Hi! I will be having a telephone call to appeal to my insurance company for their denial of braces for my son and my daughter. I am not a dentist, but I believe it when my dentist says braces are necessary for them. The orthodontist thinks so too. The insurance company does not agree. Anybody have experience with this type of situation? Any advice?
I don’t know that it makes a difference, but the orthodontist is at a University Dental Clinic, not a private practice. So, the orthodontist doesn’t stand to profit.
This shouldn’t make a difference; I doubt that your insurance company is looking at (nor cares) how much, if any, money the provider would be making on the procedure.
You have both a regular dentist and a specialist who are recommending braces as “necessary” for your children, which should help, but the insurance company seems to be question the medical “necessity.”
I can’t give any good advice, but I wish you luck.
Braces are typically for aesthetic reasons, not for medical reasons. Insurance companies typically don’t pay for things that make you look better. If the teeth are misaligned so much that the person can’t eat, then maybe the insurance company would pay since that would be more of a medical reason. But if it’s the more typical case of slightly misaligned teeth, then insurance isn’t going to cover it. That may seem unfair, but it keeps premiums lower. If you had insurance that covered braces, you’d pay for the braces over time in the higher premiums. The dentist may say braces are necessary, but that means necessary to have straight teeth. It doesn’t mean that braces are medically necessary for the child.
The other thing to consider is that dental insurance is typically very explicit in what it covers. For example, it may cover no crowns, a single crown, or unlimited crowns in a calendar year. And each level of covered services will have different premiums. You can pay a little and get a little, or pay a lot and get a lot. But regardless, the level of service is often spelled out very explicitly with dental insurance. If you don’t have coverage for braces, it’s because you have a plan which doesn’t include braces in the coverage.
No, they are not too young. Basically, uh, we have got some hillbilly teeth. They are too crowded that they are crushing each other, which is only worse looking at wisdom teeth coming in. I guess there is a score system and while they both had a lot of points, it was not enough.
I never had to make an appeal about anything before. I just know the dentists and orthodontists who have seen them are unanimous to say they need braces. To me, it’s not necessary just for the appearance. Well, one of them does have one particular noticable weird tooth, but it’s not THAT bad to make them ugly or anything. So, I don’t know.
So, my question was if anyone had any experience or advice about filing an appeal with an insurance company. Maybe you misunderstood. Nobody asked for a basic explanation of insurance.
Thank you. I think an orthodontist with a private practice has a motivation to recommend braces, even if just for cosmetic reasons. That’s a couple years contract for guaranteed income. The orthodontist doesn’t make money telling people they don’t need braces. In comparison to the student orthodontist and the attending professor at the University clinic. One is paying for the class, and one is getting paid to teach. Regardless if my insurance pays or not.
A suggestion I’ve gotten which worked for dental was to get the reason from the dentist/orthodontist as to why it is needed, be sure to get the big medical words and phrases and handwrite an appeal letter (and use those words/phrases) It worked for me getting an implant 2 decades ago when that was pretty much forbidden for insurance.
Years ago, I commented to my wife of two years (we were engaged for an additional four years previously) how lucky she was to have perfectly aligned teeth and absolutely NO cavities. She pointed out that her teeth were so straight because she only had 28 of them. True. She had no adult lateral incisors on her maxilla (upper jaw) and no third molars on her mandible (lower jaw). They were not extracted…they just never developed.
Now, how could I have not noticed in six years that she had no lateral incisors? I can understand that I would not see that she had no third molars, but being oblivious to her canines being separated by only her two incisors?
I’m just trying to be helpful with my life experience. My experiences with braces are with my own kids having braces and with talking with other parents in similar situations. No one I knew had insurance cover braces. It was either pay up front or with monthly payments. And these are with people who have high-quality, employer dental insurance. I’ve also owned a company where I shopped for dental insurance. The plans I saw didn’t have coverage for braces. If you have a plan which covers normal “my kid needs braces to straighten teeth”, then it’s a pretty unusual dental plan. Many parents would love if dental insurance covered braces, as it would save them thousands of dollars. I wish you luck in dealing with the insurance company, but unless you have some reason to believe your policy is unique in some way that it covers braces in your situation, I doubt insurance will cover it.
My advice is this: You have to read the actual insurance policy to see what they promised to cover and what they said they wouldn’t cover. What the dentist and orthodontist think is necessary is not important until you know what the dental insurance covers. If it covers “necessary” dental care, then maybe you have a point. If it excludes braces, then it excludes braces. Maybe it excludes braces, except when necessary for one reason or another. You have to review the policy and frame your argument based on the language there.
When you do so, remember that in most places (all that I know of) coverage is interpreted broadly and exclusions are interpreted narrowly. So, any ambiguity in the language should be viewed in the light most favorable to you.
Thank you. This is helpful. I am going to contact both my dentist and the orthodontist to get more information. I don’t understand the necessity myself.
My insurance did cover the orthodontist appointment. The orthodontist says braces are necessary. If the braces are medically necessary, the insurance is supposed to pay for it. It is not being suggested as a cosmetic enhancement.
Just as a data point, my dental insurance covers orthodontics, including braces. It’s a benefit specifically for that, and there’s a monetary limit which is the lifetime limit. It will only cover it, up to the maximum amount, once per person.
And I agree with Procrustus on how to appeal it. Read the coverage, frame your appeal in those terms if you can do so truthfully.
My step daughter needed braces and some other dental work due to the wonky way her upper teeth came in. My dental insurance would only pay for extractions then some of the cost for bridges. The dentist asked my my medical insurance info and submitted a request for approval. The request was granted because she needed dental surgery to make the needed corrections. Cost me about $300 out of pocket for the surgery and braces. Later while getting my teeth is order before retiring, I needed a couple dental implants installed. My health insurance paid everything to have the threaded implants installed, my dental insurance paid only $1400 towards the actual replacement teeth. In both cases, my health insurance considered the dental work necessary to maintain a healthy life.
When my brother’s kids needed braces, he switched to the extra coverage dental plan for the year the dentist wanted to put them in. And my dentist wants me to get gum surgery so I’m trying to figure out if upgrading my dental coverage next year will result in less out-of-pocket expense.
And another option is to max out your flexible spending account so at least the out-of-pocket expense is pre-tax money.
They are too crowded that they are crushing each other, which is only worse looking at wisdom teeth coming in. I guess there is a score system and while they both had a lot of points, it was not enough.