Jaw Surgery Insurance?

[Nate92]

Hello everyone, I'm back.

So I'm gathering more information on my dental case. First, I want to expand my arch, even if it is just moving my teeth, but then I'm interested in bi-maxillary surgery. So! The big thing I want covered here is the bi-maxillary advancement. My insurance is Blue Cross/Blue Shield PPO. I called and my health insurance does indeed cover jaw surgery if it is medically necessary. I would like all of your's opinion on whether or not my case has a chance of being covered!

o What led me to question jaw issues was my physical appearance. My upper jaw seems pushed back. I have a very sunken mid-face, the skin from my nose to lip slopes back, my upper lip is undetectable, and a disproportionate nose. I also have a receding lower jaw. It has caused me to be very self-conscious.
o I have difficulty breathing through my nose, it has forced me to breath through my mouth most of my life.
o I am getting checked out for Sleep Apnea. I am constantly tired and anxious.
o I have jaw pain.
o I grind my teeth TERRIBLY at night.
o I have occasional morning headaches and dry mouth

The catch is braces fixed my teeth when I was younger. I had an overbite and the teeth were moved accordingly, so I seem okay. I almost wish I had kept my teeth where they were all those years so it was more blatantly obvious that my bite was messed up!

P.S. How do you get both upper and jaw surgeries covered as opposed to one?

[sirwired]

There is a very specific list of criteria that the insurance companies use to determine if jaw surgery is medically necessary. Really the OMFS your ortho refers you to would be the best person to answer this question. (The consult will be covered in any case, even if the surgery is decided not to be necessary.) But if you want to know in advance, here's one for Anthem BCBS (other BCBS's might use different criteria): http://www.anthem.com/medicalpolicies/p ... 053349.htm

I think it's not unreasonable to request a referral from your chosen ortho (I'd pick one that has done adult surgical cases in the past) prior to commencing treatment. Go ahead and take a list of the local surgeons that take your insurance to the ortho office with you. In these parts, the only OMFSs that take insurance are the professors and residents of the OMFS dept. of the local Dental School. (My surgery will be done by the professor in charge of the residency program.)

[djspeece]

There is a very specific list of criteria that the insurance companies use to determine if jaw surgery is medically necessary. Really the OMFS your ortho refers you to would be the best person to answer this question. (The consult will be covered in any case, even if the surgery is decided not to be necessary.) But if you want to know in advance, here's one for Anthem BCBS (other BCBS's might use different criteria): http://www.anthem.com/medicalpolicies/p ... 053349.htm

I think it's not unreasonable to request a referral from your chosen ortho (I'd pick one that has done adult surgical cases in the past) prior to commencing treatment. Go ahead and take a list of the local surgeons that take your insurance to the ortho office with you. In these parts, the only OMFSs that take insurance are the professors and residents of the OMFS dept. of the local Dental School. (My surgery will be done by the professor in charge of the residency program.)

I suspect that your OMFS doc's back office staff knows what the magic combination of indications is for coverage. The difficulty breathing issue you mention may do it. My daughter underwent a septorhinoplasty (nose job) to correct a deviated septum due to a soccer injury in high school. It is the sort of procedure that could be considered cosmetic or a functional repair, and I was able to make the case working with the surgeon that it was an airway issue and needed repaired. Best of luck to you in any case!

[bmueller]

I would not worry about the fact you already had orthodontics as a kid. Orthodontics alone can't fix/hide a true skeletal problem.
I had my upper premolars extracted so my overjet was within "normal" range but I was still skeletal class II with my molar relationship classII >4 mm.

Medical nessisity has to be proved for any and every procedure you ever go through that you submit to insurance.

Hopefully it's as easy as the OMS submitting x-rays, molds, and notes telling just how far from normal your face/jaws are. Usually if you're a candidate for jaw surgery (not just genio) you are within most insurance plans criteria for medical necessity.

I also reccomend getting a letter about your breathing issues to submit to your insurance.

