Insurance Agent Forum

[msweet11]

In the process of getting dental care, I have been investigating dental implants. While getting evaluated, they sent me for a CAT scan of my jaws.
Two specialists have told me that my lower jaw is deteriorating. My lower jaw bone is only about 1/4" thick now instead of 2" or so for a healthy jaw.

They have advised me that I need bone grafts from my hip to my jaw. Then they will put in one implant on each side to prevent my jaw from deteriorating further.

If I don't have the bone grafts, I will continue to lose bone and will not be able to eat solid food eventually (about 10 years from now). Also my jaw bone will be very fragile and will break easily. I am currently 57 and lost several of my back lower teeth almost 50 years ago (when dentistry was not able to save teeth as they can today).

I have been strongly advised to have the bone grafts soon. Will my health insurance pay for the hospital stay and bone graft operation? I have Kaiser. I am not asking for any money for the dental implants.

My dental insurance has a $1500 limit per year so there's not much help there.

I am willing to appeal a negative decision from Kaiser- is there a particular format that works best? I can attach the CAT scans of my jaw which are pretty horrifying. My dentist will also write a letter for me.

Thanks so much for any help or ideas. I appreciate your time.

[STIBROKER@AUSTIN.RR.COM]

Have you tried your health insurance........

[msweet11]

I haven't sent everything into Kaiser yet- I am just asking for guidance from insurance agents on my chances of getting Kaiser to approve it.

Alos--If there is a way to structure my request that works well, I'd love your input, agents.

Or maybe I just put it out there and see what they say.

[Dave020]

I'd say the chances are going to be directly related to who makes the request for the procedure. Kaiser may not be inclined to take the advice of outside physicians or may want an in house physican's opinion.

Best thing I can think of would be to have your Kaiser doctor look at everything and make a determination of the necessity of the procedure. That might carry a little more weight with kaiser than an outside opinion.

Also, you might check and see if such a procedure would be covered under the healthcare plan and, if so, under what conditions.

It sounds like a medical procedure as opposed to dental and as such could be classified as cosmetic unless it is demonstrated to be medically necessary by a physician (and probably at least one second opinion).

Good luck and let us know what you find out.

Dave
www.davefluker.com

[K-Dub]

One of the main reasons I don't care for and don't offer HMO's!!

Good luck!

[BOR]

Msweet, even tho I'm an insurance agent I'm speaking to you as an individual who has had various bone breaks and abnormalities.

Make sure you have additional images taken of your jawbone, particularly high density images. Twice I've had bone images taken that displayed the bone as being very thin in density (very thin) yet when taken on a higher quality imaging machine the bone showed to be normal density. So the imaging machine can distort the actual bone density.

Don't let any doctors talk you into bone grafts until you are absolutely convinced you need a graft. Even if your bone is thin in that location I wouldn't jump into a bone graft unless you are experiencing pain or discomfort in the area. For all you know you may have had thin bone in that area since birth. Find out what foods and supplements/vitamins and other alternative treatment that may provide density to that bone area.

Now speaking to you as an agent: My guess is that if their is indeed a problem in your jawbone that would require treatment that there is a good chance your jawbone would be treated like any other bone in the body. I don't see any difference in needing a bone graft in the jawbone than a bone graft in your hip or anywhere else. But then again that's just my opinion. The wording in your policy would be the determinant. Make yourself a pot of strong coffee or whatever else keeps you awake, pull out your policy and start reading. Most of all best wishes, hope everything turns out the best for you :!:

[healthagent]

You're asking a question no one on this board can answer. You'll need pre-authorization for the surgery and it must be deemed medically necessary.

For example, who's saying you need the surgery? If it's an orthopedic specialist you might be in good shape. If it's just a dentist saying you need the surgery you can most likely forget it.

[msweet11]

Thanks for all your advice- it was very helpful- I shall prepare a bulletproof case or try to anyway.


Best,
M