Metal Mouth Message Board

My son is now 10 yrs of age. He was born with a Neuro Muscular Disease that affected his mouth and face shape among other things. He was further intubated for a long time and had a trache for several years. As a result his mouth and teeth are mis-shaped. His teeth don't meet and he can't chew. He has been on tube feeding since birth therefore has other aversions to eating.

His doctors and dentist are now satisfied that he is ready for work to be done on his mouth. We have an incomplete dental policy and our BCBS medical policy on its surface does not include any orthodontic work. The dental work is going to be rather expensive. I intend to petition his major medical plan BCBS anthem to cover cost. But expect difficult time.

Does anybody have any recommendations for getting BCBS to cover cost?

Thomas,

I'm a claims adjuster. The claims I handle are different from health insurance claims, but here are a few suggestions:

Generally, if a procedure is specifically excluded under a policy the company has no obligation to pay for it regardless of whether you petition. Your best bet is to find loopholes. Become friendly with people that are in charge of billing at doctor’s offices or hospitals. They can help you find them.

Get a complete copy of your BCBS policy. Look closely at what is and isn’t covered. Study the definition of orthodontics. If the policy doesn't have its own definition, use one from a reputable source. Review the requirements for how appeals are processed and adhere to them. Then work with your son’s doctors to find a way to reclassify the treatment as something other than orthodontics. They must prove the treatment is medically necessary. Some insurance policies have their own definition of this term so take a look at that as well. They will still deny your claim. That’s when you petition and/or get an attorney. It’s easier to petition something that falls into a gray area than it is something that says “not coveredâ€