LisaKinVA Posted January 23, 2011 Share Posted January 23, 2011 I've had two dentists, two oral surgeons, and one specialist all tell me this is really the *only* way to fix my jaw. Every other way will not only NOT fix the problem it will create MORE problems (I'm missing 7 teeth on my upper jaw, the remaining teeth either have zero cavities or the cavities they have are very minor. Before my surgery, I called the company to see what would be covered. I breathed a HUGE sigh of relief. Now, they are claiming it wasn't medically necessary. They say they will pay for the alternate treatment... a treatment that will last MAYBE 5-10 years, and completely ruin 4 more teeth on my upper jaw. (Anyone who is counting, that will leave me with 5 teeth on my upper jaw). UGH, UGH, UGH. Now, I need to postpone or cancel my surgery in a few weeks until we get the insurance straightened out. Guess what I'll be doing tomorrow. UGH, UGH, UGH! Quote Link to comment Share on other sites More sharing options...
Starr Posted January 23, 2011 Share Posted January 23, 2011 Keep fighting. I think they are all trained to say no. :( at the first go round. Quote Link to comment Share on other sites More sharing options...
fhjmom Posted January 23, 2011 Share Posted January 23, 2011 I am so sorry! I am having simialr problems. I have learned to ask for a pre-autherization of benefits vs. Just an estimate. I am scheduled for a root canal on Thursday, which is desperately needed, I am in constant excruciating pain and taking pain meds around the clock. The preauthorization came back covering the endodontic treatment, but denying the crown and rebuilding based on "this treatment must have proof of endodotic treatment in order to be covered". Ummm.... did you not read the line right above it APROVING THE ENDODONTIC TREATMENT!?! So, yeah, I agree with you! Quote Link to comment Share on other sites More sharing options...
amey311 Posted January 23, 2011 Share Posted January 23, 2011 Get names when you talk to people. Write down dates and times that you talk to them. While it might not help in the negotiations with the insurance, it will definitely help if you talk to Janice on January 24th at 2:15pm local time and she tells you that the procedure [named specifically] is a covered expense when performed in the office by Dr. Smith. If you then get further information denying said procedure, you can quote those facts and then ask what the difference was. And then say that you're going to file a complaint with the state insurance board because there seems to be some kind of fraud going on here if one employee tells you that something is covered, but another tells you something different. It's even more ideal if Janice (in the example above) can send you email or a fax detailing that conversation. And yes - I've used this exact conversation with a medical insurance program. Imagine my complete dumbfoundedness when I was told by the doctor's office that their contact at the insurance company told them the procedure was NOT covered and she was certain I was never told it would be. I then called "Janice" back and asked if she could please email or fax me the information she was looking at when she assured me, 3 hours previously, that the procedure was covered. There was a HUGE pregnant pause, and she nervously fumbled and said she must have misread. Which was interesting because I asked repeatedly, and in several different ways if it was covered and she very clearly and happily told me it was. That was the point I started the complaint filing. This was all over something that had already been done and I was now being told it wasn't covered, so the doctor's office was billing me. I then did all this phone calling and angry message leaving (I loved that the person I needed to talk to at the doctor's office was never available to take my call. The day I decided to threaten with the Insurance board, I was told she was gone for the day at 1pm, and was given her voicemail. I mentioned filing and was called back in 45 minutes. I actually said, "Interesting. I thought you were gone for the day.") I refused to pay the bill and said I'd file if another one came. Nothing ever did AND there's nothing on my credit history. THAT SAID, I have a family member who works for a major insurance company. She has told me that the company often denies first requests for payment for no reason other than to deny them. If you resubmit, they'll often be approved, but all those people who don't bother to resubmit save them money. So, don't assume that just because you've been told "no" that the final answer is "no." Quote Link to comment Share on other sites More sharing options...