For me, the upper jaw surgery was automatically covered... just needed to submit the proper info. The lower jaw (BSSO) was considered cosmetic until proved med necess. by the info I submitted. I believe the letter from my ENT outlining my breathing issues did the trick!

[Nate92]

There is a very specific list of criteria that the insurance companies use to determine if jaw surgery is medically necessary. Really the OMFS your ortho refers you to would be the best person to answer this question. (The consult will be covered in any case, even if the surgery is decided not to be necessary.) But if you want to know in advance, here's one for Anthem BCBS (other BCBS's might use different criteria): http://www.anthem.com/medicalpolicies/p ... 053349.htm

I think it's not unreasonable to request a referral from your chosen ortho (I'd pick one that has done adult surgical cases in the past) prior to commencing treatment. Go ahead and take a list of the local surgeons that take your insurance to the ortho office with you. In these parts, the only OMFSs that take insurance are the professors and residents of the OMFS dept. of the local Dental School. (My surgery will be done by the professor in charge of the residency program.)

Hey sirwired: That is a very specific list! I'm nervous now. How do the orthodontist and OMFS work in conjunction here? I found a OFMS online that I like, but I doubt he has any affiliation with the orthodontist I like. Does that matter? Can I just suggest that OFMS to the orthodontist I like? Also, does the OFMS need to accept my insurance or just the orthodontist?

I suspect that your OMFS doc's back office staff knows what the magic combination of indications is for coverage. The difficulty breathing issue you mention may do it. My daughter underwent a septorhinoplasty (nose job) to correct a deviated septum due to a soccer injury in high school. It is the sort of procedure that could be considered cosmetic or a functional repair, and I was able to make the case working with the surgeon that it was an airway issue and needed repaired. Best of luck to you in any case!

Hey djspeece: Thank you! I have my finger's crossed they will. So then, the OFMS does need to accept my insurance? Not just the Orthodontist?

I would not worry about the fact you already had orthodontics as a kid. Orthodontics alone can't fix/hide a true skeletal problem.
I had my upper premolars extracted so my overjet was within "normal" range but I was still skeletal class II with my molar relationship classII >4 mm.

Medical nessisity has to be proved for any and every procedure you ever go through that you submit to insurance.

Hopefully it's as easy as the OMS submitting x-rays, molds, and notes telling just how far from normal your face/jaws are. Usually if you're a candidate for jaw surgery (not just genio) you are within most insurance plans criteria for medical necessity.

I also reccomend getting a letter about your breathing issues to submit to your insurance.

For me, the upper jaw surgery was automatically covered... just needed to submit the proper info. The lower jaw (BSSO) was considered cosmetic until proved med necess. by the info I submitted. I believe the letter from my ENT outlining my breathing issues did the trick!

Well that's good. I was very nervous that a/the doctor(s) would like at my bite and say "Oh! Your teeth line up? Next!". I have a great ENT. I will be in contact with him.

Yikes, so as you guys can tell I know nothing about how insurance works. From what I have gathered I obviously need to compile a case, centered around breathing for my insurance company. So, the role of my orthodontist is to refer me to an OFMS? Hopefully of my choosing? How does that work? And then the OFMS will help me with insurance?

Thanks for the advice guys.

Another thing: How do they determine how far your jaw is off? Like in term of millimeters, how can they be certain how far it is off if your teeth are corrected?

[sirwired]

Hey sirwired: That is a very specific list! I'm nervous now. How do the orthodontist and OMFS work in conjunction here? I found a OFMS online that I like, but I doubt he has any affiliation with the orthodontist I like. Does that matter? Can I just suggest that OFMS to the orthodontist I like? Also, does the OFMS need to accept my insurance or just the orthodontist?

The orthodontist is the one that writes a referral to an OMFS. While you are free to choose whichever one you like, I think it would be best if you work with one your orthodontist personally has experience with. (It's not required by any means, but I think it helps out communication issues.) The OMFS must accept your medical insurance coverage for you to receive in-network rates. (Your ortho is covered by your dental insurance, if at all.) I suppose technically you maybe could get jaw surgery done under dental coverage (I'm not sure), but virtually all dental plans have annual maxes that would be a rounding error for orthognathic surgery. Your OMFS (not your orthodontist) would be the one eventually submitting the pre-surgery "package" to your medical insurance company.

