SMILES

Has anyone been successful in getting their medical insurance to cover dental work? I had bone graft surgery (failed) 5 years ago and have worn a retainer since. The entire pre-maxilla is unstable. I want to finally have the much needed dental work for my teeth to look 'normal'. The dentists I've consulted estimated the work at amounts between $10k-12k. It is their opinion that if the sections are bridged, my teeth will be fixed / stable. And that means I won't have to have another (possible failure) bone graft surgery. The last surgery cost close to $16k. I want to prove to the dental / medical insurance that if this is covered by both dental AND medical, it will cost the insurance company less in the long run.


Has anyone attempted this? Are my goals too lofty? Should I just bite the bullet and be prepare to pay for the $8k the dental insurance will not pay?


Any and all thoughts are welcome. Thanks.

My wife and I have a terrific 11-year-old son born with a unilaterial cleft lip & palate. He's had a number of surgeries, and we have had extraordinary good fortune in having insurance cover not just the repair surgeries but also orthodontics and oral surgeries, including bone-graft. The main thing working in our favor has been that he's been covered under my plan at work since his birth, so that's been consistent, although carriers have changed a couple times and we've had to be pretty assertive on occasion when claims were rejected, questioned, etc. Companies have balked a couple of times at dental-related expenses, and we were able to have various doctors, etc., write letters describing MEDICAL NECESSITY of the procedure at hand and explaining clearly that it's necessary as result of congenital birth defect, and also human-resources person at my company went to bat at least once. General advice after many years of filing claims is to be persistent but never lose your cool, and also doctors' and other providers' staffs are often quite adept at working with insurance companies. I realize policies vary considerably, and many don't cover pre-existing conditions, but it is possible to have these procedures covered and our experience has been a positive one. Good luck to you.

David,
Thanks for the your reply. I'm gathering all the info that I need to pursue this. I am lucky to have found a dentist who has worked with cleft patients, and assures me that the outcome will meet my expectations. I've waited for (and prolonged) this and soon I will be 'finished'.


Thanks again for the information you've given me. Good luck to you and your family.

Absolutely your medical insurance should cover this! I am a human resources professional (I work in benefits) and I have a child with a cleft lip and palate - so trust me - I know what I am talking about.


The work that you need done is due to a MEDICAL condition not a dental condition. This is the difference. If your doctor (primary care practitioner if you are in an HMO) requests the referral to a specialist for this condition and deems it medically necessary for you to have this done to correct a congenital birth defect your insurance has a hard time denying your claim.


As far as pre-existing conditions are concerned: if you have had CONTINUOUS coverage for the past 18 month FROM ANY GROUP INSURANCE they cannot claim pre-existing condition. This is federal law (HIPPA).


Good luck - if you want some help fighting the insurance let me know - I am really good at it


Feel free to e-mail me at Pony3131@aol.com

South Carolina has a law requiring any insurance policy which covers dependents to pay for the medically necessary treatment of cleft lip and palate. The law also spells out what is considered medically necessary, including prosthodontics, orthodontics, and braces. Our daughter's first surgical claim was partly denied by our insurance company. I promptly wrote them a letter which began, "Attached please find a copy of South Carolina Code Section 243 ..." I threatened to refer the matter to the State Attorney General's office. The claim was approved immediately. My advice, when you come up against the insurance company, don't practice incremental tactics. Make your first response a cannon. If all else fails, move to South Carolina.
Greg Bowden

Watch for "self-funded" insurance plans - they are exempt from state law.

I NEED A LARGE AMOUNT A DENTAL WORK,MY INSURANCE ONLY COVERS BASICS. I AM VERY SELF CONSIENCE , MY LIFE IS FINE EXCEPT FOR THIS, IT MAKES ME FEEL UGLY . I REALLY NEED A WHOLE NEW MOUTH PLEASE ANY ADVICE OR HELP. N