LisaKinVA Posted February 10, 2011 Author Share Posted February 10, 2011 (edited) Here is the letter I wrote for my appeal... Dear Sir or Madam: You recently denied a claim on the grounds that the care provided by Dr. XXXXXXX was not medically necessary, because an alternative treatment could be used. Denial of this claim was not justified, and I am appealing the denial. The explanation of benefits did not give adequate information to establish the validity of this decision. Therefore, please provide the following information to support the denial of this treatment: 1. The name and credentials of the insurance representative who reviewed the treatment records. Also, please provide an outline of the specific records reviewed, and a description of any records that would be necessary in order to approve the treatment. 2. Any expert medical opinions that have been secured by your company regarding treatment of this nature so that the treating physician may respond to its applicability to my condition. In order to assist with this appeal, I have currently asked both Dr. XXXX and Dr. XXXX to submit their evaluation of my unique case, and why the treatment plan being undertaken is not only medically necessary, but is actually the most conservative method of treatment, with the highest likelihood of success, and has the lowest lifetime costs, without adding unnecessary, additional, future health risks. Background information. I am congenitally missing nine teeth, seven of which are on the upper jaw, and only five of which are of any concern to restore. Due to excellent oral care, I retained my primary teeth as long as possible, many years beyond their expected lifetime, and only began treatment, due to the abscess of the primary teeth. Delaying treatment for this congenital defect was no longer a viable option. Treatment Plan. Medical care standards usually require the most conservative treatment plan, that offers the greatest chance of success. However, in this case, XXXXXX is essentially demanding the most aggressive treatment plan, with the lowest chance of success, the highest expected lifetime costs, and includes a greatly increased risk of additional health complications as I age. The denial of benefits essentially state that because an alternate prosthesis “could” be used, the treatment plan that is best for me, the patient in this case, is denied. “Can” and “Should” are two very different arguments. Despite the benefits being clearly outlined in the medical plan, pre-operative phone calls to XXXXXX regarding the limitations on the procedure and the implants themselves, XXXXXX has declined to cover the implants, the surgery and the related medical procedures because they feel the two adjacent, congenitally missing teeth on the left side could be replaced by a bridge, or partial denture. However, this treatment plan was overwhelmingly rejected during consultations with two dentists, two prosthodontists, two orthodontists, and three oral surgeons. The reason the alternative suggested by XXXXXXX was rejected, and the treatment plan for dental implants initiated was for the following financial and health reasons: Cost. The minimal cost to place a bridge on the left side of my mouth averages $4,000. This bridge would meet the “minimum accepted standards” – and gives this treatment option an average of 15 years until replacement. Placing a more reliable bridge would increase the average cost to between $5,000 and $6,000. By comparison, replacing the two congenitally missing teeth with dental implants is not significantly different monetarily, and none of the implants will ever need an expected replacement. Failure and Replacement: Traditional dental bridges have a failure rate of 30% within the first 5-7 years. If the bridge fails, it usually requires even more extensive and expensive work to correct. Due to my age and health, the “minimally acceptable bridge” may require replacement at minimum, twice, making the lifetime cost of this option in excess of $12,000. By comparison, dental implants have a 95% success rate, and have no expected replacement costs. Traditional Bridge could undermine the health of surrounding teeth. In order to place a traditional bridge on the left side, a minimum of two-four healthy, caries free, healthy teeth would need to be ground down in order to accept the crowns. This puts these currently healthy teeth at higher risk for disease and decay. The standard of care in dentistry requires an attempt to preserve healthy teeth whenever possible. Bone Loss. The traditional dental bridge will not stop or prevent bone loss in the jaw. Bone loss is essentially guaranteed when teeth are missing from the jaw. A traditional bridge or denture would not restore bone loss which has already occurred, it would allow it to continue unabated. Bone loss is especially prevalent in post-menopausal women, and if left unabated by the use of a traditional bridge or denture, could very easily result in additional stress on the anchor teeth and subsequent loss of those teeth over time. Dental implants have been shown to not only stop additional bone loss, but increase the bone tissue around the teeth. While bone loss in women is still prevalent, the replacement of the missing teeth through dental implants, and good oral hygiene, substantially reduce the likelihood of bone loss that would threaten the loss of teeth in the future. Summary. As you can see, when one weighs the initial costs of a traditional dental bridge vs. the implants in this situation the actual costs for the initial placement is only slightly less with the traditional bridge. However, when one adds to that calculation the expected necessary replacements of the traditional bridge, the failure rates, and the health risks, the treatment plan proposed by XXXXXX becomes the most expensive, with the least chance of success, also resulting in compounding health issues. None of which are present with the treatment plan that was undertaken and strongly supported by two dentists, two prosthodontists, two orthodontists, and three oral surgeons. Please review this claim again. If you need further information or documentation, please inform me within 10 days. I can be reached at the following telephone numbers: Thank you for your prompt attention to this matter. Sincerely, My dentist is providing photos, documentation, statistical studies, etc. His office is being *extremely* helpful. I am very grateful. My letter will accompany the packet of information. Edited February 10, 2011 by LisaK in VA Quote Link to comment Share on other sites More sharing options...
Little Nyssa Posted February 10, 2011 Share Posted February 10, 2011 I have been through this too. Aetna is the worst!!!! Quote Link to comment Share on other sites More sharing options...
Dawn in OH Posted February 10, 2011 Share Posted February 10, 2011 I think you may have a typo. Traditional Bridge could undermine the health of surrounding teeth. In order to place a traditional bridge on the left side, a minimum of two-four healthy, caries free, healthy teeth would need to be ground down in order to accept the crowns. This puts these currently healthy teeth at higher risk for disease and decay. The standard of care in dentistry requires an attempt to preserve healthy teeth whenever possible. Quote Link to comment Share on other sites More sharing options...
Jean in Newcastle Posted February 10, 2011 Share Posted February 10, 2011 I think you may have a typo. Traditional Bridge could undermine the health of surrounding teeth. In order to place a traditional bridge on the left side, a minimum of two-four healthy, caries free, healthy teeth would need to be ground down in order to accept the crowns. This puts these currently healthy teeth at higher risk for disease and decay. The standard of care in dentistry requires an attempt to preserve healthy teeth whenever possible. "caries" is correct - it means cavities Quote Link to comment Share on other sites More sharing options...
Dawn in OH Posted February 10, 2011 Share Posted February 10, 2011 "caries" is correct - it means cavities Thanks Jean. I learn something every day. Quote Link to comment Share on other sites More sharing options...
LisaKinVA Posted February 11, 2011 Author Share Posted February 11, 2011 I chose to use the "dentist-speak" vs. the colloquial term, because I want them to understand that I am fairly well-versed as to what is going on with my mouth. :D Thanks for watching out for me :D Quote Link to comment Share on other sites More sharing options...
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