Thanks for this info

Hi. Right off, thank you so much for not only taking the time, and your expertise to offer guidance to me - a lay person, but thanks for making yourself available to everyone who comes here for assistance.


I took a day or two off from this "task" hoping that I would find a reply from you, and at the very least have a little more info or insight to feel more confident in what info Cigna & the provider would come up with.


From your response, I feel a little better about not having found anything online from Cigna regarding dental services that are medical in nature. Prior to my posting here, I had found "Cigna's medical policy for Anesthesia and Facility Services for Dental Treatment," and had scribbled down Code D7250 - Surgical Removal of Residual Tooth Roots (cutting procedure.) Decades ago while working initially as a customer service rep for one of the major health insurer's, the subject of ancillary services such as radiology, and anesthesia bills related to covered services, was a common inquiry, and helped facilitate the payment of these bills for the insured. Although cross-trained in claims processing, I only needed to be familiar with a small group of the most common ICD & Dx codes. I think seeing D7250 stood out, thinking, if this is a covered code under some policy's, I might ask about it, or at the very least have it in front of me, in the likely case that I would have to prepare an appeal after the fact, focusing on medical necessity - which I see you also mentioned. As I was about to pick up the phone to call Cigna, I realized, I was not 100% sure of whether I should be routed to a Cigna Dental rep or a Cigna Medical rep? My previous two calls, I had bypassed all of the menu options, and went right to a "representative," and although they both had suggested the option to either get a new code from the provider or call Cigna back to facilitate a three way call, I wasn't sure which type of coverage they represented.


I decided to go the Dental route first, thinking 'let me ask about D7250 - could they tell me definitively, covered or not'? I had done one last internet search - simply entering this code, and I found this from Delta Dental: https://nedelta.com/Prov...r/Procedure-Code-D7250.
I found it interesting that there was mention of "confusion" with this code. I did notice that this document is from 2008, so I was not sure if this code is even still in use.


I called Cigna and opted to start with a rep on the dental side. I gave her brief overview, and pointed out that there should be some documentation of my previous calls. She found some, and asked for a minute to get up to speed. While doing so, I asked her if I had a code, would she be able to tell if it was a covered service or not, and she said stated she could. I gave her D7250, and within a moment, she informs me that it does fall under a covered dental benefit. She furthered it by saying that based on the symptoms (severe pain,) and the procedure (the oral surgeon telling my husband that the CT shows it as a root fragment,) as I described, she would think that when presented to the "reviewer" with a "narrative report," (which I have seen you refer to in other posts) and maybe a copy of the CT scan...as long as they change the code to D7250, it should be approved.


What she said next I found interesting. She said something about when the doctor's graduate, and first begin to practice, they have learned how to chart, and how to prepare info necessary for determinations of coverage to be made. She furthered by saying "and these girls who work for the providers, who went to school to become medical coders, they should know how to analyze clinical information, and be able to assign the appropriate standard codes, and for pre-approvals, should know when & what supportive information...a narrative report, X-rays, and so on, should be presented." From what she could see in front of her, they didn't supply details such as "root tip" or the tooth number, so the assumption with the original code could have meant a foreign body, like a growth or mass, on the gum or inside of cheek.

I'm curious what your input on her statement is.

Finally, she put me on hold to call the provider's office, and I expected someone from the oral surgeon's office to be on the line. Nope. The rep told me she had just spoken to *****, (whom I spoke to previosly) and told her what would be an acceptable or appropraite code for the services. She also informed her that when she resubmits for approval, to include a narrative with details. She told me that as she began to explain to the OS how & what to supply, the response she got - the description of the service, was exactly as I had explained to her. She said she is at a loss as to why the office would have used 41805, when the doctor's own words were not referring to a foreign body....but noted that it is a fragment of a root which was left from an extraction of a tooth dating back a few years. I remembered something that stood out when i had spoken to ***** from the provider's office...when i first called with Cigna's suggestion to "use another code which may put it one category or another," this person sounded like she was looking at some source with codes because she mumbled "there's 40804...no, that won't work....41805 is what we use all the time!"


This now has me wondering if it is very complicated, or made difficult because of so many insurance companies, and or typs of coverage patients have, or is it a matter of "is what we use all the time," and a lot of unknowing patients are accepting denials of coverage without question?


I have to wait about 5 to 10 days to see what the outcome of the new request or 'review' will be!

Thanks again.

Hi.
I came across this site a number of times over the past few days as I have spent hours searching, and more hours on the phone with the oral surgeon's office and the primary insurer, Cigna.

A family member has had one sided facial pain for over a year. Started out with family dentist, who took an Xray, and an 'object' is seen above the roots of existing teeth. When compared to an Xray from almost a decade ago, the dentist thought perhaps a root fragment from an extraction in that area. Went to an oral surgeon who brushed off, and referred to an ENT, who said he "was so tired of Oral Surgeons brushing patients off on to ENT's for this type of complaint." He did perform an exam and did not find anything related to sinus, or anything else. He did recommend an MRI, and most likely, seeing a new Oral Surgeon.

We knew of a very good one out of state. He took Xrays & a CT scan in office. He feels it is a fragment of a root which has moved more towards the sinus region rather than coming to surface, and offered two possible scenerios...an in office procedure or in a hospital. He did feel confident that it can be addressed in office.

The procedure is slated for 7/5/19, and the OS office called Cigna dental for approval using the procedure code 41805 Removal of a Foreign Embedded Body. This was denied by Cigna, with the notation that "considered medical in nature. Please submit to your medical carrier for possible payment." The OS office then called Cigna medical who informed not covered as it is a dental procedure, thus submit to dental.

I spoke to Cigna rep's a few times, and yesterday suggested to call OS office to see "if they can use another code which may put it in one category or another." I called the OS and they said this scenario comes up often, and she was trying to see what other codes, as the current is what they use the most. She asked if Cigna provided any covered codes, to which the Rep did not have access to. Cigna suggested that we can do a three way call between them, the provider and myself which looks like the only option, and will do.

The Cigna rep said it may be possible or it looked almost as if the employer's dental coverage may have required a separate rider to purchase, which may have covered the code / procedure in question.

Sorry so many details but, as I pour through dental and medical codes (worked for a health insurer decades ago,) I am trying to find something that may push this more towards medical, where the medical side of Cigna could confirm before procedure, covered or not. As it stands the non-covered fee must be paid at the time of service.

Any guidance you may have would be greatly appreciated.