Insurance denies girl's previously covered dental surgery after pandemic delay

Nina Pineda Image
Tuesday, November 16, 2021
Insurance denies girl's previously covered surgery after COVID delay
Nina Pineda has more on the 6-year-old from New Jersey whose surgery was no longer covered by her insurance.

TOMS RIVER, New Jersey (WABC) -- Back in the summer of 2020, the worsening COVID-19 pandemic made the prospect of going to a hospital for an elective procedure a non-starter.

As a result, appointments were put off, and even some surgeries were scuttled.

A 6-year-old from Toms River, New Jersey, delayed a surgery on her teeth -- one that her insurance had covered. But months later, a insurance technicality canceled that coverage. So the family turned to 7 On Your Side.

"I've never seen anything like that in my life," mom Gina Nagle said.

Nagle was describing the distress of seeing her daughter's suddenly decaying front teeth and gums infected.

"As soon as I saw them, I knew we had to something right away," she said.

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She soon learned that nearly a dozen of her kindergartner's teeth had to be pulled, but since little Rosie suffers from severe anxiety, all her doctors agreed the procedure had to be done in a hospital.

"Being under anesthesia for such an extensive procedure was the only option for her," Gina said.

When the tooth decay first started last year, Horizon Blue Cross Blue Shield approved the then 5-year-old Rosie's operation. COVD delayed it, and then, in June of this year, it got way worse.

"That's when the gum boils started to form," Gina said. "They were pretty severe in the front of her mouth."

But by that time, Rosie had turned 6, and Horizon denied the claim.

"Once she turned 6, she was not eligible for this procedure," Gina said.

The family couldn't afford the procedure, so Gina appealed to Horizon, submitting a letter of medical necessity and called asking for help. But she got denied again.

"She was in so much pain," Gina said. "She wasn't eating. She was lying curled up in a blanket on the couch."

She burned up social media, even started a GoFundMe page. She called Horizon pleading for help.

"There needs to be special allowances for situations like this," she said. "And no phone calls back."

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We contacted Horizon Blue Cross Blue Shield, who thanked us for bringing the request to its attention. Just days later, Horizon said since COVID prevented the surgery until after her 6th birthday, it would completely cover thousands in charges for the hospital stay and anesthesia.

"We were so grateful," Gina said.

Rosie finally went to Children's Hospital in Philadelphia for her procedure, and in all, nine teeth extractions over three hours.

Now, a resilient Rosie is working her way back to eating her favorite - pizza.

We also received a Rosie original signed with glitter, saying thank you for helping with her smile.

"Thank you, 7 On Your Side," Rosie said.



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