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.
