| | Joined: Mar 2013 Posts: 5 Member | OP  Member
Joined: Mar 2013 Posts: 5 | My husband was diagnosed with tonsillar cancer in 2006 and is now dealing with the impact of the radiation on his teeth. He just had 15 teeth pulled and 13 implants placed. Next week, he'll get the temporary dentures and 6 months or so from now, he'll get the permanent fixed dentures. The insurance is denying coverage. Has anybody successfully appealed the insurance company and, if so, do you have any recommendations? | | | | | Joined: Jan 2013 Posts: 1,291 Likes: 1 Patient Advocate (1000+ posts) | | Patient Advocate (1000+ posts)
Joined: Jan 2013 Posts: 1,291 Likes: 1 | I have no personal experience but my jaundiced view of insurance companies certainly dictates they play the preexisting conditions clause card but I am no insurance pro. Good luck. don
Don Male, 57 - Great health except C Dec '12 DX: BOT SCC T2N2bMx, Stage 4a, HPV+, multiple nodes 1 tooth out Jan '13 2nd tooth out Tumor Board -induction TPF (3 cycles), seq CRT 4-6/2013 CRT 70gr 2x35, weekly carbo150 ended 5/29,6/4 All the details, join at http://beatdown.cognacom.com | | | | | Joined: Jun 2007 Posts: 10,507 Likes: 6 Administrator, Director of Patient Support Services Patient Advocate (old timer, 2000 posts) | | Administrator, Director of Patient Support Services Patient Advocate (old timer, 2000 posts)
Joined: Jun 2007 Posts: 10,507 Likes: 6 | Keep appealing! Ive gone thru some denials for things but after appealing I have gotten them to cover what I needed done. Ask the doctor to help you by writing a letter of medical necessity to send in along with your appeal. Thats what it took for me to get mine approved.
Good luck!
ChristineSCC 6/15/07 L chk & by L molar both Stag I, age44 2x cispltn-35 IMRT end 9/27/07 -65 lbs in 2 mo, no caregvr Clear PET 1/08 4/4/08 recur L chk Stag I surg 4/16/08 clr marg 215 HBO dives 3/09 teeth out, trismus 7/2/09 recur, Stg IV 8/24/09 trach, ND, mandiblctmy 3wks medicly inducd coma 2 mo xtended hospital stay, ICU & burn unit PICC line IV antibx 8 mo 10/4/10, 2/14/11 reconst surg OC 3x in 3 years very happy to be alive  | | | | | Joined: Mar 2013 Posts: 5 Member | | OP Member
Joined: Mar 2013 Posts: 5 | The insurance companies have definitely crafted their wording well. Our company will pay for the removal of teeth BEFORE radiation and they will replace teeth that have FALLEN out because of the radiation with dentures. They do not cover implants. When my husband was diagnosed, we had quite of lot of dental work completed in preparation, but I can't imagine that anybody would pull ALL of their teeth before radiation. His teeth are deteriorating. Some have fallen out, but most have simply broken off. The oral surgeon had to extract the teeth and the insurance company doesn't pay for extractions. | | | | | Joined: Mar 2013 Posts: 5 Member | | OP Member
Joined: Mar 2013 Posts: 5 | Thank you for the encouragement! We will keep trying as I believe that this is a fight worth fighting. All of you have been through so much just dealing with the cancer, you shouldn't have to worry about how to pay for the impact of the treatment itself. | | | | | Joined: Jun 2007 Posts: 10,507 Likes: 6 Administrator, Director of Patient Support Services Patient Advocate (old timer, 2000 posts) | | Administrator, Director of Patient Support Services Patient Advocate (old timer, 2000 posts)
Joined: Jun 2007 Posts: 10,507 Likes: 6 | This exact issue was in a newspaper article recently. The person in the article is taking on "fighting city hall". Here is a link with the story from the OCF Newsfeed. OC Patient Fighting for Coverage
ChristineSCC 6/15/07 L chk & by L molar both Stag I, age44 2x cispltn-35 IMRT end 9/27/07 -65 lbs in 2 mo, no caregvr Clear PET 1/08 4/4/08 recur L chk Stag I surg 4/16/08 clr marg 215 HBO dives 3/09 teeth out, trismus 7/2/09 recur, Stg IV 8/24/09 trach, ND, mandiblctmy 3wks medicly inducd coma 2 mo xtended hospital stay, ICU & burn unit PICC line IV antibx 8 mo 10/4/10, 2/14/11 reconst surg OC 3x in 3 years very happy to be alive | | | | | Joined: Jan 2013 Posts: 1,291 Likes: 1 Patient Advocate (1000+ posts) | | Patient Advocate (1000+ posts)
Joined: Jan 2013 Posts: 1,291 Likes: 1 | Thanks for posting. I am going to prepare a note to my congressional representatives to let them know of this big loophole in MediCare coverage.
