Dental Services due to accidental injury

I was in a high-speed cycling accident on 9/11/2023 (no cars involved) and was hospitalized for ~36 hours. Injuries included a brain bleed, oral surgery (removal of 2 teeth and stitching of upper lip), road rash, and other misc. things. In terms of coverage, I have:

BCBSTX PPO plan with an annual in-network deductible of $3,000. My $100,000K in hospital bills were covered after my deductible was met – no issues there. Lincoln Financial Dental. My annual maximum is $2,000 (laughable).

The issues begin with dental services. To be more specific, I:

Chipped tooth #7 – was cut in half. Required a root canal for an exposed nerve. It will also require a crown. Lost teeth #8 & 9 – the base of the teeth were removed in the OR. Both teeth will require an implant. Chipped tooth #10 – Only requires a crown.

I am attempting to figure out how to navigate getting reimbursed for dental expenses through my medical insurance. So far I have had and will have:

Oral surgery in the OR to remove teeth #8&9 – covered by BCBSTX. [9/11/2023] Endodontist – Root Canal on chipped tool #7. Covered by Lincoln Dental Insurance. [9/13/2023] Bone graft surgery on #8 & 9 – covered by BCBSTX. [10/13/2023] Partial Bridge & Crowns by my primary dentist – Lincoln would cover portions until my annual max has been hit (only about another $400). [Early November] Dental Rods & Implants – TBD on timing but this would take about another 6-9 months. Lincoln would again cover $2,000 of this in 2024.

My BCBSTX policy states the following under Benefits for Dental Services:

"Benefits for Eligible Expenses incurred by a Participant will be provided on the same basis as for treatment of any other sickness as shown on the Schedule of Coverage only for the following. • Covered Oral Surgery; • Services provided which are necessary for treatment or correction of a congenital defect; or • The correction of damage caused solely by Accidental Injury and such injury resulting from domestic violence or a medical condition, to healthy, un-restored natural teeth and supporting tissues. An injury sustained as a result of biting or chewing shall not be considered an Accidental Injury. If a Participant is unable to undergo dental treatment in a dental office or under local anesthesia due to a documented physical, mental or medical reason, as determined by the Participant’s Physician or by the dentist providing the dental care, a Participant shall have coverage for Medically Necessary, non-dental related services to the dental treatment. Any other dental services, except as excluded in the MEDICAL LIMITATIONS AND EXCLUSIONS section of this Benefit Booklet, for which a Participant incurs Inpatient Hospital Expense for a Medically Necessary inpatient Hospital Admission, will be determined as described in Benefits for Inpatient Hospital Expenses."

I have called BCBSTX twice now and the first time they told me that both my bridge and implants should likely be covered since this was an accidental injury and those items were not explicitly excluded in the policy. I then called again today and was told that none of it would be covered and that the only thing I could do would be to go through my dental insurance.

My specific questions are:

1. I am guessing that if I kept calling BCBSTX I would continue to get different answers about coverage on the phone – I should likely just submit the medical claim form for the 1) root canal 2) partial bridge (future) and 3) implants (future) and fight it out in the claims process? 2. I paid the full endodontist fee (root canal on 9/13/2023) of $2,000 out of pocket at the office. They also submitted it to my dental insurance and ~$1,200 of it was covered. I maybe should have known to not let them submit it to my dental but this was <24 hours after ER discharge and I had no idea what was going on. I was mailed checks for that root canal by Lincoln which I have not cashed. As this is an expense after an accident, I believe my medical insurance should have to pay these. Do I submit a medical claim for the entirety of the endodontist bill to BCBSTX or just the balance that Lincoln would not pay? 3. Similar question – I have seen my primary dentist to the accident and was given an estimation of fees totaling >$10K. When I see him again in a month to get the partial bridge should I ask them not to submit it to my Dental Insurance and just have them submit it to my medical insurance? I am not sure dentist offices do that, so if not should I just pay everything out of pocket and then seek reimbursement from BCBSTX by filing a claim? 4. If BCBSTX agrees to pay any of these dental services, would they refuse to cover the implants after I already got a temporary partial bridge? Guessing their angle here would be that I already had "corrective" services. submitted by /u/jjgiv
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