Re: Dental Coverage Appeal

[Guest guest]

I rbink what I wojld do is get back to texas first as this can be long and drawn

out when you do an appeal. Then esraish a dentist. I would look for a special

needs one. And then someone gave you some good ad ie about grottos. However I

dont know where you stand financialy. Anyway insome ways texas has great medical

and dental care and in othet ways they dont. It depends on where you stand

financially.

--- Original Message ---

Sent: June 12, 2012 9:04 AM

To: Texas-Autism-Advocacy

Subject: Dental Coverage Appeal

 

Hi there-

I am writing this group to ask for advice/help on how to go about filing an

Appeal to our insurance company for denial of medical coverage for anesthesia

for our son for a dental cleaning & possibly x-rays...

Basically, I scheduled a dental cleaning approximately 6 wks ago for our son

through his Pediatric Dentist & requested he be put under anesthesia due to a

few factors: 1- Be didn't receive an adequate cleaning at his last appointment.

2- This was likely due to his severe Autism (cognitive level appx 24

month/non-verbal & non-communicative). 3- Also due to his Sensory Processing

Disorder. 4- Diagnosed ADHD is a factor as well.

We received a letter yesterday (6/11)- ELEVEN days prior to the scheduled

surgery that the request was denied/not covered due to being coded under his

Diagnosis code of ADHD, (no mention of Autism or Sensory Processing Disorder),

Type of Treatment: Hospital Call (anesthesia & facility charges), &

Physician/health care professional (his dentist). It stated that " The services

are not eligible expenses under your plan... -under Exclusions: Dental x-rays,

supplies, & appliances & all associated expenses, including hospitalizations &

anesthesia. " His dentist isn't an approved provider under our Dental Plan but we

are willing to pay for his services as we feel that he knows our son & we are

comfortable with his approach & sensitivity to patients with Autism in general &

our son's needs but we feel that we have grounds for an appeal on the other

issues.

The irony of this is that when we lived in Texas, our son was put under

anesthesia for a dental cleaning in a hospital setting & under the care of his

then- dentist & his care including hospitalization & anesthesia was covered by

our insurance about 2 1/2 years ago under a different insurance co/policy.

For a written appeal the ins co recommends (among other things):

*An explanation of why the requested service should be considered for coverage

*The specific coverage decision you would like us to review

Would you all recommend I contact his Pediatrician for an additional

recommendation (he can't even get a tongue-depressor in his mouth to check his

throat/tonsils & has verified his Sensory Processing Disorder) or his dentist-

or both? Also, I am leaving on vacation for 3 days & we are moving from S Dakota

back to Texas in 1 month & I don't want to have to start this process all over

again.

Would you think that an Expedited Internal Appeal would be granted (stated in

our denial letter that it may be available if the " patient's medical condition

is such that the time needed to complete a standard appeal could seriously

jeopardize the patient's life, health, or ability to regain maximum function. " )?

I can't really say if it would jeopardize his life but hypothetically it could

jeopardize his health if there are bigger issues with his teeth that we don't

know are going on since an adequate exam without anesthesia can't be conducted.

He only tolerates me flossing his 2 top front teeth & brushing his teeth twice a

day is still a struggle after over 10 years. This has been addressed at school

in his IEP for the past 7 years or so & his O/T has tried various approaches as

well. We've tried different dentists, toothpastes, toothbrushes, & behavioral

therapies- none of which has made a difference. When it takes 3 grown adults to

hold him down while he screams at the top of his lungs in order to take even a

cursory glance in his mouth, it begins to get to you & breaks your heart that

your son likely thinks he's being tortured.

Sorry for the long post & rambling but any advice Would e welcomed. Any

experiences you've had or recommendations dealing with appealing this decision

in the most efficient & expedited manner would be appreciated.

Thanks,

Dolly

[Guest guest]

The Humanitarian Foundation (Grotto) is a national organization.  It is not based on parent income.  It is only based on a child with special needs.

[Guest guest]

can it be used after the fact? or do u have to apply at the time of service. like can i use it to be reimbursed for what insurance didnt pay from last december?Sent from my iPhone

The Humanitarian Foundation (Grotto) is a national organization. It is not based on parent income. It is only based on a child with special needs.

[Guest guest]

That I don't know.  You would have to contact them on that.  All I know is that we went to a Grottos provider (The Dental clinic at Children's Medical Center in Dallas).  We showed them his diagnosis of Autism from his doctor.  Then we got our ID card and number in the mail and we were good to go.  We've been going there for dental care ever since.

http://www.hfgrotto.org/