When Sarah, age 15, was told by her dentist that she needed braces, her family assumed their health coverage through a Managed Care Organization (MCO) would help. But instead, Sarah’s orthodontic claims were denied again and again, with the MCO insisting the treatment was not “medically necessary.”
Unsure how to fight the repeated denials, Sarah’s mother, Kathy, turned to Lone Star Legal Aid (LSLA) for help. Elizabeth Green, a staff attorney in LSLA’s Public Benefits Unit, filed an appeal on the family’s behalf. Despite presenting evidence, the MCO upheld its denial. Kathy reached out again, and Green agreed to represent them in a state-level appeal. Together, they gathered medical records and prepared testimony from Kathy, Sarah, and Sarah’s dentist to prove why the braces were essential.
At the hearing, Green cross-examined the MCO’s representative and argued that Sarah’s treatment should be covered. Even so, the family received another unfavorable decision. Rather than give up, Kathy asked LSLA to continue with a second-level administrative review. Green filed the appeal, and just eight days later, Kathy received the news she had been hoping for: an Administrative Law Judge (ALJ) reversed the denial and ordered that Sarah’s orthodontic treatment be approved.
With the ruling in hand, Green followed up to confirm the MCO had authorized the coverage. Soon after, Sarah was finally able to receive her braces.
Kathy expressed her gratitude to LSLA and said she hopes her family’s experience inspires others to persist when they are wrongly denied healthcare coverage. “We want others to know not to give up,” she told the team.
*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