I want to share an update with you about my Journey to Dental Implants. You may recall that last year I shared that I started my journey to dental implants as a teenager, but was unable to complete the journey at that time. In April 2017, I took up the journey again because I’m having increasing problems with denture slippage. It has been 11 months, so I thought I would take time to share my journey to dental implants – part 2.
The Journey to Dental Implants – Part 2
So, what has happened in the last 11 months?
Let me make sure I understand this correctly. So, I can have have surgery to place studs in my cheeks that will support a fixed plate, to give me permanent dentition, but I can’t have the fixed plate? So the surgery is then pointless? Yep. That about sums it up.
The Language of Our Blue Cross Blue Shield of Illinois Health Plan
Our insurance policy clearly states the following, in writing…
“This plan covers medically necessary services and supplies that are required to treat congenital abnormalities and hereditary complications (a physiological or structural abnormality that exists from birth or latent abnormality or hereditary complication that appears after birth). This benefit applies to covered newborns and to all other plan participants. ”
“This plan covers certain services and supplies that are provided by a physician or dentist. These services include… surgically placing endosseus implants, but only if success is reasonably expected for at least five years or longer… If these services also are covered by your Company-sponsored dental plan, the dental plan will pay benefits first, and the medical plan will pay second under the medical plan’s coordination of benefit rules.”
“This plan covers… artificial limbs, artificial eyes, and other prostheses that replace a missing body part. Repair and replacement of prostheses when required because of normal use or a change in condition (such as growth of a child).”
Why Coverage Should Be Granted
AEC Syndrome is one of the ectodermal dysplasia syndromes. Ectodermal Dysplasia is a congenital abnormality (i.e. birth defect). Ectodermal Dysplasia can affect anything that arises from the ectoderm — hair, skin, teeth, nails, sweat glands, salivary glands, and mucosal layers of certain organs. Wait… teeth? Yes. Teeth. TEETH. Ectodermal Dysplasia can result in partial or complete anodontia. Partial anodontia is the congenital absence of most primary or permanent teeth. Complete anodontia is the congenital absence of all primary or permanent teeth. So, Ectodermal Dysplasia can result in the partial or complete absence of primary or permanent teeth.
AEC–> congenital abnormality –>anodontia (partial or complete)
Are you tracking with me?
So, if I rewrote the insurance statement above, it would say…
“This plan covers medically necessary services and supplies that are required to treat congenital abnormalities (ectodermal dysplasia) and hereditary complications (a physiological or structural abnormality (anodontia) that exists from birth or latent abnormality or hereditary complation that appears after birth). This benefit applies to covered newborns and to all other plan participants.
But Blue Cross Blue Shield of Illinois doesn’t see it like that. So, I have a stack of denial papers, one denied appeal, and another appeal in the works.
The Language of the Denial Letters
The denial letters from Blue Cross Blue Shield of Illinois state, “No benefits are available for the procedure” and “would not be eligible under the member’s health care benefit plan.”
Remember the luxury automobile that the implant specialist compared the cost of my zygomatic implants to? Right now insurance is saying they will cover the engine, but not the rest of the automobile. Zygomatic implants without a fixed plate are about as useless as an engine without a car.
The benefit plan says birth defects and prostheses are covered. So, can we jump out of the loop hole and do the right thing?
I won’t lie. This is incredibly frustrating, because it is SO UNFAIR. I watched my Mom battle insurance companies my entire life for medically necessary treatments for my sister and I. I had hoped that insurance companies had moved beyond the practice of denying coverage for procedures that are clearly covered by the policy. Apparently, they haven’t.
All that said, my son and I are are excited to be asked to represent Missouri at the NFED Advocacy Day on Capitol Hill on July 18, 2018. We will fly to DC on July 17th for training. We’ll meet legislators, on July 18th, to share our stories of unfair insurance denials, including this current ongoing battle, and advocate for legislation requiring medical insurance to cover medically necessary dental treatment that arises from a birth defect, like the ectodermal dysplasias. We will fly home on July 19th. We are fundraising a portion of our trip, so if you’d like to help us get there, please visit our NFED Advocacy Day on Capitol Hill Fundraiser.
Stay tuned for future updates, because I refuse to give up before I’ve exhausted every last appeal and independent review available to me.