Dental Insurance Problem?

What do I do when I thought I went in for a TMJ guard but came out with a bruxism guard? Now my insurance won't pay? My dental office prior to setting the appointment said my dental insurance would pay 80% now that the dental insurance won't pay because only TMJ not bruxism (which are closely related but not the same) is covered. We specifically asked if our insurance would cover this or we wouldn't of had the guard made as it is $1250. Also the insurance is not covering the x-rays either because the dental office didn't send them to the dental insurance for review. I already called the dental office and was told they "never guarantee any coverage by insurance" and would resend the appeal letter. The appeal letter still says in the notification that it is for bruxism so it was denied again. Not one mention when we were at the dentist office about bruxism. What do we do?

Night guards are a tricky billing situation. The majority of the time, insurance will only cover them for "bruxism", which is grinding of the teeth. Many if not most insurance plans have a TMJ exclusion. So, your dental office did what they thought was best.

You are right - TMJ and bruxism are related. Your insurance comapny is being ridiculous and you should be upset with them, not the dental office. I would suggest an appeal in writing from both you, and the dentist. Let them know the night guard will help with BOTH bruxism and TMJ (which is true).

Also, there is no reason for them to deny x-rays just because they weren't sent in. There's something wrong with that. Not every x-ray taken is sent to insurance and some companies won't even accept the films or return them if they ARE sent.

What your dental office probably should have done was pre-authorize the appliance. For an amout that high, pre-authorization is usually a good idea, especially with a "gray area" procedure.

unfortunately when dental insurances quote benefits they ALWAYS include the disclaimer "benefits are a quote only, not a guarantee of payment". a dental office submits claims only as a courtesy, and patients need to take responsibility to know what their coverage is before a procedure is done. one way is requesting a pre determination be done by the office and calling the insurance themselves. most people don't know that their insurance is their responsibility. write an appeal yourself and stay on top of the office. you should have explanation of benefits for all procedures. pull those out and go over them. if your ins has TMJ coverage, they should pay a little, if not ask your office for payment options. the nightguard that i have changed my life. it's worth it. i won't sleep without it. good luck to you.