hi folks,

i had radiation and chemo in '01, so i don't produce much saliva anymore. i've been on prescription fluoride toothpaste since then. always approved by BCBS, until this past week...

denied, denied, denied. sounds like Suze Orman has gone to work at BCBS.... they claim that it is excluded because it is 'preventative' dental.

i need to send letter to them, which will be reviewed by outsiders, to overrule their assertion.

i'm seeking some help putting this together... i suppose that other folks are likely run into this, so i suspect that a 'form' letter on this site would be helpful.

i'm thinking that this should be payable because
(a) i have a medical condition that requires it. this is an existing condition (what's it called)?
(b) the medication is treatment for the condition.. 'treatment' not prevention!!
(c) flouride is a minineral
(b) the toothpaste is only available by prescription

given those factors, my claim doesn't fit their exclusion,
it fits under normal prescription terms.

am i close?

cu,
larryb

Larry,

Have your dentist or ENT write the letter...they can use all the phrases that need to be included. Did you have BCBS when you were undergoing treatment...that might help establish the need. Even if you didn't, you can still show what your dx and treatments entailed. You have xerostomia, a result of radiation to your parotids..plain and simple. If you go to the main OCF site and into the link for dental issues after treatment, you should have lots of ammunition for your letter. But, I would first ask the docs to write the supporting letter.

Deb

I agree, if you need the letter, it needs to be written by your doctor, medical if it is medical that is paying for it, dental if dental insurance.

Who did you speak to at BCBS? A peon or a supervisor? Did you point out that this has been covered since 01 ansd give them dates of service for recent coverage? You need to call back and find out fron a SUPERVISOR why the change in coverage and what the letter needs to state so that is covered again. It could be being denied because they need info that the condition still exists. They do this to me all the time - like a total laryngectomy is going to go away. I only wish. I have an item that I have a letter for, but I have to call for any override eveytime to get it processed at the correct price. Can't teach them computers to do anything out of the ordinary. Good luck and keep fighting it.

Take care,
Eileen

Why bother with the tooth paste? Why not ask for prescription foam instead? I do pay for my own fluoride foam but I have not attempted to submit a claim. They might cover that.

Get your RO to call and explain that this is a medical necessity. That's how my RO got them to pay for Carnation VHC which I is what keeps me alive and kicking for now.

larryfb,
First, I would like to say that I believe you should be covered for fluoride supplementation due to your recent history. Prescrition fluoride toothpaste is a good product. I don't utilize it very often in my patients with reduced salivary flow because in my experience topical fluoride applied via custom fluoride trays are much more effective in protecting the teeth from deterioration and patients prefer them and are much more inclined to follow my instructions.
However in the research I have read there is no significant difference in the benefits of prescription fluoride toothpaste compared with fluoride rinses and/or gels in protecting the teeth if used properly. In my practice, in Canada, I have had few occasions where a patient's insurance has not, at least partially, covered additional fluoride use if presrcibed by a dentist or doctor. In recent memory I have had to write one letter for a patient to their insurer and it resulted in coverage for the patient.
If the letter you send to your insurer is unproductive ask your dentist and/or doctor about alternative fluoride products as you may have coverage for a different method of application.
Please contact me if I can offer any further assistance or answer any questions.
Cheers,
Mike

thanks for everyone's input.
the letter below follows the insurance company's guidelines.

we'll see how it goes.

cu,
larryb


====================================
Dear Customer Care Representative,

I have been a BCBS participant for more than 10 years. This letter is in response to the BCBS denial of payments for 1.1% Sodium Fluoride dental cream. BCBS has paid for this medication for 7 years, so this denial was a surprise to me and seems to be due to a misunderstanding. My medical condition has not changed and will persist. Herein I review the circumstances so that the error can be corrected.

In 2001, I was treated with radiation and chemotherapy for oral cancer. Radiation treatment for the illness resulted in me having Xerostomia. The attached material explains Xerostomia and states 'To protect against tooth decay during and after treatments, patients with xerostomia should apply fluoride to the teeth daily to protect them.' I have followed that protocol since 2001 and continue to do so. Until now, BCBS has paid the co-pay. The facts:
a) I have a medical condition, Xerostomia.
b) My physician, Dr. S a licensed dentist in the US, prescribed fluoride treatment.
c) The drug is FDA regulated and only available by prescription.
d) The treatment is normal\standard\recommended for the condition that I have.
e) I purchased a generic equivalent.
f) I purchased the medication at a retail pharmacy.
This medication is for treatment of an Existing Medical Condition. Therefore the appropriate section of 2008 BCBS Service Benefit Plan book is Pages 85-87, where the requirements for payment of Covered Medications are presented. The facts of my claim conform to those requirements for BCBS payment of 'Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United States require a prescription for their purchase.' On the other hand, the BCBS handbook does not list exclusion of payment for treatment of Xerostomia, or any other existing medical condition.

Thus BCBS should reimburse me for my prescription expenses on 4/6/08 (75% x $20.99 = $15.74) and provide similar payments while I am a BCBS participant. Thank you for your efforts.

Sincerely,


Larry Bliven

I concur with the medical facts of this letter. _______________________Dr. S.
Attachments: Oral Cancer Foundation article on Xerostomia.
Walgreens Pharmacy Receipt

Good luck. Mine has never been pad for, either. You can appeal it as high as you feel like going. I really hate insurance companies. I know they have to control costs but what makes them think they can over ride a doctor?

Good luck, let me know how it turns out.

The insurance company responded to my letter with a demand that i get a letter from my doctor and that i release the medical records for the past year. paperwork to be completed within 60 days.

i thought this was a bit much and decided to sit on it.

then someone with a functioning brain at the insurance co read the material that i submitted - they sent me an approval letter.

in the grand scheme of things, this was a very minor victory. however, i feel better because i went thru the process and things worked out.

the material from the OCF certainly strengthen\made my case for me. thanks for being there.

cu,
larryb