits Unit, filed an appeal on their behalf, but the MCO upheld their decision to deny the procedure. Kathy requested assistance from LSLA again to represent her and her daughter in a state-level appeal for the denial of the procedure. Green helped Kathy obtain the proper documents needed to testify at the state level hearing. Kathy gathered medical records while Green prepped her, Sarah, and Sarah’s dentist for their upcoming hearing. They were all to testify.
At the hearing, Green argued the validity of approving the procedure, and cross-examined the appointed representative for the MCO. Unfortunately, Kathy received another unfavorable decision for the state-level hearing. Kathy told our team of attorneys and paralegals that she would like to move forward with the second level administrative review to appeal the decision from the state-level hearing.
Green filed a second level administrative review appeal. Eight days later, Sarah’s mother reached out to inform us that she had received a notice stating the Administrative Law Judge (ALJ) had reversed the decision, and Sarah’s orthodontic procedures were to be approved. Green followed up with the MCO, and they confirmed they approved it on their end.
Kathy reached out to LSLA after the case was closed to inform us that Sarah finally received her braces, and expressed she would love to share their story with others. She hopes her family’s positive outcome encourages others similarly situated to stay the course.
*Names have been changed to protect the client(s) identity.
Lone Star Legal Aid (LSLA) is a 501(c)(3) nonprofit law firm focused on advocacy for low-income and underserved populations by providing free legal education, advice, and representation. LSLA serves millions of people at 125% of federal poverty guidelines, who live in 72 counties in the eastern and Gulf Coast regions of Texas, and 4 counties in Southwest Arkansas. LSLA focuses its resources on maintaining, enhancing, and protecting income and economic stability; preserving housing; improving outcomes for children; establishing and sustaining family safety, stability, health, and wellbeing; and assisting populations with special vulnerabilities, like those with disabilities, the aging, survivors of crime and disasters, the unemployed and underemployed, the unhoused, those with limited English language skills, and the LGBTQIA+ community. To learn more about Lone Star Legal Aid, visit our website at www.LoneStarLegal.org.
Media contact: media@lonestarlegal.org
