| 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: 7 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: 7 | 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: 7 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: 7 | 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.
| | | | Joined: Jul 2012 Posts: 3,267 Likes: 1 Patient Advocate (old timer, 2000 posts) | Patient Advocate (old timer, 2000 posts) Joined: Jul 2012 Posts: 3,267 Likes: 1 | Good suggestion David! Medicare does not cover routine dental care, and need to see about my teeth myself, which are all in disrepair from radiation in 2011, and are now either chipped, down to the pulp, gum line, and missing, and need all taken out most likely. I had an infection during my last treatment ending in November, 2012, and needed to see the oral surgeon in the otolaryngology department, and he did not want to remove anything at that time, but to come back after Tx to do HBO treatment, which I did before, t have extractions. That never happened between recovering, illness, dr visits, follow-up scans, hospitalization, etc, and held off as much as I could, and wonder how they will do that with my mouth only opening 3/4 of an inch. Plus, even if the teeth are removed, I can't get dentures due to the cost of them. Now I have another infection, took antibiotics, but didn't help much. I'm calling the oral surgeon today, and last time they set up a "Clinic" for me, whatever that means, but probably means charity work. The funny thing is I have full Medicare with A/B, D, and a supplemental or GAP coverage, and pay $600 a month and can't even get my teeth checked. If I had Medicaid, no problem, I would get everything, and then some. So much for working 30 continuous years, and paying taxes.
10/09 T1N2bM0 Tonsil 11/09 Taxo Cisp 5-FU, 6 Months Hosp 01/11 35 IMRT 70Gy 7 Wks 06/11 30 HBO 08/11 RND PNI 06/12 SND PNI LVI 08/12 RND Pec Flap IORT 12 Gy 10/12 25 IMRT 50Gy 6 Wks Taxo Erbitux 10/13 SND 10/13 TBO/Angiograph 10/13 RND Carotid Remove IORT 10Gy PNI 12/13 25 Protons 50Gy 6 Wks Carbo 11/14 All Teeth Extract 30 HBO 03/15 Sequestromy Buccal Flap ORN 09/16 Mandibulectomy Fib Flap Sternotomy 04/17 Regraft hypergranulation Donor Site 06/17 Heart Attack Stent 02/19 Finally Cancer Free Took 10 yrs
| | | | Joined: Jan 2013 Posts: 1,291 Likes: 1 Patient Advocate (1000+ posts) | Patient Advocate (1000+ posts) Joined: Jan 2013 Posts: 1,291 Likes: 1 | [quote]The funny thing is I have full Medicare with A/B, D, and a supplemental or GAP coverage, and pay $600 a month and can't even get my teeth checked. If I had Medicaid, no problem, I would get everything, and then some. So much for working 30 continuous years, and paying taxes.[/quote]I was gonna start but did not want to set off a bomb. LOL
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 | | |
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