Guardian Insurance denying my periodontal treatment claim? (Chart & Letters Attached)
I'm really frustrated and confused about my dental insurance claim denial. I'm hoping someone here might have some insight or advice. Here’s the situation:
CHART, CLAIM FORM, AND DENIAL LETTER HERE
Background:
Periodontal Treatment: I recently underwent a heavy cleaning for periodontal disease, which included treating significant bone loss. Claim Submission: My dental office submitted the claim, which included detailed notes from my dental hygienist, my dental chart indicating the bone loss, and a comprehensive treatment plan.
Attachments:
THE FOLLOWING IS INCLUDED HERE
Dental Chart – Shows the bone loss and other relevant information. Claim Form – Includes notes from my dental hygienist outlining my condition and the treatment. Denial Letter – The letter from my insurance company denying the claim.
Details:
Initial Denial: The claim was initially denied, which surprised both me and my dental office. They assured me that all necessary documentation was provided. Appeal Process: My dental office has already submitted an appeal with the insurance company, but the claim was denied again. Insurance's Reason: The denial letter is vague and doesn't clearly explain why they won't cover the treatment. It simply states that the procedure doesn't meet their coverage criteria, when the materials supplied indicate that it does.
Current Status:
My dental office suggested that I personally contact the insurance company, which I did, but they are still refusing to cover the treatment. They just keep reiterating that the treatment isn't covered without providing a detailed explanation.
Questions:
What should I do next? Are there specific things I should ask for or documents I should provide to strengthen my case? Appeal Tips: Does anyone have experience successfully appealing a denial for periodontal treatment? What worked for you? External Help: Should I consider getting help from a third-party like a patient advocate or contacting a regulatory body? submitted by /u/dmfornood
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