Insurance told me they'd cover me, I got the procedure done, now they say they won't?

Question

About 3 months ago I went to the dentist for the first time in about 7 years because I had been having horrible jaw pain and figured I had a bad tooth. Turns out, it was my wisdom teeth, which were fully impacted and developing cysts around them and deteriorating my jaw bone.

My dentist told me I needed to get them out ASAP, and referred me to a maxillo facial surgeon. I called my insurance company first to make sure it was covered, they told me I would have to pay a $300 deductable and they cover the rest.

So I went, had my teeth removed and went through the week of excrutiating recovery. 3 weeks after I get my teeth out I get a letter from my insurance company saying that it in fact will NOT pay for my wisdom teeth removal because it does not cover procedures done on NORMAL, HEALTHY, FUNCTIONING teeth (I do not understand how they were normal or functioning, but oh well) and that I owe this surgeon $1598.

What went wrong and is there anything I can do about it?

Who do I call?

Thanks

Answer 1

Call your insurance company, and tell them you wish to protest their decision.  They will review your case, and may or may not find in your favor.  If they do not find in your favor, get a hold of your state insurance commissioners office (or equivalent) and request a hearing.

In the mean time, contact the surgeon and let them know what the situation is, so you do not go into collections in case the process is slow.

Good Luck!  

Answer 2

Yeah, that's weird.  I would actually call your dentist and tell him/her about it.

They may have presented it to the insurance co. wrong.

Answer 3

It sounds like there may have been a problem with the way your surgeon's claim was coded.

Normally, full bony impacted wisdom teeth would be eligible for coverage under a medical policy.

Since the rejection stated "normal, healthy, functioning teeth," my best guess is that the wrong diagnosis code was billed on your claim.  (The diagnosis code on a medical claim indicates what the procedure was done for...there is a specific diagnosis code for full bony impacted wisdom teeth.)

I would ask the surgeon and/or the insurer if that's what the problem is.  If so, its a relatively simple fix.  All the surgeon's office has to do is provide a corrected code.  You don't need to go through an appeal process or anything like that.

If its not the diagnosis code that's causing the problem, then you'd have to ask about the appeals process.  But seriously...I'd make a phone call and ask about the diagnosis code first.

Answer 4

You can go back to the surgeon, and ask fi they were normal, healthy, functioning teeth.  If he says no, get it in writing, and file an appeal with your insurance company.

If he says yes, file a complaint with your state insurance commissioner.

Answer 5

~~Contact the surgeon who performed the procedure and tell them why your claim was denied. The dentist who referred you to the surgeon as well as the surgeon, need to call or submit letters outlining the medical necessity. It does not sound as if your insurance was ever made aware of the medical problems that warranted the surgery. Once they communicate this to the insurance company, they should cover it.~~

Answer 6

I would contact your state's bureau of insurance. I am sure there are other places you can contact. It may have been in how, it was written up by your dentist.