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  1. #1
    sugarpuddin is offline Junior Member
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    When does a dental issue become a medical issue?

    What is the name of your state? Oklahoma

    Can someone please tell me when a dental issue becomes a medical issue?

    I have had problems getting a bone graft and dental implants approved through my health insurance. The first denial I received stated it was not a covered benefit because it was TMJ. After appealing the decision and pointing out coverage for TMJ disorders, it was denied again, with the insurance provider stating it is a dental issue.

    In the second denial the provider stated I could bring civil action as allowed in the ERISA Act of 1974. I plan to do so, but really need to know the answer to my question. Any help or guidance in this matter is greatly appreciated.
  2. #2
    Beth3 is offline Senior Member
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    The answer depends entirely upon what medical conditions are listed as ineligible/not covered in the group health plan document. It sounds like the medical plan excludes TMJ and related expenses from coverage which is perfectly legal for the insurer to do.
    A person, who is nice to you, but rude to a waiter, is not a nice person. (This is very important. Pay attention. It never fails.)
  3. #3
    sugarpuddin is offline Junior Member
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    Thank you for responding. I apologize for not getting back before now. After changing insurances at the first of the year I was able to have the much needed surgery under my medical coverage, not dental. I am now 3 weeks post-op.

    From what I can tell from the member handbook from my previous provider, this should have been covered, but it is very difficult to determine. I had an accident 16 years ago and suffered severe head injuries. The bone grafting was medically necessary and is considered to be reconstructive. I had 3 letters, one from the surgeon, a dentist, and my medical doctor, there was ample evidence that this was not a dental issue. I have a strong feeling it was denied because the provider was no longer going to be offered in my employee benefits and they just didn't want to pay out the kind of money this surgery is costing.
  4. #4
    cbg
    cbg is offline Senior Member
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    A dental issue becomes a medical issue when the terms of the policy say it does.

    This is not a legal issue; it is a contractual issue.

    Many medical plans exclude the type of procedure you describe. The fact that is is not considered a dental issue in your case does not obligate them to cover the procedure if it is considered an exclusion.
  5. #5
    lkc15507 is offline Member
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    Sugarpuddin

    Although there is not enough information in your post to determine the situation, I can say this. I have never run across a situation in which dental implants are considered medical. Every plan I have ever reviewed would only cover repair of natural teeth resulting from an injury. Even then, that is often time limited. Replacement with implants 16 years later is almost certainly going to be considered a dental procedure by virtually any insurer. As far as the bone graft that you mention, its purpose is not clear from the post, but I can say that if the purpose of the graft is to structurally repair the bone to receive the implants (which is often needed), then its purpose would be considered dental as well. I know it's difficult for many people to understand, but having teeth is simply not considered a medical necessity. If you have followed your appeal process completely and still feel the determination in error, I think that your best bet is to ask the insurer to provide all documentation used in the determination process and then find an independent physician review organization to review your records. Although costly, I think it will be cheaper than a lawsuit that I think is doomed to fail. I am a nurse and I review medical records and plans for coverage determinations daily. I truly suggest doing your homework well before starting expensive legal actions. As far as your physician and dentist, they are advocating for you to have the procedure and ensure themselves payment at the same time. They have every motivation to make a case to get the procedure covered under medical benefits since dental plans usually have much less coverage. But, the physicians do not determine the contractual language of the health plan. The fact that your provider is no longer going to be a contracted “network” provider is probably a non-issue or at worst a minor issue for your insurer and unlikely to be the reason for an “arbitrary and capricious” determination that risks legal action. If the service were a covered service and you went to a non-network provider, more than likely they would simply apply a reduced benefit. Again, I urge you to do your homework well, but I suspect that your insurer’s determination is absolutely correct based on norms. Sincerely, lkc15507
  6. #6
    sugarpuddin is offline Junior Member
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    Thank you for your insight to my ordeal. Here are a few more pieces of information for you to ponder:

