PPACA Pediatric Dental and Wisdom Tooth Extraction

[sengsational]

Has anyone been able (or tried) to get their PPACA policy to cover "third molar" (aka wisdom tooth) extraction for their age <19 kid?

I resisted having my daughter's wisdom teeth removed, but she started having impaction issues, so since she was less than 19 at the time, and the policy said (extracted salient parts):

Pediatric Dental Services (this benefit is only available for members up to age 19):
Basic and Major Services -
* Simple Extractions
* Surgical removal of teeth
* Anesthesia limited to deep sedation and IV when clinically necessary and related to covered complex surgery

I thought "How can they wiggle out of that?" Well, they (BCBSNC) are trying mightily to do just that.

I've done a little searching and found a few pre-passage (of the PPACA) discussions that said that there was a wish that there was more guidance on the more expensive procedures (like wisdom tooth extraction). Apparently the law says "medically neccesary". Maybe that's the wiggle room? My thinking is that if one insurance company is paying for certain procedure codes (involving impaction of wisdom teeth) and another is not, then one of the insurance companies is messing up.

Any experience out there, or hints for finding a precident?

 

[sengsational]

BTW, the diagnosis codes are 520.6, 523.4, 524.31. The treatment codes (procedure codes) are D7240, D9220, D7220, D7210.

 

[MRG]

Has anyone been able (or tried) to get their PPACA policy to cover "third molar" (aka wisdom tooth) extraction for their age <19 kid?

I resisted having my daughter's wisdom teeth removed, but she started having impaction issues, so since she was less than 19 at the time, and the policy said (extracted salient parts):

I thought "How can they wiggle out of that?" Well, they (BCBSNC) are trying mightily to do just that.

I've done a little searching and found a few pre-passage (of the PPACA) discussions that said that there was a wish that there was more guidance on the more expensive procedures (like wisdom tooth extraction). Apparently the law says "medically neccesary". Maybe that's the wiggle room? My thinking is that if one insurance company is paying for certain procedure codes (involving impaction of wisdom teeth) and another is not, then one of the insurance companies is messing up.

Any experience out there, or hints for finding a precident?

I'd try to get the dentist/oral surgeon to write you a letter saying the procedure was "medically necessary". That might change their mind. With the codes that might imply certain things, sometimes they code it incorrectly. Good luck.

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[sengsational]

After they sent the "final determination" where rejected all of the procedures, I took one of the actions that they're required by legislation to print in the denials: request all documents that allowed them to arrive at this denial.

Then, as if my magic, it looks like they are no longer fighting the extractions, and are only fighting the anethesia (although I haven't confirmed that a check was mailed to the surgeon yet).

This is a scam by Blue Cross Blue Shield of NC: deny claims and hope the customers don't pursue it. Why does BCBSNC pursue a policy of scamming customers like this? Why not just define and price a policy where they can honor the terms of the policy?

 

[rodi]

I'm still trying to figure out how the ACA minor children dental coverage works. My kids are (as of 1/1/2015) on an exchange plan through covered CA. In theory that includes dental. We have Kaiser permanente - which does NOT have dental. I've been all over the Kaiser website and all over the covered CA website. I asked our family dentist.... no one knows how this coverage works.

I found a reference to kaiser small business plans through the ACA using delta dental - but couldn't find anything about individuals.

 

[sengsational]

My "Blue Book", the plan description that BCBS NC sends out to customers, has it described right there next to all the medical and prescription stuff.

 

[rodi]

I haven't gotten squat from Kaiser... Perhaps because I was already a customer, just a new plan through the ACA now..

 

[MRG]

sensational, glad your persistence paid off. If you really believe it's a scam report it to your state insurance commission. When they get enough complaints they do investigate.

From some prior experience I've seen how these processes work. Humans are seldom involved, until a complaint comes in. Many insurance companies outsource claims processing. So you have multiple vendors involved that have to have their software handling the message format, claim, and codes the same correct way. The message and the content frequently change due to new rules etc. The default if there's an error(like a code one system doesn't handle) is claim denied. A human typically doesn't review those unless you complain.

Your experience makes a great point, be diligent and fight. Many times you will win. I'm not defending how they work, IMHO that type of issue should be caught in QC, but that doesn't always happen.


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[athena53]

If you really believe it's a scam report it to your state insurance commission. When they get enough complaints they do investigate.

This is good advice for any disagreement with an insurer. Certainly approach them first and give them a chance to resolve your issue, but if you believe you have a valid claim and they're just denying it because they hope you'll go away, telling them that you plan to take it up with the Insurance Commissioner if they don't come through in X days usually wakes them up. Every state has an Insurance Commissioner although they may go by some other title.

Years ago I had one insurer just sit on a claim for DH's hearing aids (we had filed a claim including receipts, policy definitely covered them up to $1,500). I couldn't get a response out of them till I pulled the Insurance Commissioner card. Then they paid the claim.