Paul, a minor diagnosed with a rare form of brain cancer, has relied on Medicaid for years to receive specialized treatment for his eye condition. For five years, UnitedHealthcare, his Managed Care Organization (MCO), covered visits with a neuro-ophthalmologist who understood his complex needs. But without warning, UnitedHealthcare suddenly denied coverage for Paul’s annual visit, claiming his doctor was out-of-network.
Instead, the MCO recommended in-network physicians who had never treated Paul. Federal and state law require MCOs to pay for out-of-network care when medically necessary services are not available in-network. But when Paul’s mother, Nancy, contacted the recommended doctors, both confirmed they lacked the expertise to treat Paul’s condition.
Nancy filed a Fair Hearing appeal with the Texas Health and Human Services Commission (HHSC), but the officer ruled against her, stating it was not medically necessary for Paul to see an out-of-network specialist. Overwhelmed but determined, Nancy turned to Lone Star Legal Aid (LSLA) for help.
LSLA’s Public Benefits Unit accepted the case, and Staff Attorney Elizabeth Green immediately went to work. Green instructed Nancy to call the in-network neuro-ophthalmologists again and record conversations verifying they could not treat Paul. Armed with these recordings, along with letters and testimony from Paul’s treating physician, LSLA filed a second-level appeal before an Administrative Law Judge.
At the hearing, Green demonstrated why Paul’s ongoing care with his established physician was medically necessary given his rare diagnosis. The judge agreed, overturning UnitedHealthcare’s denial and ordering coverage for 12 clinical visits over the next year.
With his care reinstated, Paul can continue receiving the treatment he needs to manage his condition—and his family can focus on his health rather than fighting insurance denials.
*Name(s) 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 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. To learn more about Lone Star Legal Aid, visit our website at www.LoneStarLegal.org.
Media contact: media@lonestarlegal.org