Appealing Denial of Coverage for Crown

[slackmax]

Sigh. I already posted about this in the topic 'dental claim for crown not immediately approved' and thanks to everyone who replied. 

Well, after being reassured by the dental staff that it would be approved, it has officially been denied. I got the letter a few days ago.  The reason for the denial is that it is 'not medically necessary' according to their guidelines.

I called the dentist office, and they say they will start the appeal by writing an appeal letter. They said the insurance company is unprofessional, and 'loses' documents that the dentist sends them. And I am the very first person who was denied due to the work being 'not medically necessary'. Great.

OK, what now? I can also file my own separate appeal. The insurance co is mailing me a form. I have 60 days to get it started. I plan to let the dentist office do the appeal for now.

The dentist office suggested I call the insurance co to  'give them heck'. I did call the ins co, but just asked them why the crown was not medically necessary. They said they could not tell me, and would not transfer me to the dental reviewer who denied the claim. If the appeal is denied, then they will let me talk to the dental reviewer.     

A third course of action is to file a complaint at the Pa Dept of Insurance.  I spoke to them and they said that if I filed a complaint, they would investigate the claim, and could cause the claim to be approved, possibly, but that if all the ins co's rules were followed, the denial would stand. IE, even if the rules weren't fair, if they were followed, then the denial stands. Ugh.

Looking back, I think I might have been able to avoid the denial by asking for a 'predetermination of benefits' for the crown. I had thought about it, but reasoned that I needed the crown, and would have to get it anyway, no matter what the predetermination said. What I did *not* think of was that had I asked for (and waited a month for, with the broken tooth) a predetermination, it may have come back saying the crown would be approved, *if* certain evidence were supplied by the dentist, as in X-rays, photographs, etc, and then the dentist could have crossed all the t's before doing the work. 

One of the things the ins co had been asking for was an xray of the tooth from the last 6 months. Whatever that means. What if you don't have an xray from the last 6 months? Out of luck? What about an xray from 9 months ago? Strange.
I was able to speak with the dental reviewer a few months ago, when they were asking for a 'narrative of medical necessity' and he mentioned needing an xray from the last 6 months.  I couldn't get him to make sense, he just kept reading from a script.       

BTW, the dental ins is Blue Cross Dental, but I am accessing them through a Capital Blue Cross HMO, if that makes any difference. 

Thoughts, advice, condolences?

Thanks 

   

[Metalcat]

Yes, you should have gotten a predetermination. From here on out, you know to get one.

If your dental office has already sent in all of the evidence they have of medical necessity, then you are shit out of luck.

It's not whether or not it was medically necessary, it's whether or not they have proof that it was at the time that they did it.

So if I go for a check up today and my x-rays look fine, and then I crack my tooth in half tomorrow, and the dentist can clearly see the problem, and doesn't need to take an x-ray to start the work, then they can do the crown that day, but without an x-ray or photo the day it cracked, then the insurance company has no evidence that it was ever cracked.

Likewise, a lot of cracks and problems don't show up on x-rays, so some dentists are really good about taking photos of what they see with their own eyes in order to have back up evidence.

However, this it's not technically their responsibility to meet the burden of proof of your insurance company. Their burden of proof is to be able to diagnose what you need, if they can do that visually, then they've met their legal burden of evidence for need of the crown.

So your dentist technically does nothing wrong if they fail to document damage in a way that satisfies your insurance company, especially if you give them the go ahead to do it regardless.

I've seen cases where the insurance company suddenly changed their criteria for reimbursing crowns so that two corners of the tooth needed to be missing. This has nothing to do with whether or not a crown is needed, just whether or not they'll pay for it.

So yes, you will likely end up out of pocket, and it's too bad that you didn't know the risks of not being covered despite needing a crown. Insurance companies are known for their non-payment strategies, it's how they make money.

Next time you will know to ask for a predetermination and maybe for photos to be taken in addition to x-rays.

[slackmax]

Malcat,

Thanks for your reply.

