UnitedHealthcare Community Plan NY – Impacted Wisdom Teeth Removal Denial

I went to my general dentist for a regular cleaning, they did a basic X-ray, saw the impacted teeth, and referred me to an OMFS. Went to the OMFS, got a consultation and a 360 x-ray, surgeon came in to answer questions and was shown the x-ray that wisdom teeth are impacted and should get it out asap before it hits other surrounding teeth. I'm also experiencing pain and swelling in the back of my mouth too.

Fast forward: They sent in the treatment plan to UHC for pre-approval and it got denied. (All of the anesthesia portions got approved but the extraction portions got denied – the codes denied were D7240, 7230, 7220, 7921). I filed an appeal by phone with one of the UHC agents and it just got denied yesterday. Called them up again to check for the reason for denial and this is what they said in the letter below. The agent then called up my dental office to figure out what's going out to rule out any potential miscommunication/billing error/treatment plan submission problems and the staff is unwilling to send in additional letters of medical necessity for appeal since they've sent in their treatment plan already since they're a busy practice and they've got no time to deal with denials and appeals. He advised me that the best bet would be to just submit a second appeal outlining my symptoms of trouble sleeping and eating, excessive weight loss due to pain from eating, and damage to surrounding teeth.

I'm not sure why it got denied by UHC even though the OMFS told me that it's a necessary procedure and I should get it done asap. Any tips on how to navigate this and for next steps?

See also  How to Get Your Medical License in Virginia

–What if my second appeal gets denied again? Should I look for another OMFS for a second opinion and have them write up another treatment if they think it's also medically necessary?

–Should I just switch to another insurance and go through the entire process?

Thanks in advance!

Letter from UHC:

"UnitedHealthcare Community Plan decided to deny this service because the:X_ service is not medically necessary.

Dr. xxx DMD, specializing in dental medicine, reviewed the appeal. This doctor didnot make the original decision. The decision was based on New York state Guidelines / NYMember Handbook – Part II Your Benefits and Plan Procedures – Dental Care – Pages 34 – 35.

To the member:Tooth Removal will not be covered if records your dentist sent show the following conditions. 1.Normal growing pains due to teeth coming in. 2. Cleaning the tooth unless a medical conditionis present. 3. Lack of symptoms. Records sent by your dentist show one (1) of theseconditions.• You asked for extraction on teeth 1, 16, 17 and 32 because your dentist submitted records which show your condition required attention.• To approve this service, the following criteria must be met: Tooth Removal will not be covered if records your dentist sent show the following conditions. 1. Normal growing pains due to teeth coming in. 2. Cleaning the tooth unless a medical condition is present. 3. Lack of symptoms.• These criteria are not met because records sent by your dentist show one (1) of theseconditions. This decision was made under 42 CFR Sections 438.210 and 438.404; NYS Social ServicesLaw Sections 364-j(4)(k) and 365-a(2); 18 NYCRR Section 360-10.8; 18 NYCRR 506.2

See also  Pandemic affected HSA use, often in unpredictable ways - BenefitsPro

submitted by /u/kuromimi123