don
Don Male, 57 - Great health except C Dec '12 DX: BOT SCC T2N2bMx, Stage 4a, HPV+, multiple nodes 1 tooth out Jan '13 2nd tooth out Tumor Board -induction TPF (3 cycles), seq CRT 4-6/2013 CRT 70gr 2x35, weekly carbo150 ended 5/29,6/4 All the details, join at http://beatdown.cognacom.com | | | | | Joined: Dec 2003 Posts: 2,606 Likes: 2 Patient Advocate (old timer, 2000 posts) | | Patient Advocate (old timer, 2000 posts)
Joined: Dec 2003 Posts: 2,606 Likes: 2 | [quote=txcaregiver]The insurance companies have definitely crafted their wording well. Our company will pay for the removal of teeth BEFORE radiation and they will replace teeth that have FALLEN out because of the radiation with dentures. They do not cover implants. When my husband was diagnosed, we had quite of lot of dental work completed in preparation, but I can't imagine that anybody would pull ALL of their teeth before radiation. His teeth are deteriorating. Some have fallen out, but most have simply broken off. The oral surgeon had to extract the teeth and the insurance company doesn't pay for extractions. [/quote]
My teeth started breaking off at the gums so I had crowns put on. I spent over $18,000 mp and fought with insurance for 3 years. Eventually they agreed and paid some because the dentist was out of network. There is a dentist in Garland that takes a OT of insurance and does pre-treatment consults for oral cancer patients. He has had success. Don't know what part of Texas you are in though.
Oddly, it took almost the same time to get some extracts paid for and we had to show that Medicare even paid before they would. Insurance companies are just a blast to deal with. Almost as much fun as a root canal without anesthesia. The hygienist tells me all the damage to my teeth is far less than what she sees and the office specializes in oral cancer patients.
Ed
SCC Stage IV, BOT, T2N2bM0
Cisplatin/5FU x 3, 40 days radiation
Diagnosis 07/21/03 tx completed 10/08/03
Post Radiation Lower Motor Neuron Syndrome 3/08.
Cervical Spinal Stenosis 01/11
Cervical Myelitis 09/12
Thoracic Paraplegia 10/12
Dysautonomia 11/12
Hospice care 09/12-01/13.
COPD 01/14
Intermittent CHF 6/15
Feeding tube NPO 03/16
VFI 12/2016
ORN 12/2017
Cardiac Event 06/2018
Bilateral VFI 01/2021
Thoracotomy Bilobectomy 01/2022
Bilateral VFI 05/2022
Total Laryngectomy 01/2023
| | | | | Joined: Mar 2013 Posts: 5 Member | | OP Member
Joined: Mar 2013 Posts: 5 | Thank you all for your comments and support. Between the extractions, implants, and fixed dentures, we're looking at over $50k out of pocket. I'm glad to see that people are fighting this injustice. We are not eligible for medicare and are fighting our insurance company. Hopefully, we can make a difference on both fronts. | | | | | Joined: Sep 2006 Posts: 8,311 Senior Patient Advocate Patient Advocate (old timer, 2000 posts) | | Senior Patient Advocate Patient Advocate (old timer, 2000 posts)
Joined: Sep 2006 Posts: 8,311 | I'm not suggesting that you don't "fight city hall" but have you considered going to a dental teaching school? Most offer free to discounted services.
David
Age 58 at Dx, HPV16+ SCC, Stage IV BOT+2 nodes, non smoker, casual drinker, exercise nut, Cisplatin x 3 & concurrent IMRT x 35,(70 Gy), no surgery, no Peg, Tx at Moffitt over Aug 06. Jun 07, back to riding my bike 100 miles a wk. Now doing 12 Spin classes and 60 outdoor miles per wk. Nov 13 completed Hilly Century ride for Cancer, 104 miles, 1st Place in my age group. Apr 2014 & 15, Spun for 9 straight hrs to raise $$ for YMCA's Livestrong Program. Certified Spin Instructor Jun 2014.
| | |
| Forums23 Topics18,168 Posts196,924 Members13,103 | | Most Online458
Jan 16th, 2020 | | |
|
