Appealing a denied Anthem BCBS claim

Hi,

I hope this is the right place to post asking for advice, but if not please let me know and I will delete this. The instructions for submitting a post say to include the following information as well: I am 28, I make ~$52,000, my zip code is 46835, and my insurance is Anthem Blue Cross Blue Shield through my employer.

Anyway, I have recently had an odd issue with my insurance and I have no idea how to properly submit an appeal for the denied claim. I read their process on their website, and the confusing part is that they need supporting documentation. I understand the concept, but I am not sure what specifically they need. I’ll tell you guys the story and hopefully someone has seen this and knows what’s what.

Two months ago, my sleep specialist referred me to a dentist to be fitted for an oral appliance that holds my jaw forward to treat obstructive sleep apnea. At the time he told me that it should be a Medical coverage since it was prescribed by him, not the dentist. A few weeks later I got fitted for the appliance and received it a week after that. I was told that Anthem BCBS had denied the claim and I had to pay $2400. I had worried this would happen, and I ended up having to pay for it with a CareCredit card. My life got a bit crazy after that, and I didn’t get around to trying to appeal the claim until last week.

I called Anthem and they told me that the claim had been filed as a Dental claim, and my dental coverage does not cover the appliance. They told me that my dentist needed to resubmit it as a Medical claim. My dentist then told me that they cannot do so since they do not have Medical codes, so there is nothing they could do. I called back Anthem and let them know the situation. The person I talked to didn’t really even acknowledge the situation and reiterated that my Dental coverage does not cover the appliance and that I should submit a written appeal. I looked up the process and saw that I needed to have documentation to support my appeal. I asked my sleep specialist for the paperwork showing that he referred me to the dentist for the appliance and just got it in the mail yesterday. Now I need to actually write up the appeal and I am really worried that I will be missing some important bit of information that would decide the appeal. Anthem’s website isn’t clear at all as far as I could see on what documentation they need.

My reasoning is that while the dentist did fit and build the appliance, it was prescribed by my sleep specialist. It is not designed to treat a dental issue, but rather a medical one. Anthem not covering it would be like them refusing to cover a Cpap because a factory produced it instead of the sleep specialist. At least, that is my reasoning, but maybe I am completely wrong here. If so, I can live with it, but I want to make sure I have at least done everything I can before giving up.

I have all the paperwork from my sleep specialist showing that he referred me to the dentist and prescribed me the appliance. I have the claim number that was denied. I can write up a letter detailing the entire situation and my reasoning for why it should be covered. Is this all that I need, or is there going to be more that they want? I have to mail it in and they have like a month or so to decide. If they deny it because I screwed up paperwork, it could take more than a month to be able to appeal again. I just really want to do this right the first time.

Thank you all for your help and any advice you can give me.