Very frustrated with Anthem insurance and oral appliances

[robertin75]

Hello:

I have been struggling with Anthem for the coverage of an oral appliance.

I currently have Anthem Blue Cross Blue Shield insurance throught my job.

Today after a 1 hour phone conversation with an Anthem supervisor (after several unsuccessful tries over the last 2 weeks) I just found out that out of the total cost of the oral appliance ($2,800) they are only authorized to cover $510.

And because I have not met my deductible yet ($500) I practically would have to pay the dentist (Dr. Daniel Urban in Fort Wayne,IN who is not on Anthem's network) the full $2,800 out of my pocket.

Is this how this works?

I could not believe that Anthem could not find any provider in the USA that can do an oral appliance and that is on their network too.

Best help they could offer was to call a bunch of general dentists on their network ( YES, I said General Dentists) to see if one of them could do an oral appliance which I doubt.

Has anyone been successfully work with Anthem to find an in network dental sleep medicine specialist who can make an oral appliance?

I already have the insurance letter of authorization for the oral appliance.

I don't care if I have to travel out of Fort Wayne, Indiana as long as the dental sleep medicine specialist is on Anthem's network.

Thanks and help is greatly greatly appreciated,
Roberto

[NightMonkey]

Best help they could offer was to call a bunch of general dentists on their network ( YES, I said General Dentists) to see if one of them could do an oral appliance which I doubt.

There are many general dental practices that also fit oral appliances (mandibular advancement devices or MADs). Many of these do excellent work with the appliances, others don't. Your challenge is to find one that does and also pick the right appliance.

There is a general dentist that works with my sleep doc and he has an excellent reputation for fitting MADs. He meets with the sleep doc and talks about each patient she refers.

Maybe a more important question for you is what is your diagnosis and how do you know that a MAD will effectively treat your problem?

BTW, most insurance companies will gladly cover anything the employer wants to be covered. However start adding things to the list of benefits and the premium price will have to go up. Then either the employer or the employees will feel the pain of higher premiums.

[robertin75]

I am not sure what you mean by "general dental practices that also fit oral appliances". Are you saying that general dentists not trained in dental sleep medicine would be willing to take impressions, take them to the lab and get a custom fitted MAD? I personally would not like to go to one of those "self trained" general dentists. Unless of course I am misunderstand what you are trying to tell me.

I already went to one of those "I read a bunch of websites about oral appliances and am self proclaimed an expert in the subject" several years ago and I regret I did it.

So does your insurance covered your MAD cost made by a general dentist? Remember that in order for an insurance company to cover the costs of a MAD it has to go through a medical provider and not a dentist.

From what Anthem told me the only way they could cover my oral appliance is that the dentist is listed as a medical provider which I found to be almost impossible.

I mean how can a general dentist that does dental cleanaings, root canals, extractions, etc. is going to know about dental sleep medicine, how those appliances work, etc.

You asked about my diagnosis:

Diagnosis: UARS RDI=33.3. Been feeling miserable for the last 14 years (since 1997). Diagnosed by Dr. Barry Krakow in Albuquerque who was the one that just recommended me the oral appliance as I could not tolerate a PAP machine. I do have some cranofacial patterns includying a V shaped face that make me prone to have a sleep disordered breathing problem, most likely UARS.

I don't think going to my employer route is a good idea as I do not want them to know about my condition.

Any other suggestions on how to find an Anthem's in network dental sleep medicine provider that I don't have to pay them right away out of my pocket $2800 and get only $4 dollars refund?

As I said before Anthem only has authorized a maxinmum coverage of $510 for an oral appliance for out of network providers.

Thanks for your help,
Roberto

[josh816]

I had the same thing with Cigna and started a Network Adequacy Request. Because the oral appliance is a covered medical service, and their network has no trained/qualified/specialized providers to provide this covered service, they should pay for you to go to an Out Of Network trained/qualified/specialized provider at In Network benefit level.

With Cigna, it took a ton of calls, lots of pushing, but I finally got everything approved and in writing. I had to pay out of pocket for the device, which I was ok with. However, once they paid it, they initially paid it as Out of Network. Took another call to a supervisor to get that fixed. Then, they said that the charge was higher than their maximum allowable charge. I had my notes from where a previous supervisor had told me that did not apply for a Network Adequacy Claim, and had the verbiage from the plan document explaining the same. Finally got it paid at the correct level.

But I would suggest that you document everything very well, get everything in writing, be persistent to get everything paid correctly. Luckily, the dentist's office provided help which made the process go faster.

I am not sure what you mean by "general dental practices that also fit oral appliances". Are you saying that general dentists not trained in dental sleep medicine would be willing to take impressions, take them to the lab and get a custom fitted MAD? I personally would not like to go to one of those "self trained" general dentists. Unless of course I am misunderstand what you are trying to tell me.

