Question
Hello,
I apologize in advance for the long-winded explanation of my problem.
In August, I was experiencing severe tooth pain. I went to my dentist and asked him to yank the tooth out. He said the pain was the result of clenching my teeth at night, and that my tooth did not need to be yanked out. He said I needed to wear a mouthgaurd, which he fitted me for. Wearing this mouthgaurd exacberated the pain in my teeth/jaws,and so I ended up not being able to wear the mout guard. Instead, I took a lot of Motrin.
One night in November, I experienced my first-ever severe migraine (accompanied by jaw pain). I suspected that I maybe had a condition called TMJ disorder, which I learned about doing internet research of my symptoms. I scheduled an appointment with a TMJ dentist on Friday. But on Thursday morning, after 3 nights of watching me writhe in agony all night, my boyfriend took me to the emergency room. At the ER, the doctor ordered a CAT-SCAN to make sure I didn't have a brain tumor, gave me some heavy-duty pain killer medicine, and sent me home (I told them I thought I had TMJ disorder and that I had an appointment with the dentist the next day).
On Friday, the TMJ dentist confirmed that I have TMJ disorder. He was surpised at the mouthguard that the dentist gave me, and fit me for a new one.
This past week, I formed a "blister" above the tooth that was hurting in August. I went to the TMJ dentist (now my new dentist), and he discovered that I had a dead tooth (the one that hurt in August) and that I need a root canal immediately.
Also on Friday, I received a notice from my insurance company. The letter said that they are denying the claim for my November ER visit; they said the services I received at the ER were coded as "TMJ Treatment" and that diagnosis and treatment for TMJ or other jaw issues is not covered under my insurance plan. I did not receive TMJ treatment at the ER! They ran a CAT-SCAN to rule out a brain tumor as the cause of the migraines. They gave me heavy-duty pain medicine, and sent me on my way. In no way did they treat me for TMJ. I am stunned by this $3,095 ER bill that I have to pay myself. I was in serious pain. I didn't know what was wrong with me (other than doing some internet research and having an idea of what my problem COULD be). Why wouldn't I go to the ER? Do I have a chance of successfully appealing this? Any tips or advice are greatly appreciated.
Thank you,
Nan
Answer
Hi Nan!
I think I would first contact the hospital and see if they can code your claim correctly. Explain that you went to the ER for your headache not TMJ. Perhaps you can convince them to change the coding. This would end all your issues if they would. They probably will not but I would give it a try first.
If not, do send an appeal backing up the appeal with any information you can get perhaps from the treating DR at the hospital and your new dentist.
Just the mention of TMJ anywhere in notes keep insurance companies from paying. You need to focus your treatment away from TMJ completely. Concentrate on your headaches.
Good Luck!
Tricia
