Patient Ping-Pong

Patricia Austin woke up one morning in March and couldn't move her jaw. Hours later, the Arlington woman was in a dentist's chair and got the word: She had a dislocation of the temporomandibular joint (TMJ).

Little did she know there was more pain to come -- from her insurance company, CareFirst BlueCross BlueShield.

"They denied my claim because they said it was for a dental problem," she says, despite her having three letters, two from medical doctors, explaining that a dislocated jaw is not a dental claim but a medical issue. Austin has no dental insurance.

Her dispute with CareFirst is a common one, says Tysons Corner orthodontist and TMJ specialist Brendan Stack, who treated Austin and says his patients "get ping-ponged back and forth" by carriers over whether their treatment falls under dental or medical purview. Health insurers insist it's a dental problem, dental insurers the opposite -- a pattern that should call the objectivity of the insurers' judgments into question. "It's a source of great frustration," Stack says.

Most carriers have rules for distinguishing between dental and medical issues. Mamsi will pay for claims under its medical policies if, say, there is a medical condition that leads to gum problems, dental problems arising from treatment for oral cancer or if teeth are injured in a car wreck or a fall, says spokeswoman Beth Sammis. Aetna's criteria include traumatic injury and certain circumstances when tooth extraction is required as part of medical treatment. CareFirst spokesman Jeffrey Valentine says the carrier's "basic policy is that dental issues would be covered under our medical policies if they result from accidental trauma and treatment is immediate."

Many carriers have guidelines for a dislocated TMJ. Most Aetna HMO plans, for example, exclude such coverage, says spokesman Walt Cherniak. But some states, including Virginia, have said such treatment must be covered under medical policies. While this mandate presumably would have applied in Austin's case, CareFirst didn't see it that way; Valentine declined to explain why.

Consumers should prepare to appeal if they are getting ping-ponged between medical and dental insurers, says Ron Pollack, director of Families USA, a health care advocacy group. "Do not take no for an answer," Pollack says. "These are judgment calls, and the health plan will normally err on the side of not providing the service. Given that the decision of the insurer is at best questionable, this should be pursued and done through an internal and then external hearing, and then even contacting the insurance commission, if necessary. There's a reasonable chance you will win."

Which is what happened with Austin. Four months after she was diagnosed, she underwent TMJ surgery. By then, CareFirst had agreed to pick up the tab for her whole painful experience.

-- Melody Simmons

The System welcomes reports from patients, providers, insurers and others about the delivery of health care. WE CANNOT ADVOCATE ON BEHALF OF INDIVIDUALS PURSUING CLAIMS OR COMPLAINTS. But we are looking for patterns of problems and excellence that may direct our reporting. By e-mail: thesystem@washpost.com. By U.S. Mail: The System, Washington Post Health Section, 1150 15th Street NW, Washington, DC 20071. Include name and phone number; no phone calls, please. We can't guarantee a response or return of submissions; do not send original documents.