Do you think that demanding a predetermination increases the likelihood of the claim being approved? Sort of like forcing the insurance  company  to show their hand?

I asked for a predetermination for the first work I had done by this dentist. The clerks were stunned and said 'no one ever asks for a predetermination'. 

[Metalcat]

Malcat,

Thanks for your reply.

Do you think that demanding a predetermination increases the likelihood of the claim being approved? Sort of like forcing the insurance  company  to show their hand?

I asked for a predetermination for the first work I had done by this dentist. The clerks were stunned and said 'no one ever asks for a predetermination'.

Did you ask for a predetermination for fillings? Because yeah, that's unusual, but where I'm from, it's pretty standard practice for crowns because otherwise the dentist is left with a pissed off client like you, which is ten times more of a hassle than the few hundred bucks they make off the crown is worth.

Your dentist would probably much rather you just refuse the crown than be stressed about you thinking this is their fault, and possibly writing something bad about them online. 

Also, no, a predetermination will make no difference as to what the insurance company decides, they do not care. What it could have done though is prompt your dentist to take photos for more evidence before they drilled away the evidence that you needed a crown in the first place. Because once they drill away the problem, to the insurance company, it never existed.

Sometimes x-rays and photos won't show how bad things are, so a dentist might stop in the middle of drilling to record just how bad a fracture or decay is. Not everyone does this, and they are in no way ethically or legally obliged to.

[slackmax]

Yes, I asked for a predetermination for the replacing of 2 existing fillings that were 'showing signs of' wear.  Not for decay. I thought the insurance  co might think it was  not 'medically necessary'. Therefore the predetermination.

<<  Also, no, a predetermination will make no difference as to what the insurance company decides, they do not care. What it could have done though is prompt your dentist to take photos for more evidence before they drilled away the evidence that you needed a crown in the first place. Because once they drill away the problem, to the insurance company, it never existed    >>

You're sort of agreeing with me, though. About the crown. Let's say they do a predetermination and refuse it. The dentist could then ask them why, and then the ins co might say 'because you didn't send a photo in enough detail or an  xray from angle Y'.   At which time the dentist could still do those things, and get approved, since I would have been living with the broken tooth for a month until the predeterm got done, which I would not have minded doing. 

So I would possibly have had an initial predeterm negative, but with added evidence, second predeterm positive.

I think if I had the fillings replaced without a predeterm they would have denied it. No?  Or maybe they don't bother with anything under $500.   

[Metalcat]

Yes, I asked for a predetermination for the replacing of 2 existing fillings that were 'showing signs of' wear.  Not for decay. I thought the insurance  co might think it was  not 'medically necessary'. Therefore the predetermination.

<<  Also, no, a predetermination will make no difference as to what the insurance company decides, they do not care. What it could have done though is prompt your dentist to take photos for more evidence before they drilled away the evidence that you needed a crown in the first place. Because once they drill away the problem, to the insurance company, it never existed    >>

You're sort of agreeing with me, though. About the crown. Let's say they do a predetermination and refuse it. The dentist could then ask them why, and then the ins co might say 'because you didn't send a photo in enough detail or an  xray from angle Y'.   At which time the dentist could still do those things, and get approved, since I would have been living with the broken tooth for a month until the predeterm got done, which I would not have minded doing. 

So I would possibly have had an initial predeterm negative, but with added evidence, second predeterm positive.

I think if I had the fillings replaced without a predeterm they would have denied it. No?  Or maybe they don't bother with anything under $500.   

Sorry, I thought you meant that the predetermination would change what the insurance company would do somehow, as I'm, they might be more likely to approve it for some reason with a predetermination.

As for fillings, it has nothing to do with the amount, it's that the insurance company doesn't typically ask for evidence when approving fillings, you either have coverage for them or you don't.

For every crown, bridge, implant, etc, they have a dentist on their end assess if the images meet their criteria for reimbursing the work.

That's why no one does a predetermination for fillings because if you have filling coverage, it just automatically gets paid out. There's no reason attached to the claim, so the reason doesn't matter.

