Need medical reason for dental surgery

[Elise N. T.]

My son recently had dental surgery. He has ADHD and sensory problems and completely freaks out even for normal teeth cleanings. We're also having him tested for autism/aspergers spectrum disorders but we won't have the results back until next month.

We went to two different dentists and they both said he had lots of abscessed teeth and needed general anesthesia to get it done due to his hysteria. He could not stay still safely unless they were to tie him down and force his mouth open. I wasn't about to do that to my terrified nine year old!

When I went to the hospital for the surgery they said the dentists office hadn't sent over the insurance approval yet, and that it was probably approved but the office was being slow. They faxed another paper to the insurance and wrote "adhd/possible aspergers" for the reason. They had me sign a paper saying I would pay if the insurance didn't approve it.

Now the insurance sent me a letter saying they would not approve it unless I send a letter with a medical reason for the surgery. What would be a good medical reason they would approve?

If they don't pay it we will go bankrupt over this. I was so terrified this would happen when I signed that paper but it would be considered medical neglect if I didn't get it done.

He had a similiar surgery five years ago and medicaid didn't approve it because it was coded more dental then medical. I played phone tag with medicaid and the hospital with it for a while and they finally stopped sending me bills but I don't know how it was resolved. I assume insurance eventually paid since we had this surgery at the same hospital and they didn't mention any outstanding charges.

 

[Andy]

Ask your dentist to write a letter of appeal. Include everything regarding why his ADHD and sensory problems make it impossible to do any work chair side.

The dentist can include his records that I would hope includes behavior issues while at the dentist and his recommendation for surgery. If you can get the second dentists' opinion in writing to include, that would also help.

You can include your own appeal letter stating symptoms being exhibited that have lead you to test for aspergers/autism. State that he is in the process of being diagnosed for this.

The dentist also gets an EOB (explanation of benefits). Contact them to see if they have started the appeal process.
Maybe the dentist never got the approval info to the hospital which just had to bill without it?

When I worked for a dentist that did surgeries, we would postpone any surgery that an approval didn't get done. The hospital asked for ALL paperwork to be sent a few days before surgery (no consent, surgery cancelled - no physical, surgery cancelled, ect.)

1st contact your dentist office, they may already have taken care of it?