Dental or Medical claim?

[chicklet]

What is the name of your state? GA.

A few years ago my husband had radiation treatments to his neck, which resulted in his salivary glands and the enamel on his teeth being destroyed. (The cancer is also gone, so we're grateful for that.) His teeth are now in terrible shape and he is in the process of having extensive dental work done (numerous crowns).

Since the dental problems are directly related to medical treatment, our dentist suggested filing a medical claim, and did so on our behalf, but the claim was denied. All our coverage is through Blue Choice.

My husband saw the dentist regularly before, during, and since the treatments, so there's no question of neglect. We also looked into the less expensive option of dentures, but because of other health issues - low body weight, slow healing, etc. - the dentist, whom we trust, does not recommend going that route.

I'd like to know if anyone else has experienced something similar and/or can suggest anything else we can do. If anyone thinks this is a lost cause or we're not entitled to coverage, I'll consider that advice too.

Thanks for any comments.

 

[cbg]

Unless your policy with Blue Cross specifically states that it will accept dental work done in connection with medical treatment, they have no liability for that work. They are not responsible for paying dental work unless the plan specifically says that they are. It is rare that a medical insurance plan will cover crowns - the only dental work I have ever seen accepted by a medical plan is the removal of impacted wisdom teeth, and not all plans will even pay that. If you have dental insurance submit the claim to them - they would have the responsibility.

 

[lkc15507]

I agree that it is not likely that dental work as a result of medical treatment will be covered under the medical plan. Medical plans will usually spell out very clearly what procedures will be covered or not. That will be explained in a section of a plan document likely headed "care of mouth, teeth, and gums", under the medical benefits section. Unless a specific situation is listed here, then any other care would fall under "dental".

Although this is not something that will help your husband at this time--unfortunately--but, perhaps it may help others. There are now dental devices that are developed for the purpose of protecting dental structures during radiation treatments to the neck / jaw area. Depending upon the actual wording of the medical plan, some times these devices may be argued as being medically necessary. Please keep this in mind if Heaven forbid, your husband should need further treatment.

I always advise that one should always READ and UNDSERSTAND their insurance coverage. If coverage is not clear, ASK. Pre-service determinations of coverage are your right.

Best to you,
lkc15507