However, there is an exception. If you were to get a bunch of fillings on your front teeth, the insurance company might demand proof that they're not just cosmetic.

[slackmax]

Malcat wrote:

<<  Sorry, I thought you meant that the predetermination would change what the insurance company would do somehow, as I'm, they might be more likely to approve it for some reason with a predetermination.  >>

Yes, that's what I meant.  You disagree?

[Metalcat]

Malcat wrote:

<<  Sorry, I thought you meant that the predetermination would change what the insurance company would do somehow, as I'm, they might be more likely to approve it for some reason with a predetermination.  >>

Yes, that's what I meant.  You disagree?

100% disagree.

The insurance company will either agree that the evidence they're given fits their approval criteria or they won't. They don't give a shit when it's submitted.

The only difference a predetermination would have made in your case is that you would have known in advance that they were going to reject your claim based on the evidence they were given. You then may have had a chance for your dentist to take and submit more evidence to try and demonstrate that your case did meet the criteria.

Why would the insurance company have different standards for approval for predeterminations vs claims after the fact?

[slackmax]

Malcat wrote:

<<  Sorry, I thought you meant that the predetermination would change what the insurance company would do somehow, as I'm, they might be more likely to approve it for some reason with a predetermination.  >>

Yes, that's what I meant.  You disagree?

100% disagree.

The insurance company will either agree that the evidence they're given fits their approval criteria or they won't. They don't give a shit when it's submitted.

The only difference a predetermination would have made in your case is that you would have known in advance that they were going to reject your claim based on the evidence they were given. You then may have had a chance for your dentist to take and submit more evidence to try and demonstrate that your case did meet the criteria.

Why would the insurance company have different standards for approval for predeterminations vs claims after the fact?

I really think you agree with me.

Reread your second paragraph, in which you state that I get a second chance to be approved, once they reveal the  criteria needing to be met. The only way to discover the criteria is file a predetermination (assuming they would even do that). 

And I agree with you that the ins co has the same standards before and after the claim, but the only way to **know**  what the standards are, and to then meet them, is to file the predetermination. 

If you call them up they won't tell you anything about standards over the phone.

[Metalcat]

Malcat wrote:

<<  Sorry, I thought you meant that the predetermination would change what the insurance company would do somehow, as I'm, they might be more likely to approve it for some reason with a predetermination.  >>

Yes, that's what I meant.  You disagree?

100% disagree.

The insurance company will either agree that the evidence they're given fits their approval criteria or they won't. They don't give a shit when it's submitted.

The only difference a predetermination would have made in your case is that you would have known in advance that they were going to reject your claim based on the evidence they were given. You then may have had a chance for your dentist to take and submit more evidence to try and demonstrate that your case did meet the criteria.

Why would the insurance company have different standards for approval for predeterminations vs claims after the fact?

I really think you agree with me.

Reread your second paragraph, in which you state that I get a second chance to be approved, once they reveal the  criteria needing to be met. The only way to discover the criteria is file a predetermination (assuming they would even do that). 

And I agree with you that the ins co has the same standards before and after the claim, but the only way to **know**  what the standards are, and to then meet them, is to file the predetermination. 

If you call them up they won't tell you anything about standards over the phone.

I think we're just arguing semantics.

Yes, getting a predetermination can help you realize when not enough evidence has been submitted for them to evaluate a claim as meeting their criteria.

My point is that they aren't more likely to approve any given claim whether or not it's a predetermination or after the claim has already been made.

Perhaps I was just misunderstanding what you were saying.

FWIW, your dentist should have a good idea of what evidence the insurance company needs in order to get approval for reimbursement. So it's a very rare case they won't send it what it needed to get a crown approved.

[tygertygertyger]

I used to work for a dental office. It was fairly common for us to have to write appeals if a crown was denied as a medical necessity. We even wrote the exact same letter every time... I don't know what insurance you have, but I'd say most of the time our appeal worked, and INS would cover their portion.

