Best Way to Appeal HMO decision?

choufleurAugust 18, 2005

I had been in a lot of pain for months. I was taking about 20 Tylenols per day for the migraine headaches and oral pain. Within the last two months, I visited the dentist twice about the pain. She took X-rays and stated the pain was due to night time teeth grinding. Last week, everything came to a head. Half my face became extremely swollen (one of my eyes was practically closed shut) and the pain in my mouth, throat, ear and eye was just about unbearable. My GP diagnosed sinusitis and referred me to a Ear-nose-throat specialist. The ENT doctor correctly diagnosed a tooth abscess and referred me to an oral surgeon. However, my HMO rejected the referral, claiming they would not cover dental treatment for cosmetic purposes. Independently, I found a new dentist who provided treatment.

Had I not received dental treatment, the infection could have spread to major organs. I had rheumatic fever as a child. How do you suggest I appeal the HMO's decision besides including the dentist's treatment record (seared the abscess and prescribed antibiotics) with my letter indicating the seriousness of the infection.

Thanks for your suggestions.

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"cosmetic" is something like braces and caps on healthy teeth.

A dental ABSCESS is absolutely NOT cosmetic ... it's right up there with any other abscess. Let the HMO know that you will have a chat with the state agency that coverns HMOs if they don't cover a legitimate medical expense like an abscess.

    Bookmark   August 19, 2005 at 11:47PM
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I've had a number of dental abscesses, so I know that there are (at least) two ways to treat them - one is by pulling the tooth, the other is by root canal and crown. I would think the health insurance company might be persuaded to cover the cost of extraction, though I would think they would argue that the second option is cosmetic.

Do let us know how this turns out - I've never asked my health insurer to cover an abscess, even though I have two serious medical conditions that would make an infection life-threatening.

    Bookmark   August 20, 2005 at 1:20AM
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First off, I'd get a new dentist that could spot an abscess... if this is one of the HMO's "recommended", I'd use that as the first bullet.

Second bullet would be that the swollen eye and the ENT referral to an oral surgeon... "their" dentist wasn't ableto pick up on it... HELLO?? Do you only subscribe to sub-standard or cheap dentists?

Use oral surgeon's report that tells of 'coulda been's" and then submit a cc to their corp hq, and attorney gen in your state.

    Bookmark   August 21, 2005 at 1:56AM
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It sounds like you had someone at an administrative level (claims processor type) reviewing your referral/or claim documentation. Saying this is cosmetic is utterly silly. Maybe it was 5PM and they were anxious to go home for the day. Who knows?

Was it a periodontal abscess or a pulpal abscess? Your use of the term "seared the abscess" leads me to belive it was a periodontal abscess, but did you ever end up with a root canal and a crown?

The former is limited to the soft tissue and can originate for a variety of reasons - most commonly periodontal disease. Treatment in this case is to drain the abcess, clean and flush the area with warm saline solution and sometimes hydrogen peroxide, and a regimin of antibiotics.

The latter originates in the pulp tissue inside your tooth -due to infection which can be caused by invasion of caries into the pulp chamber--"cavity", or when the pulp tissue slowly dies and becomes necrotic - most often from trauma of some kind. In a pulpal abscess - since this tissue is encased inside a hard structure - enamel and dentin - the infection has no where to drain other than through the apex of the root, where it will eventually appear as swelling just adjacent to the position of the root tip, but through your tissue. The swelling and pain from a pulpal abscess can be extreme and once this happens, it has to be treated immediately. The treatment for pulpal abscesses is a root canal and crown - along with antibiotics.

It is disturbing that your DDS failed to diagnose and treat - though there are times when you can have a subclinical situation where you are expereincing the symptoms of pain, but the cause cannot be determined because it is not yet noticable on an x-ray or though clinical exam. We have had situations where we could not diagnose a pulpal abscess in the early stages when it is chronic and before it becomes acute for this reason, in which case we would either take an x-ray as a baseline and then schedule the patient to come back in a few months (as long as the symptoms were mild and not severe) or refer to an endodontist for a more detailed diagnostic workup and treatment. Referred pain is also common with pulpal abscesses. It can feel like it is your upper right first molar when it fact it could be your lower right molar, or even a tooth on the other side of the mouth. (Of course this assumes that obvious causes are absent). This is one reason we just don't jump in and do a root canal unless we are absolutely sure which tooth it is. In the early stages of the abscess that can be difficult to determine. In the acute/swelling stages, it is pretty simple to determine which tooth is the cause - both on an x-ray and by testing each tooth with slight pressure.

Regardless of what the cause was, medical plans rarely cover dental treatement. Dental services are covered under dental plans, not medical plans. If you have dental insurance, then that is where the claim should be sent.

The complicating factor you have on your side in an appeal situation is your history of Rheumatic fever--which means that there is some heart valve damage and any kind of systemic infection can be extremely dangerous unless the cause of the infection is treated and antibiotics given immediately. This would even apply before going to your hygienist for a routine cleaning. The standard of care is to always prescribe antibiotic premedication prior to doing any dental procedure on patients with a history of rhumatic fever.

The only times we have seen dental procedures covered under medical plans (rarely HMOs, occasionally PPOs or indemnity plans) is in the case of accidental emergency where someone is in an auto accident and fractures the bones in their face, jaws, and possibly injures their teeth. Another case that will come up once in awhile is orthognathic surgery - surgery to reposition the lower jaw relative to the upper jaw - but this coverage is rare because it is most often done to treat TMJ pain and the success rates are questionable at best.

First you should go through your SPD or EOC document - the lengthly documents provided by your EER that describes what is covered and lists the limitations and exclusions. Dental will usually be listed as an exclusion. See if you can find any language that says the plan covers "medically necessary care" or "care needed to protect the life of the patient." The HMO does have an obligation to make exceptions when failure to treat can cause serious health consequences - which seems to apply here - Also, it is not your fault that your original DDS failed to diagnose. I would be sure to state on the appeal - clearly and in short bullet points - the series of events that led up to the final resolution. You may want to do an google search under rheumatic fever and provide some authoritative documentation on the serious risk that infections can cause in patients with this in their health history-it is called bacteremia - where the bacteria in your bloodstream will attach themselves to the damaged heart valve and it can be fatal. I would provide your documentation in a dispassionate, factual, simple, sequential manner, but make it clear that you are aware that you could have died from this condition and that you did everything within your power to get it resolved. When the health/life of the patient is at risk - even if dental is excluded under your plan - you may be able to get some coverage.

At a minimuim, the HMO should cover all of the visits up to the final dental treatment itself, which should be covered under dental, if you have dental insurance. If not, then I suggest you base your appeal on the above description.

Lynne (RDH, CA, OR, WA)

    Bookmark   August 21, 2005 at 1:13PM
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Your HMO probably also has a procedure to follow for disputes. You'd have to look that up in your HMO info packet as they are all different. Some states also have an appeals board so these types of disputes don't clog up the court system. You can check with your state insurance board for info on that front. Can't add much more except what Lynne said...

    Bookmark   August 22, 2005 at 6:08PM
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