I already went to one of those "I read a bunch of websites about oral appliances and am self proclaimed an expert in the subject" several years ago and I regret I did it.

So does your insurance covered your MAD cost made by a general dentist? Remember that in order for an insurance company to cover the costs of a MAD it has to go through a medical provider and not a dentist.

From what Anthem told me the only way they could cover my oral appliance is that the dentist is listed as a medical provider which I found to be almost impossible.

I mean how can a general dentist that does dental cleanaings, root canals, extractions, etc. is going to know about dental sleep medicine, how those appliances work, etc.

You asked about my diagnosis:

Diagnosis: UARS RDI=33.3. Been feeling miserable for the last 14 years (since 1997). Diagnosed by Dr. Barry Krakow in Albuquerque who was the one that just recommended me the oral appliance as I could not tolerate a PAP machine. I do have some cranofacial patterns includying a V shaped face that make me prone to have a sleep disordered breathing problem, most likely UARS.

I don't think going to my employer route is a good idea as I do not want them to know about my condition.

Any other suggestions on how to find an Anthem's in network dental sleep medicine provider that I don't have to pay them right away out of my pocket $2800 and get only $4 dollars refund?

As I said before Anthem only has authorized a maxinmum coverage of $510 for an oral appliance for out of network providers.

Thanks for your help,
Roberto

[robertin75]

Unfortunately I already did lots of pushing, tons of phone calls, etc. and they told me that the maximum allowed coverage for an oral appliance is $510.

So there is not going to be in the whole USA a dental sleep medicine specialist that is an in-network provider? That amazes me to be honest

So how much did you end up paying out of your pocket and how much did the insurance reimbursed you?

Seems to me that you got full coverage because a supervisor told you verbally what he shouldn't.

[josh816]

Stick with it. It's a covered service and my coinsurance was 20%...so either they have to have a provider who will provide it at 20% of the allowable amount, or if their network is not adequate to provide a covered service, they have to cover an out of network provider at an in network rate. Here's a post that has all the details of my cost, etc. viewtopic.php?f=1&t=65759&p=613428&hili ... ce#p613428

Their maximum allowed charge is based upon calculations of like services provided in your geographic area. Challenge them to find where you can get it for $510. Are you sure they looked up the right HCPCS code?

Continue to push and escalate it. If they do not approve it, file a written appeal. Form is here: http://www.cigna.com/customer_care/memb ... l.pdf?5357 Then you can fax it in to 859-410-2419.

Let us know how it goes. Make sure you use a doctor who has experience with the oral appliances...not one who just started selling them for $$$.

Here's some links for more info that may help:
http://www.snoringisntsexy.com/
http://www.ihatecpap.com/
http://www.cigna.com/healthinfo/hw49127.html
http://www.aasmnet.org/Resources/Practi ... icance.pdf

Unfortunately I already did lots of pushing, tons of phone calls, etc. and they told me that the maximum allowed coverage for an oral appliance is $510.

So there is not going to be in the whole USA a dental sleep medicine specialist that is an in-network provider? That amazes me to be honest

So how much did you end up paying out of your pocket and how much did the insurance reimbursed you?

Seems to me that you got full coverage because a supervisor told you verbally what he shouldn't.

[NightMonkey]

robertin75

Sorry for the delay but I am very busy this week.

Two more questions before I reply.

How old are you?

How long do you want to live?

[robertin75]

robertin75

Sorry for the delay but I am very busy this week.

Two more questions before I reply.

How old are you?

How long do you want to live?

??????????????

Please stick with the discussion.

I don't want to answer those kind of questions.

Thanks

[NightMonkey]

It's not off topic. Age makes a difference in what therapy you might want to pursue.

[robertin75]

Stick with it. It's a covered service and my coinsurance was 20%...so either they have to have a provider who will provide it at 20% of the allowable amount, or if their network is not adequate to provide a covered service, they have to cover an out of network provider at an in network rate. Here's a post that has all the details of my cost, etc. viewtopic.php?f=1&t=65759&p=613428&hili ... ce#p613428

Their maximum allowed charge is based upon calculations of like services provided in your geographic area. Challenge them to find where you can get it for $510. Are you sure they looked up the right HCPCS code?

Continue to push and escalate it. If they do not approve it, file a written appeal. Form is here: http://www.cigna.com/customer_care/memb ... l.pdf?5357 Then you can fax it in to 859-410-2419.

Let us know how it goes. Make sure you use a doctor who has experience with the oral appliances...not one who just started selling them for $$$.

