Mine was not during the ACA era but it was wonky. I had to ask my parents because I couldn’t remember exactly how it worked.
For me, I had 5 wisdom teeth. The part of the jaw with 2 wisdom teeth was covered by insurance because it was medically necessary to get them removed. The other 3 were not impacted and were covered (only a fraction) by dental insurance as insurance wouldn’t cover it (they weren’t medically necessary to remove). Same operation, same care, same everything- two different billings. Such a bizarre system!
Thanks all for the responses. Lots of wisdom tooth experience at these ages! Not so many that happened under a PPACA policy in 2014, though
Concerning “the purpose for insurance”, yes, I agree it should be for things you can not self-insure against. But big brother (the federal government) created this monster, and I’m just trying to utilize what I’ve been compelled to buy.
My plan is constructed to comply with (at least) the minimal standards set out in federal law (PPACA/Obamacare). So I was looking for examples of any state’s 2014 PPACA coverage of impacted wisdom tooth extraction. This pre supposes that those PPACA compliant policies all meet (and don’t exceed), the minimal pediatric dental coverage layed out in the federal law.
Before the procedure, I did check my plan (quoted in the original post). Also, the oral surgeon’s office called Blue Cross Blue Shield of North Carolina and they gave them the go-ahead. But now that it’s time for BCBSNC to pay-up, they are saying it’s not covered. They are not giving a reason why, though. So the OP was for me to see if I could find examples where others’ had extractions under a PPACA policy in 2014 that was (or wasn’t) covered.
The diagnosis codes are 520.6, 523.4, 524.31. The treatment codes (procedure codes) are D7240, D9220, D7220, D7210.
Well, if that’s your response and you’re confident the oral surgeon’s office is reporting correctly to you, then just appeal it. Hopefully there’s a paper trail between the oral surgeon’s office and BCBS.
I agree that appeals can be successful, especially if you were already given a pre-approval as noted by the oral surgeon’s office & BCBS of NC. Please keep us posted–sure hope you get SOME coverage, especially since they did APPROVE.
sengsational: 7210–surgical extraction (tooth already present in the mouth, comes out in more than one piece), 7220–soft tissue impaction (surgeon only has to cut the gum to get the tooth out), 7240–complete bony impaction (surgeon has cut the gum and remove bone to get the tooth out), 9220–IV sedation.
A verbal okay over the phone is not a guarantee of payment. Was there a predetermination sent? If the procedures have already been billed and denied, BCBS has sent an explanation of benefits to the surgeon and probably also to you. The reason should be listed. I suspect it will be: this service is not a covered benefit.
We are not having wisdom teeth extractions covered under pediatric Obamacare in Michigan.
So, we’re talking about tomorrow, Wed 4pm. Should I be buying popsicles? What is the usual protocol? I know I can google and/or call the dentist, but I am looking for what one or two things worked best for you that you might not have thought about before?
And is it usually 24-hours and they are good-to-go? Or is that unrealistic? If he takes off Thursday, can he sit through 3 classes of 1 hour lectures on Friday?
I think 24 hours is mostly unrealistic, but it all depends. D had hers out on Tuesday and attended an outing on Friday for 2 hours and was exhausted afterwards. It just took her a while to get her energy back. She also had a weird reaction to her pain meds so just switched to ibuprofen. Friend’s son got an infection - very painful, solved with antibiotics, but extended recovery time. Smoothies, yogurt, mashed potatoes or yams, juice, applesauce, constant ice packs and sleeping on a recliner.
I was out for a solid week afterwards, and really didn’t fully recover for another month and a half (couldn’t open my mouth more than a centimeter and a half). It really depends
Only thing I can say you are lucky with is that you have a boy. Girls are at greater risk for dry socket. We did wisdom teeth when the kids had no commitments within that first week.
Problem both my kids ran into is (and I know this has happened to many others), they don’t have much of an appetite, so when they take the pain killers (often narcotics) it’s on an empty stomach, it upsets their stomachs, which starts a nasty cycle. And patients are typically NPO after midnight the night before, so they come out of the procedure with an empty stomach and the office typically tells you to get the prescription pain killer filled on the way home and not to wait until the anesthesia wears off before taking it. So I learned… on the way home, make your first stop some place to get a smoothie and have the kid start drinking it (they won’t be allowed to use straws, so pick up a plastic spoon at the smoothie place) while you’re inside the pharmacy getting the prescription filled.
The problem is that I did appeal but they denied it.
The oral surgeon’s office called up Blue Cross and filled out a treatment plan that had prices BCBSNC would accept. It was just verbal, though, as far as I know. I have sent in a request to get all related paperwork that was used to determine the claim’s status (that was listed as one of my next steps after the appeal was denied).
The EOB and the denial of the appeal just said ‘not covered’, but with no explanation of why the policy says pediatric extractions are covered, then they deny a pediatric extraction!
I just looked and they MIGHT have paid the oral surgeon a portion of the bill! But their systems are so messed up, I can’t really tell. If I download the raw data, I see something that might be a payment, but the claim number has no associated EOB.
Then appeal it to the company that you or your spouse work for that contracts with BCBS for coverage. If they did indeed say they would cover it, then take it to the next level beyond the first appeal if you feel like you have a case.
I hate that anyone ever has to reach this level that they know how many different levels of appeal there are, and unfortunately we’ve learned how to do this, and have had some success.
Unfortunately, there is no company to appeal to; I bought the policy from the federal marketplace (healthcare.gov). I do have another appeal route, though: Insurance Smart NC (part of Wayne Goodman’s Insurance Commissioner’s Office). They have a bad track record, though…they apparently have no “teeth” to use against unfair practices that the monster that is Blue Cross Blue Shield of North Carolina commits.
