Mother angry after UnitedHealthcare deems traumatic brain injury treatment ‘not medically necessary’ for son

GREENVILLE, S.C. (WYFF) — The family of a young man who suffered a traumatic brain injury is frustrated after UnitedHealthcare deemed their requests for rehabilitation and long-term care “medically unnecessary.”

Peyton Alvarez, 25, was riding a motorcycle in April when he veered off the road and hit a tree.

Although he was wearing a helmet, the impact was detrimental, and he suffered a traumatic brain injury.

“On April 28th, I was getting ready for work, and my phone rang. ‘We have your son Peyton, and he’s been in a motorcycle accident.’ And I was like, oh my gosh, it’s like your worst fear,” his mother, Trina Alvarez, said.

His mother said doctors told her that there was a “very good chance” that her son might never regain consciousness.

But after about two weeks, Peyton Alvarez’s eyes opened. He began responding to cues by moving his hand or trying to speak.

“I started crying. When I was talking to him, I knew he could hear me,” Trina Alvarez said.

The family, on the recommendation of Peyton’s doctors, reached out to the Shepherd Center in Atlanta, which specializes in rehabilitation for brain injuries.

The rehab center does not accept everyone, but Trina Alvarez was thrilled to hear that the center accepted her son. The family set up transportation to get him there.

But their insurance, UnitedHealthcare, immediately denied covering it, deeming the care “not medically necessary.”

Both Trina Alvarez and the hospital staff appealed the decision, citing risks of complications with his recovery.

In repeated denial letters, the insurance company upheld the decision.

A UnitedHealthcare spokesperson told WYFF a skilled nursing facility would be covered by Peyton Alvarez’s health plan and would be a “middle ground” between the current care he was receiving and the rehabilitation requested.

In a statement to WYFF, UnitedHealthcare said in part that “Mr. Alvarez’s current condition does not meet the criteria for coverage of the requested level of inpatient rehabilitation therapy.”

The rehab center does not accept out-of-pocket payments, so without insurance paying for it, Peyton Alvarez cannot receive treatment there.

“Shepherd won’t take out-of-pocket funds for their disorder of consciousness. They said years back they used to take out-of-pocket funds, and people would spend thousands and thousands of dollars and their loved one wouldn’t wake up,” Trina Alvarez said.

The Alvarez family is now seeking alternative care where they can pay out of pocket.

“This is the rest of his life. And it’s not. It’s not right. They should not be able to make that kind of decision. All of his friends would describe him as a fighter. One of the most stubborn people they’ve ever met. I can’t stop fighting for my son,” Trina Alvarez said.