[slackmax]

I used to work for a dental office. It was fairly common for us to have to write appeals if a crown was denied as a medical necessity. We even wrote the exact same letter every time... I don't know what insurance you have, but I'd say most of the time our appeal worked, and INS would cover their portion.

Thanks for your encouraging words, tygertygertyger.

It's Blue Cross Dental. 

Should I file an appeal of my own, separate from the dental office appeal? Would it make any difference? 

Thanks   

       

[tygertygertyger]

It probably wouldn't do any harm, but I think greater weight would be placed on the dentist office letter. I am guessing because I can't recall any situation when a patient told us they appealed (though I'm sure they called INS)... I think they typically left it up to us. Please update when you hear more.

[slackmax]

It probably wouldn't do any harm, but I think greater weight would be placed on the dentist office letter. I am guessing because I can't recall any situation when a patient told us they appealed (though I'm sure they called INS)... I think they typically left it up to us. Please update when you hear more.

I'm glad you have experience in the dental claim field, tyger! 

I am trying to be 'pro-active', as they say, and do whatever I can to have the outcome I want. Apparently not only can I file my own appeal, but I can file a complaint with the Pa Dept of Insurance.
 
I have called SHIP (State Health Insurance Assistance Program) and got vague responses about what to do. Not much real help about what to do when, etc.

You might know the answer to this:  Is the dentist responsible for making sure he has all the ducks in a row before submitting the claim? For example, if the xray of the tooth does not clearly show the degree of tooth loss, should he take an xray from a different angle (if possible)?  Or take an actual photograph that shows the loss clearly? 

I think all he did was one xray, when I got the tooth filled.  And no photograph.
I don't want to be the bad guy, by blaming the dentist, and I think he does good dental work, but I'm looking at paying $1,000 more than I planned to on this crown.

Thanks

   


 

[Metalcat]

It probably wouldn't do any harm, but I think greater weight would be placed on the dentist office letter. I am guessing because I can't recall any situation when a patient told us they appealed (though I'm sure they called INS)... I think they typically left it up to us. Please update when you hear more.

I'm glad you have experience in the dental claim field, tyger! 

I am trying to be 'pro-active', as they say, and do whatever I can to have the outcome I want. Apparently not only can I file my own appeal, but I can file a complaint with the Pa Dept of Insurance.
 
I have called SHIP (State Health Insurance Assistance Program) and got vague responses about what to do. Not much real help about what to do when, etc.

You might know the answer to this:  Is the dentist responsible for making sure he has all the ducks in a row before submitting the claim? For example, if the xray of the tooth does not clearly show the degree of tooth loss, should he take an xray from a different angle (if possible)?  Or take an actual photograph that shows the loss clearly? 

I think all he did was one xray, when I got the tooth filled.  And no photograph.
I don't want to be the bad guy, by blaming the dentist, and I think he does good dental work, but I'm looking at paying $1,000 more than I planned to on this crown.

Thanks

 

No, it is not technically the dentists responsibility to take any records beyond what are medically necessary for treatment.

Your plan is your plan, it is not legally their responsibility to anticipate the demands of your insurer.

That said, most dentists will proactively document with photos for the sake of insurance to avoid this type of thing because it can happen.

So yes, they should have taken photos if the x-ray didn't clearly show the extent of the damage, but no, they are not obliged to, and they are not at fault if they don't.

Also, it's entirely possible that they did think the x-ray showed the extent of the damage, but that your insurance company has stricter than typical criteria for crown approval, which again, is not the dentists responsibility.

Remember, the insurance company is always looking for new ways to justify saying no, and they don't necessarily have anything to do with the dental standards of when treatment is needed.

For example, an insurance policy may dictate that they only reimburse fillings on a given tooth every two years. You get a small cavity on one part of the tooth and get a filling, and then the next year, the other side of the tooth develops a cavity as well, but the insurance company won't pay for it, no matter how medically required it is.

