January 7, 2024 by Natalie Cochran
Lone Star Legal Aid’s Elizabeth Green Reverses Medicare Denial for a Young Client with Rare Brain Cancer
Paul was diagnosed with a rare form of brain cancer and developed eye problems because of it. He is a minor and has been a Medicaid recipient for the last five years which has helped treat his eye condition. United Health Care, a Managed Care Organization (MCO), provided Paul with benefits throughout that time, until suddenly Paul was denied an annual visit with his neuro-ophthalmologist.
After looking into it, Paul’s mother, Nancy, found out that his eye doctor was not in the network approved by UHC. Because of this, UHC refused to cover the cost and recommended different doctors who were in their network. Paul had never been to these new doctors before. State and federal regulations require MCO’s to pay for out-of-network care for medically necessary services if they cannot provide the medical care in-network.
Nancy called the recommended doctors and they were not able to treat Paul’s condition. Nancy filed for a first level administrative appeal which is an Texas Health and Human Services (HHSC) Fair Hearing. She gave testimony that these two in-network physicians don’t have the expertise to treat Paul. Nancy verified this information and pleaded that Paul must see the physician he had been seeing for the last five years. The Fair Officer issued an unfavorable decision for Paul and stated that it was not medically necessary for Paul to see an out-of-network neuro-ophthalmologist.
Nancy called LSLA and our Public Benefits Unit accepted the case and immediately started working on a HHSC level appeal. LSLA had Nancy call and record conversations with the two neuro-ophthalmologists offices to prove that they cannot treat Paul. LSLA filed for the second level appeal also known as a Administrative Law Judge Hearing (ALJ), with the additional audio recordings as evidence.
During the fair hearing, LSLA presented extra medical letters and testimonials from Paul’s regular neuro-ophthalmologist. LSLA Staff Attorney Elizabeth Green provided information explaining why Paul’s ongoing physician is crucial for treating his severe brain cancer. The hearing officer overturned United Healthcare’s denial and made a positive decision for Paul. The officer directed United Healthcare to authorize 12 clinical visits for Paul over the next year.
*Names have been changed to protect the identity of the client(s).
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
