Insurance Denial

[IcarusJaw]

Hi everyone!
Hoping to be an active member on the board.

I currently have braces and am like ready for surgery just need the approval but got denied.
I have Horizon Blue Cross of NJ. Even though my surgeon sent it my x-rays, letter of medical necessity and that my measurements where "off the charts" (cross bite).
My insurance wants proof that I tried to treat it or had symptoms before. The only thing I've had in terms of conservative treatment is massage therapy for TMJ symptons.

I have a telephone appeal (the last one) next week with my surgeon and Horizon.

I'm trying to get together a plan b.
Any suggestions?
My surgeon suggested switching insurance? Any in the NJ area suggestions?

Really bummed out that this is happening but from what I gather getting coverage is difficult.

[sirwired]

Well, to get an idea of what you and your surgeon must do, you need to consult Horizon BCBS's coverage policy. (Your surgeon undoubtedly has a copy already, but you probably want to look at it yourself.) Google "Horizon BCBS Orthognathic" One of the results will be "Guidelines for Determining Necessity of Orthognathic Surgery"; for me the link didn't work, but if you click the small down-arrow next to the URL, you can retrieve the cached copy.

As far as other insurance goes? You'll need to examine their coverage guidelines before making a decision. Some insurance companies have kind of a "free-form" policy (like the one you are dealing with). Others have a strictly delineated stating exactly what will and will not be approved. Some of those policies require a "significant functional impairment", others merely require bad measurements (usually two+ standard deviations from the norm.)

For me, Cigna required significant functional impairment AND measurements far off, and this was fixed when my employer shifted to Anthem BCBS which only required impairment OR measurements to be off. Cigna denied me, Anthem sailed through.

Alternatively, you can discuss self-pay with your OMFS. For instance, if you are only up for a segmented LeFort I, that can often (though not always) be done on an outpatient (and therefore much less expensive) basis as long as you have a dedicated person that will agree to take care of you on discharge, especially through the first night. In states where insurance coverage is tough for orthognathic (I've heard TN listed as one of those states), surgeons and hospitals are used to self-pay, and offer relatively reasonable rates (at least compared to the "rack" rates it might ordinarily cost.) Your OMFS might also might be able to refer you an OMFS program at a dental school; such programs (and their associated hospital) often treat less expensively than a non-academic setup.

[aubreyskingdom]

My insurance company declined the insurance claim (from United Healthcare) for surgery 3 days before surgery. I signed up for Mass Health the day after I was informed, and was approved - apparently Mass Health has a good history of approving the surgery. I am in a lucky situation where I can cancel my United Healthcare at the end of August, and use Mass Health as my primary. We are rescheduling the surgery for October. Not sure if this is an option for you or not but ask the surgeon or place doing the surgery which insurance companies they have luck with, and see if you can enroll (I am aware most states have different enrollment dates - I got very very lucky since I live in Massachusetts and have great health care) and possibly schedule the surgery once your new coverage starts.

[aubreyskingdom]

Forgot to add that you can always appeal it. You can do both an internal appeal and an external appeal. They will both take time from what I hear.

[2017JawSurgery]

Hi there, I, too, was denied coverage for a double jaw surgery. I have Horizon Blue Cross Blue Shield of New Jersey as well. I am in the middle of my 2nd appeal right now.

Do you have an update or a final outcome on your appeals for your jaw surgery? What else can I do to proactively fight for this medically necessary surgery?

[IcarusJaw]

Hi,

I got my denial overturned through the external review. In addition to doctors files I included the following:

1. Went on pubmed and found studies on maxillofacial cases similar to mine (class 3) . Printed those and included them in my appeal.

https://www.ncbi.nlm.nih.gov/pubmed/

2. Paid 450 for a sleep apnea home test. Even if you have a little sleep apnea or think you might, get the test done and include the results.

3. Ever get a massage? Go back to that spa and have them right a letter stating you got it to deal with stress and headaches. Then include a pubmed study showing massages is a conservative treatment for maxillofacial headaches, facial pain.

You can win this! You need to fight insurance till the end. I did and am now 1 year and 4 months post op. Feels like ages ago.

Good luck!