How should I respond to my insurance not wanting to pay to fix my tooth?
January 1, 2021 5:45 PM   Subscribe
I have a crack in one of my teeth. My dentist wants to perform a root canal and put a crown on the tooth, in order to save the tooth. My insurance is denying this. Can you help me with my appeal to the insurance company?

My insurance is Liberty Dental Insurance, a part of Empire Blue Cross Blue Shield Health Plus, which I am receiving under Medicaid in New York state.

Here is the info about the tooth from Liberty:
"Your provider asked for Cleaning inside roots of tooth (Root Canal) - Tooth Number 28."
"Liberty Dental Plan decided to deny this dental service because this service is not medically necessary."
*You asked for cleaning inside roots of tooth (Root Canal) - Tooth Number 28 - to rebuild or protect your tooth To approve this service, the following criteria must be met, under New York State Medicaid MMIS Dental Policy and Procedure Code Manual:

*NNYA8: Your dentist's notes/pictures of your teeth show that you have more than 8 real or fake back teeth that bite together. You have at least four upper teeth and at least four lower teeth that bite together without this tooth. You are able to chew with the teeth you have.

*MM93.1: The service is denied. For this service to be approved the treatment must not be able to be done by your general dentist. Based on your dental records that your dentist sent in this service can be done by your general dentist. There is no medical need for you to have this service done by a specialist. [scans of the letter are here]

1. Is there any way I can successfully appeal this? What can I tell them to convince them to cover this tooth getting fixed? (I do in fact have my other teeth - but that shouldn't be a reason to lose this tooth, right?)

2. My dentist told me that when they deny this it's because the insurance company thinks it would be cheaper for the tooth to become more damaged, and then they will pay to have it extracted. Does that seem like what is happening?

3. Any tips or advice for anyone who has been in a situation like this about how to move forward?
posted by andoatnp to Health & Fitness (7 answers total) 1 user marked this as a favorite
 
#2 is what happened to me. (My tooth has been cracked for like 5 years and I still haven’t had the root canal.) I didn’t push back very hard so hopefully others have more proactive advice.
posted by stoneandstar at 6:19 PM on January 1


Predeterminations are tricky, because a lot of the time the damage to the tooth that necessitates the root canal or crown is not apparent on the xray. The risk you then take is to have the dentist do the procedure and report the why of the need for the root canal and subsequent crown after the fact. You go in, however, on the hook for the procedure if the insurance doesn't pay. But, if the dentist finds that the crack clinically necessitates a root canal, then submits a claim with a narrative indicating what happened, then it's more likely going to be covered.

I have to admit that i'm new to medicaid. I was in private practice most of my career, and never wanted the hassle of dealing with medicaid's hoops; but now i work in public health, and have a billing coordinator who has been doing this for decades. she's a gem.

In my experience, medicaid doesn't cover root canals on premolars in adults, nor do they cover crowns after the root canal. they sure don't pay for implants if you lose the tooth, and only pay for partial dentures if you're missing a lot of teeth.

the wording of that denial is very strange, ive never heard of a root canal being described as "cleaning inside the tooth" by a professional entity. interesting.

Only you can put a dollar value on your teeth, but at least have it taken care of one way or another before it swells or starts to hurt.
posted by OHenryPacey at 6:42 PM on January 1 [1 favorite]


(I do in fact have my other teeth - but that shouldn't be a reason to lose this tooth, right?)

I used to work in managed care program development on the insurer side in several different states, including NY. Each state has its own approach to dental coverage under Medicaid, and NY typically requires better coverage than other states when it comes to carving in particular service categories. OHenryPacey's state (which I've never worked in) will likely have a different set of covered services. These essential services change and evolve according to funding requirements, political environments, public sentiment, etc.

I took a closer look at the code manual you linked and, yes, there are limitations to dental services that are covered. Over at the bottom of page 24, under "Essential" Services, it says:
Eight (8) posterior natural or prosthetic teeth (molars and/or bicuspids) in occlusion (four (4) maxillary and four (4) mandibular teeth in functional contact with each other) will be considered adequate for functional purposes. Requests will be reviewed for necessity based upon the presence/absence of eight (8) points of natural or prosthetic occlusal contact in the mouth (bicuspid/molar contact).
This means if losing this tooth entirely meant that you would lose the ability to chew by having too few points of contact (because you were missing teeth already), this service would be covered because saving the tooth would be considered medically necessary.

2. My dentist told me that when they deny this it's because the insurance company thinks it would be cheaper for the tooth to become more damaged, and then they will pay to have it extracted. Does that seem like what is happening?

Your dentist isn't entirely correct here when it comes to Medicaid -- I mean, yes, of course, it is cheaper to pull a tooth than it is to perform a root canal. But this isn't your insurer waiting for more damage to happen so they can justify cheaper treatment -- this is NY State itself saying that treatment must cover only what NY State defines as medically necessary for you to be able to chew and digest nutrition, and your insurer is simply meeting that guideline according to their contract with the state.
posted by mochapickle at 7:33 PM on January 1 [3 favorites]


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(And yes, sometimes there are plans that offer more than the baseline what the state requires. I’m not sure whether any other plans in NY offer more comprehensive coverage.)
posted by mochapickle at 7:40 PM on January 1


I have heard that it can help if you contact your insurance and ask for the names and qualification level of everyone who was involved in denying your claim. Often this results in them backpedalling sharpish, because they don't want to admit that it was reviewed by unqualified interns and no medical professionals at all. So you could, you know, call their bluff, if you want.
posted by HypotheticalWoman at 3:58 AM on January 2


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I am probably fixing crowns in a progressive city in Mexico for half the price.

Reddit has multiple references for Mexican dentists. Advised to pick a proper city and bring a friend.


.. viva Mexico.
posted by Wichienmaat at 9:38 AM on January 2 [1 favorite]


*MM93.1: The service is denied. For this service to be approved the treatment must not be able to be done by your general dentist. Based on your dental records that your dentist sent in this service can be done by your general dentist. There is no medical need for you to have this service done by a specialist.

It looks like this part of the denial is denying sending you to a specialist to have this done. Is your dentist capable of providing the service themselves?
posted by platinum at 12:13 PM on January 2


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