    The need for bone grafting was not just to prepare for the implants. And it was not just so I would "have teeth." I had 1 mm of bone left, which was "razor sharp" and have lived in constant pain from skull and facial fractures. I have not been able to eat solid food for several years, which in turn has caused other medical issues. I have been on no less than 20 different medications in the last 2 years to alleviate the pain to no avail. Not to mention the multitude of pills and surgeries in the past. I have facial paralysis which makes it virtually impossible to wear dentures (which I tried desperately for 7 years to do. I have had 3 sets of "teeth" since February 1998.) I endured "migraine like" pain 24/7 for 26 months, with no ease, and was told after an MRI that there was nothing physically wrong with me, I needed a psychiatrist. WRONG!!! Most people do not understand, or better yet, do not want to understand the type of pain I have endured. Until it happens to you or a loved one, you won't know. This has been my own personal hell and given what I have gone through, I believe I have held up pretty well.

    I did not ask for this procedure for vanity purposes, I asked for it for sanity purposes. I am only 40 years old and have a family history of longevity. (My grandmother just this year passed away at the age of 88). I can't live for another possible 48 years in constant pain, sixteen and a half have been too many. If something can be done to take the pain away, then it very well should be.

    It is rather strange that my "new" insurance provider, which I have both dental and health coverage with, covered the procedure under medical, not dental. This provider happens to be the same one I had 16+ years ago when I had my accident. Please do not try to sell me on the idea that the doctor only had his own interest in mind, because he certainly did not. Also, my previous provider had no problem paying for me to get addicted to hard narcotics rather than have surgery. They did finally pay for a co-worker to have much needed surgery after a celebrity died from the same problem. Non-issue or minor issue, I think not. This entire ordeal has cost me tremendously, and I do not mean just monetarily.
  7. #7
    cbg
    cbg is offline Senior Member
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    Sugarpuddin, no one is denying the medical necessity. But there are a few things I think you don't fully understand yet.

    1.) This procedure is considered a medical, not a dental, procedure on next to all medical and dental plans. I have been working with medical and dental plans for twenty five years and I have NEVER seen this procedure covered on the dental plan instead of the medical. It's not something that your insurers are doing to try to avoid payment.

    2.) This procedure is EXCLUDED from about 2/3rd of the medical insurance plans in my experience. The fact that it is considered a medical procedure does not guarantee that it is a covered procedure. Other medical procedures are no doubt excluded from your plan as well. It's a rare medical policy that will cover EVERY procedure that could possibly be performed, and if such a policy did exist, the cost would be prohibitive.

    3.) If the procedure is excluded from your plan, then regardless of whether it is medically necessary or not, the insurers have no legal obligation to pay it.
  8. #8
    sugarpuddin is offline Junior Member
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    O.K., perhaps I don't understand all of the formalities of this policy. I do however understand paying $400 a month for medical insurance and I understand being denied the chance of a less painful life. I have no choice but to take the providers offered by my employer, they won't let me take the benefit allowance and get my own insurance. Seems like the least the provider could do is provide. I read the policy several times, it is ambiguous at best. There are 3 places within one section that state TMJ is covered when it is medically necessary. I have been treated for Trigemenal Neuralgia for 2 years, not TMJ. The insurance company is the one who placed that label on it, then after having the treatment coverage pointed out to them, they change their story to it being a dental issue. I did have TMJ surgery 9 years ago and paid for it out of my own pocket, trust me, I know what TMJ feels like. I asked for all the paperwork they used to make their decision with, I got a 160 page fax that made absolutely no sense to me. What little I was able to decipher shows that my doctor was not allowed to provide more information. He was given until 5 p.m. a certain day, but the decision was made at 3:30 pm that same day. How can a decision be made properly when all evidence is not allowed? I'm telling you, I have been royally screwed by this company. Sad thing is, I stayed with them after they denied me the first time. In all, this procedure was denied 3 times, but the first time I got nothing in writing. When I sent a letter to the company they swear they never received it, even though it was sent in a business reply envelope and had other requests in it that were taken care of immediately. They received it, they just didn't want to admit they were wrong and still don't want to. I could alomost understand being denied if I had only been insured for a few months, but I had this company 4 and a half years. So much for loyalty to your customers. Yes, I am cynical, I have to be or I will lose sight of myself. The pain has been unbearable and my losses have been great. I deserve to be treated better and I am going to pursue justice.

    Thank you for letting me rant...

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