David Kurtzman, D.D.S., had tried in vain for years to get insurers to cover such costs incurred by the special needs of his patients -- the developmentally and physically disabled and those with severe medical problems or dental phobias. He found out about the little-known law by chance during a call to the insurance commissioner's office.
“The law is the law.”
— David Kurtzman, D.D.S., Marietta, GA
"The main barrier to people getting dental care is financial, so if you provide a way for patients with special needs to get it, more people will get the care they need," Dr. Kurtzman said in an interview with DrBiscuspid.com. "For the past 11 years people have been paying out of their pocket because nobody knew about this law."
While it was a surprise to Dr. Kurtzman, at least 33 states have had similar laws or regulations requiring this type of coverage for particular patients since 1995, according to the American Academy of Pediatric Dentistry (AAPD).
Dr. Kurtzman said he uses general anesthesia at least three times per month on patients for whom local anesthesia is ineffective or inappropriate. In addition to developmentally disabled patients, these individuals include people who are allergic to local anesthesia, those who cannot get numb, patients with severe phobias, and those prone to excessive gagging during dental procedures.
"This is for people who cannot get dental care in any other way except to go into the hospital," he observed.
If these patients don't get the necessary dental care, they can develop other medical problems, including abscesses, septicemia, inability to eat, chronic pain, and infections, he added.
Here are the states with laws or regulations requiring that insurance companies provide coverage of general anesthesia used with particular patients:
But insurance companies are often recalcitrant in paying such claims, Dr. Kurtzman said. "They will pay for the developmentally disabled, but for others they fight," he said. "But the law is the law."
John Rutkauskas, D.D.S., CEO of the AAPD, told DrBicuspid.com that dental insurers often decline such claims by categorizing the expenses as medical rather than dental.
"The AAPD has been working long and hard to see all states pass this type of legislation," he said. "Certainly, we feel it's in the best interest of families that our members are treating to be covered for these services when necessary."
Delta Dental spokesperson Chris Pyle said, "Delta Dental complies with benefit mandates wherever such mandates exist," in an e-mail to DrBicuspid.com.
Georgia's law specifically targets children younger than 8 and the developmentally disabled, but it also mandates coverage for those with a "neurological or other medically compromising condition" or those with "extensive facial or dental trauma."
While most statutes require that hospitalization be necessary, some states require payment of expenses when such treatment is performed in dental offices, according to the ADA.
"The law was not made as a convenience," Dr. Kurtzman noted, "but it's geared to people who don't have any other way to obtain the dental care they need to protect their physical health."
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