What is the name of your state? OK
We pay a seperate premium for our dental insurance, yet both our health and dental are with the same company, through employer. We are free to choose any dentist we want, as our dental insurance is not "PPO'd", unlike our health insurance.
Went to the dentist for 6 month check up, received a referral to get wisdom tooth extracted (it was already coming through, and was impacting another molar). Dentist refered me to oral surgeon next door. Got the procedure done, then come to find out the insurance company will not cover it, because this oral surgeon is 'out of network' and the amount due is smaller than our deductible for OuN docs.
We've tried to appeal it for the following reasons:
1: It was a dental procedure. In fact, our benefits say extraction of (partially) erupted and impacted wisdom teeth (my case) are covered under "basic restorative services" and "basic restorative services" are part of our dental insurance. Since we are free to choose anyone we want for dental procedures, the "in network/out of network" issue is not applicable.
2: The codes used by the oral surgeon's office are dental codes (according to them), not 'medical' codes.
They denied our appeal (which consisted of phoning the insurance company, and getting them to review it). We are planning on now appealing it the 'formal' way, by sending them a letter, but before we do so, I would appreciate any feedback you might have.
Are we right, and should the insurance company cover the 80% (after $50 deductible met)? Or are they right, and can they deny the claim because the oral surgeon was "OoN" (which we don't see as applicable here)?
Thanks a bunch.