Understanding Denial of Surgery for Severe Pectus Excavatum: Seeking Guidance from Industry Experts
Navigating the complex world of healthcare insurance can be daunting, especially when it involves critical medical procedures for our loved ones. I’m reaching out to share our experience and seek insights from those familiar with the industry regarding a recent surgery denial for our son.
Our son has been diagnosed with pectus excavatum, a condition characterized by a deformity of the chest wall that can significantly impact the heart and lungs. His Haller Index is measured at 5.8, placing him squarely in the severe classification according to clinical guidelines. To provide context, the Haller Index categorizes pectus excavatum severity as follows:
- Normal: < 2.0
- Mild: 2.0 – 3.2
- Moderate: 3.2 – 3.5
- Severe: > 3.5
An MRI indicated that our son’s lungs are compressed and his heart is displaced. Consequently, a pediatric cardiothoracic surgeon recommended that he undergo surgical intervention now, during his teenage years when recovery tends to yield the best outcomes and potential long-term complications can be mitigated.
Despite these medical recommendations, UMR (a subsidiary of UnitedHealthcare) denied the preauthorization request for his surgery, arguing that it is not deemed medically necessary because his lung capacity does not fall below a specified threshold.
It’s important to note that our son is an endurance athlete, participating in competitive swimming and cross-country running. The surgeon clarified that while his lung function appears average, it is predominantly due to his rigorous training regimen, which effectively masks the severity of his condition. Additionally, he has experienced fainting spells that have been documented throughout his evaluations—an alarming symptom that underscores the gravity of his situation.
At present, we are in the process of appealing the decision. However, we are uncertain if the review will adequately consider several critical factors, such as:
- Functional limitations vs. measured lung volume
- Long-term health risks associated with untreated compression
- Psychosocial implications, which have been significant for our family
It has come to my attention that some insurance companies may routinely deny claims related to pectus excavatum unless very specific criteria are met. Is this a common practice with UMR/UnitedHealthcare? I
