How to talk to health insurance company about denied coverage/

[diamond]

i have tmj issues for several years and its gotten bad. i went to an oral surgeon who prescribed orthotic device which was sent for preapproval for my health insurance and it is denied. it costs total 5k. anyway to talk to the company? i heard several times you need to fight for them to cover? i am new and am not sure what to do.. thanks..

[trcy]

Yes, first talk to them and see why they are denying it and what the appeal process is. Sometimes they want you to try other things first. Also, the dr prescribing it should be willing to go to bat for you in this. Your doc can consult with a doc at the insurance company and explain why you need this.


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[pinkmomagain]

Years ago I did this with my daughter who was suffering with TMJ. I remember needing to spend $ but I can't remember if/how much we were able to get from the insurance company. But I think the dentist/doctor's office was very good about sending whatever evidence was needed to try to help us get something. Maybe try talking to the secretary at the oral surgeon's office and get her advice?

The appliance in addition to physical therapy helped my dd with the problem.

[cckwmh]

The oral surgeon should do a peer to peer review.

[sariana]

We have found that unfortunately TMJ/TMD treatment is not covered. Medical considers it dental, and dental considers it medical. We had one health policy that covered one device per LIFETIME. My DH goes through them every couple of years.

[bnme]

You need to find out what the appeals process is. For me, I was first assigned a case manager and it was a phone interview. I believe it them escalated to a nurse manager, then peer review.

[petesgirl]

We have found that unfortunately TMJ/TMD treatment is not covered. Medical considers it dental, and dental considers it medical. We had one health policy that covered one device per LIFETIME. My DH goes through them every couple of years.

Unfortunately, our dentist has made it very clear that TMJ is generally not a covered benefit and we have found that to be true with our insurance.
But, I would definitely be questioning insurance about it and doing the appeals process. Also, get your dentist on board to back up why it is medically necessary. Good luck - - hope something works out!

[JBaxter]

Its been a while since I've worked in a dental office but "back then" it was rare anything TMJ was covered. It sounds like it hasn't changed.