I pay for HIGH option dental insurance through GEHA.
In January 2023, I had to have two teeth extracted; they were located UNDER a fixed bridge. One of the two teeth requiring extraction was the ANCHOR for the bridge. In order to extract the two bad teeth, the dentist had to either send me for expensive, messy and dangerous dental surgery to remove the teeth through my gums OR remove the fixed bridge.
In order to preserve at least the crowned tooth that is the other anchor of the bridge, the dentist spent a lot of time and exertion CUTTING the bridge at that crown. This prevented injury to the anchor tooth! This procedure was done at the same time and as part of the extraction procedure. BTW, doing this saved GEHA the cost of another crown IF the tooth even survived complete bridge removal.
This procedure is called "Partial Denture Sectioning" and is covered by Dental insurance code D9120.
My dentist billed GEHA $250 for THIS sectioning as part of the overall bill for the extraction work. GEHA DENIED payment for this procedure with NO EXPLANATION.
I filed an appeal using their process and following all their arcane rules. In addition to reconsideration of payment, I requested an EXPLANATION for non-coverage.
I received a second denial for payment. The letter offers the following "explanation":
"Fixed partial denture sectioning is not a covered procedure under your plan."
IN SHORT, it is not on our list. I called and requested a reasonable explanation of WHY D9120 is NOT on the list. The very kind person who answered my call did NOT know, NOR does she know WHO in GEHA makes these determinations. They are completely insulated from the public who buy their insurance.
Readers of this should know that there are probably tens of thousands of insurance codes for Dental procedures. I very much doubt that ANYONE in GEHA has ever noticed D9120, let alone made an intelligent, rational, decision to exclude it, per se.
There is NO rational medical/dental reason that I can even IMAGINE for denying coverage when this procedure is NECESSARY as part of another, covered, procedure. Although I am not an attorney, I KNOW that this type of decision is deemed to be "arbitrary and capricious."
Since I've had NO experience with any other dental insurance companies in many, many years, I cannot say that GEHA is any better or any worse. What I can say is that ALL insurance companies are wonderful UNTIL the customer files a claim.
THIS is one reason why insurance companies are universally hated!
Followup - On September 6, 2023 - after marinating for a while, I received the EXPECTED response to my request for an "independent third party review" of the denied claim for the D9120 procedure.
The letter advises that the "independent third party" upholds the denial (HUGE SURPRISE). The reason given is identical to the IDIOT response first provided. D9120 is not covered because it is not covered.
That nicely seals the package. I am now seeking another dental insurer and I WILL be reading reviews and asking questions before I sign!
NOTE: The ALLEGED "Independent Third Party" is NEVER identified. After and unpleasant phone call to GEHA, I learned that the ALLEGED INDEPENDENT thuird party read more