I live in Maryland and have Blue Cross Blue Shield "Blue Choice" - I am currently wearing a dental appliance and receiving chiropractic therapy for TMJ. By the end of August I might be ready for reconstruction of my teeth with no surgery. The back teeth will be redone as caps or crowns to raise the heighth of my teeth to prevent some jaw pressure and bruxism. The dental appliance is doing that now and with therapy the headaches and some neck and jaw pain are gone. The front teeth however will be done (just the top) like veneers. Has anyone experience this situation and gotten some medical benefits to pay for this? I talked to representatives of Blue Choice and its all about how it is coded.
If anyone could help it would be greatly appreciated.
Last edited by hb-mod; 11-23-2009 at 12:14 AM.
Reason: Please do not post contact information, such as email address or name.
When I had private medical insurance provided by my employer (United health) they covered my oral appliances under Medical Equipment with the diagnosis of cranio-cervical disorder. My alternative treatments such as PT, chiro and cranial sacral therapy were also convered. I could probably look up the diagnosis and procedure codes they were submitted under -but this was a few yrs ago so it might take me some time to find them but I think if you provide that info to your dentist's office they should be able to look it up. My medical insurance however would not cover any work done to my teeth nor the drs fee to perform the work - they can of course argue that if the splint were worn for the rest of your life you would remain symptom free. However in researching this I did come across several lawsuits where patients sued their medical insurance carriers on the grounds the dental work was necessary to permanently correct their bites and prevent their tmj symptoms from returning and I believe few did win their case. Also - you may need your dentist to be your advocate on this - he may need to submit something on your behalf that strongly argues why the work is necessary and how it will alleviate your former tmj condition or symptoms of returning and how this will in the end also save them money in future tmj treatment (pt, chiro, etc) - he needs to point out how your condition affects you on a physical level and raise other medical issues or conditions that may result if this is not corrected. Many more states are now mandating that private insurance cos cover more and more for tmj but still shy away from anything dentally related. Also - tmj as a diagnosis code is less likely to be be covered by private insurance carriers so you may want to call them and find out if they cover myofacial pain syndrome, cranial-cervical disorder or oromandibular cranial disorders - theses often present the same symptoms of tmj/tmd and many drs and dentist use them interchangeably and don't mind using them for insurance ppurposes.
I live in PA. Now, I have TMJ which has been under the category of "surgical" for the past nine yers. In the beginning, 2000, I was still married and under my husband's company paid health insurance. The procedures were always covered at that time under medical vs. dental. Today, I am divorced and have recently been accepted under PA's Medical Assistance Health insurance. Once accepted in to the MA program, I was given a choice of three medical carriers to choose from, based on the county I live in too, I must mention, but none-the-less, I chose the insurance I wanted. Years ago, I worked with hospital based physicians and physician groups, I did the billing, ie: radiology, anesthesiology, ER docs..etc, etc, you get the picture. My point is back then Medical Assistance did not offer different health insurance carriers. MA was one insurance, a cookie cut-out for everyone who had it,and they had to make the insurance fit, no options like I have now. Back then, if you had MA, the ID card was identical to every members' card, and benefits were pretty much the same for all too.
Today, as I said, according to county, a member is given the option of three choices..and one can pick which insurance works best for him/her. I chose Keystone Mercy which is a part of BC/BS. The ID card is no different than an ID card offered though an employer. Benefits are terrific! It's actually better than my ex's insurance, and costs me nothing. It offers RX coverage with co-pays of $0, $1, or $3 depending on meds prescribed. Doctor visits have no co-pay, and so far specialists have no co-pay either..only a referral needed for certain specialists and not others. Hospitalization as in patient is $3/day up tp 7 days, then MA covers the rest at 100%!! Labs are covered 100% too. I just had pre-op testing done..H&P from PCP, EKG, blood work and chest views..all at no cost to me whatsoever. My TMJ surgery is estimated at $90,000 from all doctor fees..surgeon, anesthesiology, radiology, pathology, hospital stay..just to name a few. All OR fees are covered..just about everything I can think of. I was told every charge associated with my surgery (prosthesis too) would be covered. Even after care..PT, fixing my broken teeth resulting from TMJ..all of it. Please note though that I have been deemed unable to work due to the TMJ problems. I have read that a person can work part time, and still receive MA benefits. They have really changed what they offer peole who need it so much since I used to do billing and have the need for the coverage myself today. It doesn't carry the stigma it once had. I'm happy to see that finally happened. People deserve to be treated equally, whether they can work or not..and not be ashamed to accept MA. It's not a "hand-out". It's a right and privelage to be able to receive quality care, and choose what docs and hospitals in which to receive that care.
My point is, to Douglas Carter, that there are other options available other than traditional BC/BS..as I told you of my case. Yes it is true, that insurances do code everything form the doctor's office visit, diagnosis, procudures done to symptoms you experience. Words are converted into numbers. How and which codes used, are important. In my almost 20 years experience in doing coding for medical billing, I do know that if a code is rejected, it can be corrected by the doctor and resubmitted for reprocessing. Just keep tabs of your EOB's (Explanation Of Benefits), so you know what's happening and the office staff isn't lazy, gets the rejected EOB and just sends you the bill for what should have been covered, iof the correct coding was used. The EOB will tell you the reason it was rejected, and from there, I'd call my insurance carrier first to find out more detail, then hit up the doctor's office so it's done right, and you're not stuck making 100 phone calls. I hope this helps. I'm being rather vague b/c I'm describing a hypothetical, but commom situation according to my experience in that field.
You may want to check out Medical Assistance in Maryland too, if it is an option for you..it's worth it if you are accepted. Good luck to you and let me know what happens.
Thanx a lot to both of you! I will start my collection of benefit papers and educate myself on the procedure codes. We have weekly meetings at our office with the Blue Choice representatives. I will start "drilling" them about once a month until work tells me I'm not allowed to go anymore.
As I gain knowledge I will pass it on.
I have horizon blue in nj and they won't cover anything. The neurodentist was very good at putting the code under arthritis, myfacial pain, temporal tendonitis, etc, and they would cover maybe 1000 out of 6500, and that was maybe. I called them, the dentist called them and all without luck. i hope you have better success.
HI -WOW! I live in the neighborhood right behind Dr. Miller. I didn't know he treated tmd problems. How long have you been in an appliance and what were your original symptoms?
Stormy - I have been wearing the appliance for quite a while. I try to keep it in as much as possible. I grind my teeth very much and my symtoms where headaches, stiff neck, tooth and jaw pain. The appliance cost $550. It definitely helps. It is designed to keep your teeth apart. I also go to Dr. Hollenberg (Chiropractor) across the street at Life Force Chiropractors. Medical Insurance pays for that. Started 3 times a week, down to once a week.
If I go the whole 9 yards on the fix, I will have caps put on my rear teeth to make them taller and then possible do the veneers on the top teeth in the front. Big Money - been working on finding benefits from medical insurance instead of my dental insurance.