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THE FINE PRINT

Exhausted new parents, a tongue-tied infant, and an insurance company playing by the rules. Is there room for flexibility?

Alexzandra and Gene Lyons are in a battle with their insurer over coverage for a procedure to relieve a rare condition, tongue tie, in their son, Eugene, who was born in January.Suzanne Kreiter/Globe Staff

After their son was born in January, Alexzandra and Gene Lyons learned he had a condition known as tongue tie.

It made breastfeeding so painful for Alexzandra that she had to abandon it after a couple of days, despite being a passionate believer in its health benefits for mothers and babies.

Those first days of nursing had left her badly bruised and bleeding and had come after a sudden and difficult birth three weeks before her son’s due date.

Alexzandra switched to using a pump and bottle to feed her milk to her son, Eugene. But she felt deprived of the deep bonding experience she believed would come with breastfeeding and worried that her son would lag in weight gain, she said.

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She also feared potential long-term consequences of tongue tie, including speech and eating difficulties, even though what she read online described such problems as quite rare.

One trusted source of advice, a certified doula, urged her to arrange for laser surgery on Eugene and gave her the name of a dentist who could do it and who, she said, had “a wonderful reputation — the best in the area.” (A doula is a trained, non-medical professional who provides support during pregnancy, birth, and postpartum.)

The doula told the Lyons to act quickly.

But before they did, Alexzandra called her insurer, Point32Health, to ask if they would be covered if they went out of network, which the dentist was. She was told no, they would not be covered.

They proceeded anyway, and 13 days after his birth, little Eugene had a frenotomy, a procedure that loosens the tissue that tethers the underside of the tongue to the bottom of the mouth.

It gave Eugene a wider range of movement with his tongue, which allowed him to better latch during feedings and spare Alexzandra the agony she had previously felt.

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Alexzandra returned to breastfeeding after the surgery, and now, at six months, Eugene is thriving. She’s pleased that it turned out so well, she said.

Alexzandra and Gene Lyons are in a battle with their insurer over coverage for a procedure to relieve a rare condition, tongue tie, in their son, Eugene.Suzanne Kreiter/Globe Staff

But the surgery cost $1,400, which they paid the dentist out of pocket. Because the dentist was out of network, Point32Health denied the Lyons’ claim for reimbursement.

Alexzandra, 33, a veterinarian technician who lives with her family in Foxborough, did plenty of research during her pregnancy, including about tongue tie, which occurs in up to 10 percent of newborns.

In recent years, it has been diagnosed more often, perhaps in part because more mothers are breastfeeding. (The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months.)

Alexzandra and her medical providers agreed that Eugene had tongue tie within hours of his birth. But there is no firm consensus in the medical community on what to do about tongue tie, with some favoring surgery and others saying most cases resolve themselves without intervention.

Alexzandra tried to nurse her son, but he had trouble latching on to her. “He kept popping off,” she said. “He would hiccup and choke.”

“And I was in agony,” she said. “It was just too painful.”

Alexzandra’s pediatrician favored a wait-and-see approach, she said. But the doula she most trusted strongly recommended surgery and gave her the contact information for Heidi Aaronson, a Wellesley-based dentist.

Aaronson has performed thousands of tongue tie surgeries, called frenotomies, over the last several years, according to her website.

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Some doctors perform frenotomies by snipping the tissue (called a frenulum) with scissors, but others, including Aaronson, use a laser.

Alexzandra said she wanted to use a laser because she thought it would spare her infant son trauma and stress.

By the time Alexzandra and Gene arrived at Aaronson’s office, they were exhausted and stressed.

“It’s hard when you’re new parents and you’re desperate for help,” Alexzandra said. “We were in a little bit of a fog.”

“We just looked at each other, and it was like, ‘We need to do this,’” Alexzandra recalled.

After the surgery, Eugene “definitely seemed to latch better,” she said. “There was immediate relief, not perfect, but so much better.”

“Since then, it’s been great,” she said. “It’s made a world of difference.“

The Lyons knew when they went to the dentist that she was out of network. There was no confusion about that. Still, they want to be reimbursed for a procedure they considered urgent and medically necessary.

When I asked Point32Health about an exception, a representative said it has plenty of in-network providers who specialize in tongue tie and the Lyons could have gone to one of them.

I understand Point32Health is within its rights to reject the claim. But I’m wondering if there is room for an exception, considering the totality of the circumstances, which include that both Alexzandra and Gene came down with COVID-19 in the week after Eugene’s birth.

Maybe Point32Health and the Lyons could split the $1,400 cost, with Point32Health paying an amount equal to what it would have paid had the Lyons gone to an in-network provider.

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I know it would be contrary to the rules, but it would be nice to see an insurer show a little flexibility.

And a word of caution: make sure you understand your insurance coverage before you undertake any medical procedure.


Got a problem? Send your consumer issue to sean.murphy@globe.com. Follow him on Twitter @spmurphyboston.