My 3 year old son had extensive tooth decay. We were told due to his age, the 5 crowns, 2 cavities, and caps would need to be done under general anesthesia as an out patient procedure. Because we were told both dental and medical would be filed, I called PJP Health Agency before giving the go to have the procedure done to make sure this procedure would be covered. The customer service rep reviewed my plan after keeping me on hold to look through it and returned to the line telling me that she did find where this procedure would be covered due to his age. Because he was under 7 years old, it was covered as a medical necessity. My decision to move forward to with the procedure wasbased on this information. Had I been told it was not covered, I would have never allowed it. We would have had to find another alternative because my husband and I cannot afford to pay out of pocket over $12K.
Now the procedure is done and the EOB's are coming back denied because the decay was not caused by illness or injury. I called to inquire about this and was told by another rep I was told incorrect information and that she did ask her supervisor and the only thing I could do is file an appeal. But that was after I told her this was not right and I would continue to fight the denial. Now I'm appealing my case and feel the storm just starting. I would like to know who gives some pencil pushing idiots the right to determine what your doctor has requested as "medically necessary" as not? I am so frustrated and ready to file a complaint the the insurance commissioner in my state and contact my local news. I feel like I have to do something to expose this type of issue. This is fraud reversed! I was told it was covered by PJP Health Agency. I had no reason to doubt the PJP Health Agency employee when I called. I canceled my policy with PJP Health Agency.
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