Here's some links for more info that may help:
http://www.snoringisntsexy.com/
http://www.ihatecpap.com/
http://www.cigna.com/healthinfo/hw49127.html
http://www.aasmnet.org/Resources/Practi ... icance.pdf

Unfortunately I already did lots of pushing, tons of phone calls, etc. and they told me that the maximum allowed coverage for an oral appliance is $510.

So there is not going to be in the whole USA a dental sleep medicine specialist that is an in-network provider? That amazes me to be honest

So how much did you end up paying out of your pocket and how much did the insurance reimbursed you?

Seems to me that you got full coverage because a supervisor told you verbally what he shouldn't.

I am not sure what you mean by HCPCS code.

By the way I do not have Cigna. I have Anthem BCBS.

This is the dentist I saw:

http://www.sleepdisorderhelp.net/

Unfortunately he is out of Anthem's network and would have to pay him $2,800 and Anthem would refund me like $4 dollars. Yes FOUR dollars.

Thanks

[josh816]

Stick with it. It's a covered service and my coinsurance was 20%...so either they have to have a provider who will provide it at 20% of the allowable amount, or if their network is not adequate to provide a covered service, they have to cover an out of network provider at an in network rate. Here's a post that has all the details of my cost, etc. viewtopic.php?f=1&t=65759&p=613428&hili ... ce#p613428

Their maximum allowed charge is based upon calculations of like services provided in your geographic area. Challenge them to find where you can get it for $510. Are you sure they looked up the right HCPCS code?

Continue to push and escalate it. If they do not approve it, file a written appeal. Form is here: http://www.cigna.com/customer_care/memb ... l.pdf?5357 Then you can fax it in to 859-410-2419.

Let us know how it goes. Make sure you use a doctor who has experience with the oral appliances...not one who just started selling them for $$$.

Here's some links for more info that may help:
http://www.snoringisntsexy.com/
http://www.ihatecpap.com/
http://www.cigna.com/healthinfo/hw49127.html
http://www.aasmnet.org/Resources/Practi ... icance.pdf

Unfortunately I already did lots of pushing, tons of phone calls, etc. and they told me that the maximum allowed coverage for an oral appliance is $510.

So there is not going to be in the whole USA a dental sleep medicine specialist that is an in-network provider? That amazes me to be honest

So how much did you end up paying out of your pocket and how much did the insurance reimbursed you?

Seems to me that you got full coverage because a supervisor told you verbally what he shouldn't.

I am not sure what you mean by HCPCS code.

By the way I do not have Cigna. I have Anthem BCBS.

This is the dentist I saw:

http://www.sleepdisorderhelp.net/

Unfortunately he is out of Anthem's network and would have to pay him $2,800 and Anthem would refund me like $4 dollars. Yes FOUR dollars.

Thanks

But it sounds like they have no one qualified that is In Network, right? If that's the case, then their network is inadequate and they need to make a Network Adequacy Exception for you. If you can't get them to approve it over the phone, send in a written appeal. Written appeals will help them cover what they're required to. Be sure to get a copy of your complete benefits booklet (100+ pages) and cite the appropriate passages.

Bottom line, it's a covered service, their network isn't adequate, so they have to make that right by approving an out of network provider. And since there's no in network provider, the maximum reimbursable charge does not apply.

[robertin75]

It's not off topic. Age makes a difference in what therapy you might want to pursue.

I'm 35 years old and as I said I could not tolerate a PAP machine (BiPAP).

Thanks

[NightMonkey]

I'm 35 years old

OK, that is good to hear. Now some more questions.

- How many teeth do you have? (Go to the mirror and count them.)
- How many of the four wisdom teeth are missing?
- Do you have any "crooked" or overlapping teeth?
- If not, have you had braces for teeth straightening? Were any teeth extracted at the time?
- Are the sides of your tongue smooth or do you have scalloping on the sides due to crowding against the teeth? (http://www.sleepguide.com/forum/topics/ ... e=activity)
- What is your BMI? (http://www.nhlbisupport.com/bmi/bminojs.htm)

I could not tolerate a PAP machine (BiPAP).

- What were your pressure settings?
- Which manufacturer and model of mask(s) did you use?
- Which model of BiPAP did you use?
- Did you regularly monitor data (AHI, leak, etc.) with your machine? Did you have the software to aid this process?
- What kind of support did you have to help learn to use and sleep with the machine and mask?
- In your estimate, what were the specific problems that made CPAP intolerable for you?

Be patient.

[Robert Dauws]

Can anyone help me find a good dentist in Austin?

[CruzTerri]

Go to your employer's benefits person and ask for the SPD - This is the complete information on your coverage. Ask if you can have a copy of it. This will provide additional information. Much more so than what is in the "plan booklet" you may get.

The "SPD" will have information on how to appeal the decision, etc. It's the complete "policy" document.

Good Luck.