Same with the crown. The dentist can have an x-ray that clearly shows need of a crown, but if the insurance company has guidelines that say something like "two corners of the tooth must be missing to be eligible for reimbursement", then it doesn't matter that there's a giant crack, it won't meet the criteria.

So it's hard to say if the dentist should have proactively documented more or if your insurance criteria are excessively stringent and have nothing to do with whether or not a crown is required.

None of us can answer that for you, you will have to talk to your dentist about why they think the claim was rejected and what they might do differently in the future to try and avoid this, if anything.

If your dentist has proper x-rays and did a medically necessary crown, they didn't do anything wrong.

I know it's frustrating as a patient, but as I said, technically, your dentists doesn't have to do anything for the sake of your insurance company, they only legally have to document according to the clinical standards of their licensing body. Whether or not your insurance pays is technically not their legal responsibility.

[slackmax]

Assuming my appeal is rejected, I wonder if the dentist would give me a discount if I ask for one.

Had my claim been accepted, $1,400 total bill would be have been chopped down to say, $900 allowable by ins co. I would then have owed  50% of $900 equals $450.

Instead of $450 I could be on the hook for $1,400.

Dentist gets $1,400 instead of $900.   

Maybe he would knock off 10%.

Seems like he ought to accept $900 from me as full payment, since that is what he would have gotten in a standard situation.

Dream on, right?

[norajean]

If all else fails you could take the dentist to small claims court. You have nothing to lose but the filing fee. Just present your case to the judge - dentist promised insurance would cover but failed to meet insurers requirements.

[Metalcat]

Assuming my appeal is rejected, I wonder if the dentist would give me a discount if I ask for one.

Had my claim been accepted, $1,400 total bill would be have been chopped down to say, $900 allowable by ins co. I would then have owed  50% of $900 equals $450.

Instead of $450 I could be on the hook for $1,400.

Dentist gets $1,400 instead of $900.   

Maybe he would knock off 10%.

Seems like he ought to accept $900 from me as full payment, since that is what he would have gotten in a standard situation.

Dream on, right?

Most dentists are generally amenable to being reasonable with patients because there is so much competition and this is exactly the type of thing that makes patients leave a practice.

Getting a discount is never about what's reasonable, it's about how motivated the business is to keep you as a client.

So yeah, it can't hurt to ask.

[Metalcat]

If all else fails you could take the dentist to small claims court. You have nothing to lose but the filing fee. Just present your case to the judge - dentist promised insurance would cover but failed to meet insurers requirements.

The dentist is not responsible for the response of the insurance company. A dentist cannot promise what an insurance company will pay for.

The dentist also clearly got clearance to go ahead without pre-approval.

Technically, the dentist did absolutely nothing wrong here. The moment OP gave consent to go ahead without a pre-approval, they consented to treatment regardless of the response from the insurer.

[Weisass]

If all else fails you could take the dentist to small claims court. You have nothing to lose but the filing fee. Just present your case to the judge - dentist promised insurance would cover but failed to meet insurers requirements.

Is this amount of money really worth pissing off a dentist that this poster says they appreciate, though? This is guaranteed to mean you will need to find a new dentist.

[slackmax]

I would hate to go to small claims court. Too much drama. Not that I would let the drama prevent me from doing what I thought was right. But I would hate it. 

I did sign some form when starting up with this dentist a few years ago, that said I would be responsible for all expenses if the insurance denied any claim.

 However, I wrote something in the margin like "coinsurance and copay only".  The dentist office made no comment about that note. I do it all the time at medical places, and they never say anything about it. Anyway, let's hope it never gets to that point. Hasn't so far, knock on wood.

I researched this aspect online a few years ago, and was surprised to find out that even though I signed it, this form will not necessarily lock me into paying for a denied claim. The usual legal contradictions one finds. 

I think the dentist did everything he was responsible for. Perhaps a photograph would have been helpful.   

[slackmax]

Update: 

Thanks for the replies! 

I called the dentist office just to see what's happening with the appeal and to ask if my filing my own separate appeal would be helpful.

It turns out I am the most 'pro active' dental patient in their history.

