Maxwell, you are exactly right. I called PCHP to double check on a correction they said they'd make on another claim; the rep said she had evidence showing they had made the correction and paid the doctor [after I'd alread paid the bill]. When I called the doc's office, the insurance person there said the check would be sent to me by the end of the month. Is there any doubt that they never would have send me the check if I hadn't called to "REMIND" them? When I called to give PCHP an update on that situation, I left a message on the rep's voicemail, saying half-jokingly, "If you have any hand in PCHP's dental insurance, give me a call!" She did, I gave her the details, and she promised to get back to me. Two days later she called and said, "We fixed it! You were insured under your name with us FOREVER." Now I'll have to go back and dig up some of the high pharmaceutical bills I've been paying. . . Does the squeaky wheel get the grease, or what? chery2

It sounds like you had someone at an administrative level (claims processor type) reviewing your referral/or claim documentation. Saying this is cosmetic is utterly silly. Maybe it was 5PM and they were anxious to go home for the day. Who knows? Was it a periodontal abscess or a pulpal abscess? Your use of the term "seared the abscess" leads me to belive it was a periodontal abscess, but did you ever end up with a root canal and a crown? The former is limited to the soft tissue and can originate for a variety of reasons - most commonly periodontal disease. Treatment in this case is to drain the abcess, clean and flush the area with warm saline solution and sometimes hydrogen peroxide, and a regimin of antibiotics. The latter originates in the pulp tissue inside your tooth -due to infection which can be caused by invasion of caries into the pulp chamber--"cavity", or when the pulp tissue slowly dies and becomes necrotic - most often from trauma of some kind. In a pulpal abscess - since this tissue is encased inside a hard structure - enamel and dentin - the infection has no where to drain other than through the apex of the root, where it will eventually appear as swelling just adjacent to the position of the root tip, but through your tissue. The swelling and pain from a pulpal abscess can be extreme and once this happens, it has to be treated immediately. The treatment for pulpal abscesses is a root canal and crown - along with antibiotics. It is disturbing that your DDS failed to diagnose and treat - though there are times when you can have a subclinical situation where you are expereincing the symptoms of pain, but the cause cannot be determined because it is not yet noticable on an x-ray or though clinical exam. We have had situations where we could not diagnose a pulpal abscess in the early stages when it is chronic and before it becomes acute for this reason, in which case we would either take an x-ray as a baseline and then schedule the patient to come back in a few months (as long as the symptoms were mild and not severe) or refer to an endodontist for a more detailed diagnostic workup and treatment. Referred pain is also common with pulpal abscesses. It can feel like it is your upper right first molar when it fact it could be your lower right molar, or even a tooth on the other side of the mouth. (Of course this assumes that obvious causes are absent). This is one reason we just don't jump in and do a root canal unless we are absolutely sure which tooth it is. In the early stages of the abscess that can be difficult to determine. In the acute/swelling stages, it is pretty simple to determine which tooth is the cause - both on an x-ray and by testing each tooth with slight pressure. Regardless of what the cause was, medical plans rarely cover dental treatement. Dental services are covered under dental plans, not medical plans. If you have dental insurance, then that is where the claim should be sent. The complicating factor you have on your side in an appeal situation is your history of Rheumatic fever--which means that there is some heart valve damage and any kind of systemic infection can be extremely dangerous unless the cause of the infection is treated and antibiotics given immediately. This would even apply before going to your hygienist for a routine cleaning. The standard of care is to always prescribe antibiotic premedication prior to doing any dental procedure on patients with a history of rhumatic fever. The only times we have seen dental procedures covered under medical plans (rarely HMOs, occasionally PPOs or indemnity plans) is in the case of accidental emergency where someone is in an auto accident and fractures the bones in their face, jaws, and possibly injures their teeth. Another case that will come up once in awhile is orthognathic surgery - surgery to reposition the lower jaw relative to the upper jaw - but this coverage is rare because it is most often done to treat TMJ pain and the success rates are questionable at best. First you should go through your SPD or EOC document - the lengthly documents provided by your EER that describes what is covered and lists the limitations and exclusions. Dental will usually be listed as an exclusion. See if you can find any language that says the plan covers "medically necessary care" or "care needed to protect the life of the patient." The HMO does have an obligation to make exceptions when failure to treat can cause serious health consequences - which seems to apply here - Also, it is not your fault that your original DDS failed to diagnose. I would be sure to state on the appeal - clearly and in short bullet points - the series of events that led up to the final resolution. You may want to do an google search under rheumatic fever and provide some authoritative documentation on the serious risk that infections can cause in patients with this in their health history-it is called bacteremia - where the bacteria in your bloodstream will attach themselves to the damaged heart valve and it can be fatal. I would provide your documentation in a dispassionate, factual, simple, sequential manner, but make it clear that you are aware that you could have died from this condition and that you did everything within your power to get it resolved. When the health/life of the patient is at risk - even if dental is excluded under your plan - you may be able to get some coverage. At a minimuim, the HMO should cover all of the visits up to the final dental treatment itself, which should be covered under dental, if you have dental insurance. If not, then I suggest you base your appeal on the above description. Lynne (RDH, CA, OR, WA)

We women are usually good about taking ourselves for check ups, mammograms, colonoscopys, etc, our men are not. Make it a priority to make that appt. for him, and make him keep it. Go with him. I wasn't as good as I should have been and I should know better. I'm a nurse. DH put it off and put it off. I bugged him, I cajoled him, I made appts and let it go. (One MD had the audacity to ask him why he felt he needed to be seen!)He never went back. He felt fine, he wasn't overweight, he was active. I was too busy caring for my dying mother. After spending a weekend with her after a long week at work, he came to me Sunday morning. He had just started a culinary arts program and had felt worn out. Now his feet were swollen. I took him straight to the ER, my worse fears were that this was the only way to get him to a Dr.(through the ER) He went without a word, he was scared. That was April. His heart was failing due to arrythmias. Its been a long road, but he is doing better. He has never seen so many Drs. and followed my advice more closely. It could have been worse. Make sure your DH is taking care of himself.

You can Google it, but my main symptoms are extremely dry eyes and nasty dry mouth with thick terrible tasting and smelling saliva. I also have Hashimotos. if someone has one autoimmune disease, they usually have 2 or 3.