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I am upset about the way United Health Care (UHC) is handling a case that they claim is in the gray zone between medical and dental care.
My six year old child had a tooth ache; we went to the dentist who finds the tooth (baby tooth molar) needs to be pulled and a few smaller cavities repaired. We were sent to an oral surgeon who to
remove the hurting tooth. The child didn't cooperate and the surgeon decided it's unsafe to proceed. The pediatric dentist made a second
attempt, trying to use a sedative and the NO2 gas method, but without success: the child was fighting too hard and they couldn't proceed safely.
So the verdict was, from both the oral surgeon and the pediatric dentist, that a surgical daycare setting is needed so that the dental procedures (extraction and restoration) can be done under
anesthesia. For this I needed pre-approval from UHC.
The dentist's office warned me already upfront hat I would likely encounter a lot of resistance from UHC - they had similar cases before where UHC was the only insurance company that would try to not cover such a procedure.
I called the insurance and sure enough I was told that the procedure isn't covered because dental treatment is not covered in general by my insurance plan. I argued that this is not dental treatment in a strict sense, as the dentist can't do the work without being able to get the child sufficiently sedated. This didn't work using the standard procedures. Anesthesia requires the participation of a specialist, like in any surgical intervention. Therefore, what is usually
considered a dental treatment becomes a medical treatment. - Not for UHC.
The discussion went long back and forth with three staff members of UHC and they didn't budge: I am supposed to send in an appeal for a pre-determination, consisting in a letter describing the planned procedure and a doctor's attestation that it is a medical necessity. However, the minimum time for such a preapproval is 30 days, I was told. And I know already that the out-of-pocket pay for such a treatment could easily exceed 5000 dollars, if they don't cover
it.
Of course, the UHC staff can well understand that only an insane person would recommend that I wait another month letting my child suffer, to wait for their approval. But they insisted: This is a dental treatment and dental treatments aren't paid for. I was told that the only way it would be OK for them to pay would be if the dental treatment was part of or consequence of a treatment for something like oral cancer, bone infectious disease in the gum, requiring maxillar surgery, or other disease. It comes down to separate the human body into teeth and not teeth: If there is something done with the teeth, they won't pay, and
of course, the dental insurance won't pay for anesthesia.
I could make a little bit of progress poking into the hierarchy of the UHC castle by means of challenging their artificial and buerocratic separation of all issues into medical versus dental. In my opinion, and I believe pretty much according to common sense, just like teeth are part of the human body, dental treatment (apart from teeth whitening perhaps) is part of modern medicine. There isn't a gray zone: The gray zone
only exists because two areas of medicine are artificially separated.
I asked the rep about the roots of the teeth, where exactly is the boundary between "dental" and "medical". Take the pulp and nerve of the tooth: is it part of the human oral anatomy or of the tooth? If you pull a tooth out, is it a dental or a medical condition if it then hurts and bleeds? Why the distinction between tooth and human body,
the artificial separation of everything medical versus everything dental? Looks like the main activity of UHC staff is to push the bucket to someone else.
They couldn't yield: The reps tried to stay professional", and I noticed how well trained they were not to get drawn into a common sense discussion of their guidelines. I could feel how they knew pretty well that some of their guidelines make no common sense, but it didn't help.
The only positive side is that after pressing on a while (and I must have been a bit obnoxious in their view, asking so many questions), I got a level higher each time they referred me to the next person. The final story is, that if the dentists and doctors involved in this case
can find a proper formulation, in the terms of UHC guidelines of course, to turn this into a medical necessity, then the bureaucrats may approve. Now I have to figure out what this really means. The UHC
staff was talking of "formula" that they need from the dentist and doctor.
Maybe a medical doctor has to write a letter that the gum of my child needs to be surgically liberated, under anesthesia, from an attached
small object consisting mainly of cristalline calcium phosphate, to allow access for medical treatment of the developing gum infection under
the object.