I am having a problem with insurance. As part of my routine dental visit, my dentist discovered a Erythroleukoplakia on the inside of my cheek.

I saw a DDS/MD who thought Ddx: Erythroleukoplakia Vs SCCa
- High suspicion for SCCa. I was then refereed to an oral cancer ENT / MD. My medical insurance carrier is denying all of the claims, CT, Biopsy and doctor visits because they say this is a dental claim and is excluded from my medical coverage. My dental policy has a very low maximum annual benefit. Is this right? Is all cancer a dental , not a medical issue? Do all oral cancer patient have to pay out of pocket?
Suggestions?

This is a fight many patients face every day.

It should be considered medical, not dental. Its all in the coding.

Without a biopsy its only guesswork. A biopsy is NOT dental, its a medical procedure.

Any denials should be appealed immediately.

You should be seeing the ENT for this. Its not something a dentist should be treating.

Good luck!!!

In reading the long contract of coverage for my plan, it specifically excludes all oral surgery. They are saying that this cancer inside my cheek is oral surgery and therefor excluded from the plan. The original DDS/ MD I saw ordered at CT and some blood work. They were all denied,

Thats from having the dentist refer you for these things. Most patients see an ENT who specializes in oral cancer. They are doctors who will oversee your care. The ENT can and should order all the necessary tests for you in order to treat you.

Below is a list of comprehensive cancer centers (CCC). They are the countries top hospitals to treat cancer. The CCC facilities all use a team based approach where the specialists get together so everyone is on the same page. If you cant get to a CCC, there is also a list of the top US hospitals. Look for a teaching hospital or university hospital. Find the best medical care you can and go with it.


CCC list

US News Best Hospitals List


Good luck!!!

Christine, My problem is I've already had the testing. They are refusing to pay for anything related to my diagnosis. I first saw an MD who is also a DDS in the dentistry department. I didn't know better. My dentist, who discovered it, referred me to an oral surgeon.
My insurance company is refusing to pay for the CT, LARYNGOSCOPY or the biopsy that was done by the head of the oral cancer section at the Cleveland Clinic. They are saying it is all oral surgery. Which is excluded from my plan.

It looks to me like time to "Lawyer-up" and contact the local press. In fact, I'd even consider contacting the press in the Insurance company's home town.

In my view, the insurance company is taking an absurdist approach, a competent lawyer who specializes in these kinds of cases would probably have fun with this, and the I should think that the press would appreciate a crack at it also.

Best of luck to you as this plays out, and "Illegitimus non-carborundum"

(Don't let the bastiges wear you down)

Bart

A biopsy should be considered medical, its a medical procedure no matter if its and ENT or oral surgeon who does it. Its possible that the coding is not correct which would cause the claim to get rejected.

I hate to say it but it sounds to me like this is going to be back and forth with no quick and easy fix. Dont give up! Keep appealing! You may need to send letters from the OS stating exactly what was done with correct codes and resubmit the claim. When talking with the insurance company be sickening sweet to whoever you speak to, it really does help.

Good luck!!!

[quote] When talking with the insurance company be sickening sweet to whoever you speak to, it really does help.[/quote]I often find when speaking with insurance agents they understand fully what is right and what is not right. And as humans they understand the right thing that should be done and if you appeal and connect on a personal level it is quite enlightening what they may offer at least as insight and often real suggestions of actions to move you forward and get out of the loop or banging the wall.

I find often that when speaking with insurance agents that regardless of whether they know what is right or not, they have an agenda to disallow things. It's a company designed to make money for the stockholders after all as their primary reason to exist. A new Rx drug is always a pain in the rear to get them to approve for instance, in my own case.

Don must be working with some extraordinary agents at the insurance companies as his experience does not parallel the experience of hundreds of people that call OCF with regularity that are have difficulties with their insurance companies. While any business has helpful and less so people in it, and any comment positive or negative about them is going to have exceptions, but for profit insurance companies have a history of behaving badly. Hence the need for the government to step in all too often and regulate them.

All that being said, I think that both Don and Christine's ideas that being polite is the obvious starting point is valid. But it does not always work unfortunately, and we as patients spend far too much time writing letters, documenting treatments that are necessary and needed, asking doctors to write letters that they should not have to, to justify a particular treatment or medication decision to the insurance company. Persistence, and even complaints to the state insurance commission are too often necessary. Bart's comment about the press is a tactic that we have used in the past, and companies in general do not like to be shown in a negative light publicly. You don't get what you deserve (and have paid for), you get what you negotiate or fight for, is a phrase that I hear far too often related to insurance companies.

As it appears there is no EDIT option on my post, I offer some clarification.

I agree wholeheartedly about the motives and structure and operation of for profit companies and that includes insurance companies. Left to their own account, their moral compass sit in the dumpster and regulations define boundaries and actions on behalf of their missing moral and ethical compass.

To clarify, I had two primary messages. 1) Be as nice as you can to the human on the other end of the call. Work hard communicating and connecting on some personal level; it only helps the human on that end to remember you are a human too.

2) They do this all day long and they know the standard procedures, escalation paths, and know very well the unmentioned options alternatives to move things along. A click on their screen can send you back to a variety of loops or might move you one step further to resolution.

Great post, full of wisdom, donfoo!