chapotraphouse

Our denial is based on the following findings:

Lack of Prior Authorization: Our records indicate that you failed to obtain prior authorization before seeking care for the gunshot wound to your chest. While we acknowledge the emergent nature of the situation, our policy requires that all non-preventative services, including “unexpected chest injuries,” be pre-approved through our 24/7 Prior Authorization Hotline. Unfortunately, our hotline received no such call during your ambulance transport or at any point before your admission to the emergency room.

2. Failure to Prove Medical Necessity:

The submitted documentation does not sufficiently demonstrate that treatment for a penetrating chest wound meets the definition of “medically necessary.” Our guidelines specify that life-threatening conditions must be substantiated with a second opinion from a network provider, preferably before care is rendered.

3. Alternative Options Not Explored:

Based on our retrospective analysis, alternative, more cost-effective treatment options—such as a virtual telehealth consult or at-home first aid—were not attempted prior to your emergency room visit. We understand that you were actively “bleeding out,” but this does not exempt you from exploring lower-cost care pathways.

4. Out-of-Network Care:

The emergency room where you received treatment is not within our network. While City General is geographically closer to the location of your shooting, our network partner, DiscountCare Clinic, is only 25 miles away and equipped with staplers and gauze for such injuries.

Next Steps: You may file an appeal within 30 days if you believe this decision is incorrect. Appeals must include:

A notarized letter from the attending physician, explaining why you thought you were entitled to not bleed to death while waiting for approval. Evidence that your injuries were, in fact, serious enough to merit immediate attention, such as photos, videos, or live reenactments. We encourage you to familiarize yourself with your plan benefits and utilize in-network providers for future incidents. Please do not hesitate to reach out to our customer support team if you have questions about this

Sincerely and in good health, United Healthcare

P.S. Remember: Preventative care is the best care! If you’d like, we can help you schedule your annual physical or connect you to a mindfulness seminar to prevent future traumatic injuries.