Need braces? United Healthcare might help cover the cost. Sometimes, orthodontia isn’t just cosmetic. It can be medically necessary. This means it fixes problems that affect your health. You might need a special letter to get coverage for it. This letter explains why your braces are needed for medical reasons.
Writing to insurance companies can be tricky. It’s hard to know what to say. Don’t worry, we’ve got your back. We’ll share some letter templates.
These samples will make things easier. You can use them as a starting point. Just tweak them to fit your situation. Let’s get started!
Sample Letter To United Healthcare Requesting Medically Necessary Orthodontia
[Your Name]
[Your Address]
[Your City, State, Zip Code]
[Your Phone Number]
[Your Email Address]
[Date]
UnitedHealthcare
[Insurance Company Address]
[Insurance Company City, State, Zip Code]
Subject: Pre-Authorization Request for Medically Necessary Orthodontia – [Patient Name], [Patient ID Number]
Dear UnitedHealthcare,
I am writing to request pre-authorization for orthodontic treatment for my [son/daughter/dependent], [Patient Name], whose member ID number is [Patient ID Number].
[Patient Name] has a severe malocclusion that affects their ability to [chew properly/speak clearly/maintain proper oral hygiene]. The malocclusion is classified as [specific classification, e.g., Class II malocclusion with severe overjet]. This condition is causing [specific symptoms, e.g., pain in the jaw joint, difficulty eating, speech impediment].
Enclosed you will find supporting documentation from [Patient Name]’s orthodontist, Dr. [Orthodontist’s Name], which includes a comprehensive treatment plan, detailed diagnostic records (including X-rays and photographs), and a narrative explaining the medical necessity of the proposed orthodontic treatment. Dr. [Orthodontist’s Name] believes that orthodontic treatment is essential to correct [Patient Name]’s malocclusion and alleviate the associated symptoms. Without treatment, the condition is likely to worsen, potentially leading to more serious health problems in the future.
We understand that orthodontic treatment is not always covered by insurance, but we believe that [Patient Name]’s case warrants an exception due to the significant impact on their health and well-being. We kindly request that you carefully review the enclosed documentation and approve this pre-authorization request.
Thank you for your time and consideration. We look forward to hearing from you soon.
Sincerely,
[Your Name]
How to Write Sample Letter To United Healthcare Requesting Medically Necessary Orthodontia
Subject Line: Clarity is Paramount
- Employ a direct subject line: “Prior Authorization Request – Medically Necessary Orthodontia – [Patient Name] – [Member ID]”.
- Subtlety is not your friend here. Be explicit and leave no room for misinterpretation.
Salutation: Address with Authority
- Avoid generic greetings. Aim for “Dear United Healthcare Medical Director,” if possible.
- If a specific contact person is known, utilize their name; otherwise, this is an acceptable convention.
- Maintain a professional tone right from the outset.
Introduction: State Your Case Concisely
- Begin by unequivocally stating your purpose: “This letter constitutes a formal request for prior authorization for medically necessary orthodontic treatment for [Patient Name], Member ID [Member ID].”
- Briefly allude to the functional impairment necessitating treatment. For example, mention difficulty chewing or speech impediments.
Body Paragraph 1: Detail the Malocclusion
- Thoroughly describe the patient’s malocclusion. Include specific diagnostic codes (ICD-10) and orthodontic terminology.
- Elaborate on the severity of the condition. Is it a Class II Division 1 malocclusion with excessive overjet? Be precise.
- Quantify the measurements whenever feasible (e.g., “Overjet measures 9mm”).
Body Paragraph 2: Articulate Functional Impairment
- This is pivotal. Explain, in detail, how the malocclusion is deleteriously impacting the patient’s functional abilities.
- Consider difficulties in mastication, deglutition, speech articulation, or temporomandibular joint (TMJ) dysfunction.
- Provide concrete examples. “The patient experiences pronounced difficulty biting into apples and other firm foods due to the anterior open bite.”
Body Paragraph 3: Substantiate Medical Necessity
- Explicitly connect the orthodontic treatment to the alleviation of the functional impairment.
- Expound on how the proposed treatment will remedy the specific issues outlined above.
- Bolster your argument by referencing peer-reviewed literature or clinical guidelines that support the medical necessity of orthodontic intervention in similar cases.
Closing: Demand Deliberation and Specify Enclosures
- Conclude with a polite but firm request for a comprehensive review of the case.
- State: “I implore you to grant prior authorization for this medically necessary treatment.”
- List all enclosed documentation: “Enclosed please find: Comprehensive orthodontic records, cephalometric analysis, photographs, and a detailed treatment plan.”
- End with a professional closing, such as “Sincerely,” followed by your name and credentials.
Frequently Asked Questions: United Healthcare Orthodontia Medical Necessity Letters
This FAQ section addresses common inquiries regarding letters requesting pre-authorization for medically necessary orthodontia from United Healthcare. It aims to provide clear and concise answers to assist in the application process.
What constitutes “medically necessary” orthodontia?
Orthodontia is deemed medically necessary when severe malocclusion significantly impairs essential functions such as chewing, speech, or breathing, or when it is required as part of a broader treatment plan for a congenital or acquired condition.
What information should be included in the letter?
The letter should include the patient’s identification information, a detailed description of the malocclusion, its functional impact, the proposed treatment plan, and supporting clinical documentation such as X-rays and photographs.
Who should write the letter?
The letter is typically written by the orthodontist or dentist providing the treatment, as they possess the clinical expertise to articulate the medical necessity of the proposed intervention.
To whom should the letter be addressed?
The letter should be addressed to the specific department or individual at United Healthcare responsible for pre-authorization of orthodontic treatments, as indicated on the patient’s insurance card or policy documents.
What happens after the letter is submitted?
United Healthcare will review the submitted documentation and may request additional information. A decision regarding pre-authorization will typically be communicated within a specified timeframe, as outlined in the policy.
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