The clerk said she 'never heard of' a patient doing that, so she didn't know.

They haven't heard anything back from Blue Cross Dental, since they filed the appeal May 5. She said this is standard practice for Blue Cross, and that they do it simply to drag out the process to delay making payment.  The dental office has  a 'big stack' of Blue Cross Dental patient claims that are being appealed, or being dragged out for some other reason, so I should not feel like the only one.   

I made a point of asking her if my having filed a predetermination would have  avoided the denial.  Her response was 'No one ever does that, since the Xrays these days are so crystal clear, the case of medical necessity is black and white''.

She said there was no chance the Xray wasn't clear enough. And it showed medical necessity for a crown.   She agreed that people used to do the predeterminations back in the 90's, but 'No one ever does that' anymore.   

I forgot to ask her if a photograph could have been taken.

I told her I thought her theory that the ins co was denying, simply to drag it out made sense to me. 

I am holding off on filing my own appeal, at this point. I have 180 days, from the April denial date, to appeal,  regardless of what others do.

I also (heavy breath) asked her if filing a complaint to the Pa Dept of Insurance would do any good, and she said, again she 'never heard of anyone doing that' (Mr. Proactive again!)  but she wanted me to do it, just to  expose the unethical tactics of the ins co.   

She said I should not worry about it, and the claim will eventually be paid, and that they are 'on top of it'.   

So, I guess I am going to allow myself to be unstressed about it, and maybe even forget about it,  for at least a few weeks.

[tygertygertyger]

Thanks for sharing the update!

Everything your dental office said tracks with my memory of filing claims and appealing denials. We sent the single xray of the tooth (no photographs) with the claim. @Malcat is correct that the dentist office isn't responsible for dealing with insurance, but the practices that I worked for always handled it "as a service" though it wasn't technically our responsibility.

On a different note, a lawyer friend of mine had lots of extra time on his hands and called his (medical) insurance repeatedly to inquire about a denied claim. All the representatives told him the code wasn't covered in their manual. Eventually (weeks later), he kept requesting to see a copy of this manual and he got high enough up the chain and someone admitted there was no manual. It was all just their process...(to deny deny deny). They did cover part of the denied claim finally, but I can't imagine how much time he put into getting them to cover that relatively small claim, especially at his corresponding hourly rate. 

[Metalcat]

Thanks for sharing the update!

Everything your dental office said tracks with my memory of filing claims and appealing denials. We sent the single xray of the tooth (no photographs) with the claim. @Malcat is correct that the dentist office isn't responsible for dealing with insurance, but the practices that I worked for always handled it "as a service" though it wasn't technically our responsibility.

On a different note, a lawyer friend of mine had lots of extra time on his hands and called his (medical) insurance repeatedly to inquire about a denied claim. All the representatives told him the code wasn't covered in their manual. Eventually (weeks later), he kept requesting to see a copy of this manual and he got high enough up the chain and someone admitted there was no manual. It was all just their process...(to deny deny deny). They did cover part of the denied claim finally, but I can't imagine how much time he put into getting them to cover that relatively small claim, especially at his corresponding hourly rate.

Lol, yep, I once submitted a claim for a patient 17 times just to piss off the insurance company, they ended up paying in the end just to make me stop submitting it.

Insurance companies are bullshit.

[slackmax]

Update:  I wrote a letter to the appeals dept of CapBlueCross Blue Journey about the absurd denials by Blue Cross Dental. Might be a coincidence but 3 weeks later I got a letter from the appeals dept saying they were approving my appeal.

I just paid my share of the bill to my dentist, for the crown.   

When I got back from paying the bill, I had a letter from Blue Cross Dental, saying they were denying the 'core buildup with pin' portion of the claim. Oh my God, what asshats. I guess no one told them to take my claim out of the "auto-deny" algorithm they are using, lol.   Not worried about it.  My EOB says it has been finalized already. Ha ha.   

[DaMa]

Hurray!  It's nice to hear someone getting a win with an appeal.