Guardian Nurses Healthcare Advocates brought new hope, health, and happiness to a patient who had lived with a severe underbite since birth.
For years, she suffered from headaches, digestive problems, and dental issues, but insurance companies denied coverage for surgery, saying that the corrective jaw surgery would be merely cosmetic, a label that dismissed her pain and struggles.
Fortunately, through her union’s health and welfare fund’s partnership with Guardian Nurses, she was able to enlist Mobile Care Coordinator Suzy Parker, RN, to her worthy cause.
“She only had two molars on the left, upper and lower, and two on the right that actually touched,” Nurse Parker explains. “Her ability to chew food was greatly impaired and impacted, and there were many types of foods she simply couldn’t eat. She had to chew everything very carefully to avoid gastric issues. She also had three teeth split right straight down the middle. And there were some words that she pronounced a little differently, which caused her young son to mispronounce them as well. On top of all that, she suffered from chronic headaches.”
Nurse Parker collaborated with the patient’s orthodontist and maxillofacial surgeon, gathering medical records, x-rays, and testimony to build a compelling case to present to the board of trustees’ appeals meeting. She has helped six patients appeal for coverage and has a remarkable success rate — she is currently batting six for six.
“When spearheading the appeal process,” she explains. “I help with getting all the medical records, make sure all of the T’s are crossed and the I’s are dotted before I send everything off to their third-party administrator, who will then review it and forward it on to the appeals committee. It’s a legal proceeding, so their attorney runs it.”
The surgeon even testified during the appeals hearing, a rarity that highlighted his dedication to the patient. Nurse Parkers thorough preparation and the testimony of the surgeon resulted in the health and welfare fund approving the surgery, acknowledging its medical necessity.
The surgery was a success. For the first time, the patient could chew properly and her chronic headaches diminished. Post-surgery, her recovery was smooth, and she expressed immense gratitude for Guardian Nurses’ support, which she described as life-changing. She now looks forward to a future free from pain.
Nurse Parker’s Advice: You can and should appeal unreasonable denials of insurance. I always say, give it a shot, right? Because all they can do is say no, and they’ve already said no.
A lot of times, they will deny treatment for something as simple as the patient didn’t do physical therapy for the issue. It just takes a doctor’s note, whether it’s already in the chart or not, saying, “This patient didn’t do physical therapy because it was going to cause too much pain or it could increase their injury.”
Advocates can help a lot. Guardian Nurses isn’t with every health and welfare fund in the country or with every company, but we can support individuals, and there are other advocates who can help, too.