Depending on the specific circumstances of your case, the orthodontist may send you for a consult before commencing braces treatment, or he may not bother until he has you prepped for surgery. (For me, this took 16 months.)

[Nate92]

Hey sirwired: That is a very specific list! I'm nervous now. How do the orthodontist and OMFS work in conjunction here? I found a OFMS online that I like, but I doubt he has any affiliation with the orthodontist I like. Does that matter? Can I just suggest that OFMS to the orthodontist I like? Also, does the OFMS need to accept my insurance or just the orthodontist?

The orthodontist is the one that writes a referral to an OMFS. While you are free to choose whichever one you like, I think it would be best if you work with one your orthodontist personally has experience with. (It's not required by any means, but I think it helps out communication issues.) The OMFS must accept your medical insurance coverage for you to receive in-network rates. (Your ortho is covered by your dental insurance, if at all.) I suppose technically you maybe could get jaw surgery done under dental coverage (I'm not sure), but virtually all dental plans have annual maxes that would be a rounding error for orthognathic surgery. Your OMFS (not your orthodontist) would be the one eventually submitting the pre-surgery "package" to your medical insurance company.

Depending on the specific circumstances of your case, the orthodontist may send you for a consult before commencing braces treatment, or he may not bother until he has you prepped for surgery. (For me, this took 16 months.)

Okay. I want to choose a OMFS just because I am looking for a specific procedure. Distraction Osteogenesis which is also covered by insurance, is a way to lengthen the jawbone. I guess I will ask my orthodontist if he knows anyone who does it. I know that my bet to get coverage is with medical insurance not dental (I called).

You mean get a consultation with the OMFS before braces? If that's what you mean, yes. I would want to know if my jaw surgery will be covered before getting braces. That is crucial to my treatment plan.

I also attached a picture of my jaw to this post. Please check it out. You can tell that my jaws are receded. Chiara help me find my plan, which states:

A. Mandibular hypoplasia and/or maxillary hyperplasia (angle classification II)
a) maxillary/mandibular incisor relationship—5mm or more overjet (n= 2 mm)
b) maxillary/mandibular molar buccal discrepancy—4mm or more (n= 0-1 mm

B. Mandibular hyperplasia and/or maxillary hypoplasia (angle classification III)
1. Maxillary/mandibular incisor relationship—0mm or negative overjet
2. Maxillary/mandibular molar buccal discrepancy—3mm or greater

Appearance wise would you think I qualify?

As you can tell my underbite is more disguised by moving my upper teeth back, and thus the "non-existent" upper lip.

[Nate92]

Here's another photo.

[sirwired]

Unless your jaw is extremely underdeveloped (and it does not appear to be from your photos), a regular BSSO (which extends the bone all in one shot, is easier on you, and has a lower complication rate) would probably be sufficient. And your ortho should be able to tell you if he feels you should see the OMFS prior to starting treatment.

[bmueller]

Do you have any pictures of your teeth?

Even if your teeth line up below the limits for medical necessity, I would think that the rethongenia of your jaws would be outside of "normal" and qualify you anyways.

If you can prove sleep apnea/breathing problems then "medical necessity" for double jaw advancement shouldn't have anything to do with proving a teeth discrepancy rather an airway insufficiency.

Either way, I reccomend going to the OMS before starting treatment so you have a good idea of what the surgery plan will be and find out for sure if your insurance will cover it.

The OMS will file for a pre-authorization, basically the insurance will confirm that they are willing to cover the procedure based on medical necessity. That should put your mind at ease. Be sure to have your ENT and sleep study results available for the OMS to see as well. You want to make sure the surgical plan will fix all of your problems including breathing.

[Nate92]

Unless your jaw is extremely underdeveloped (and it does not appear to be from your photos), a regular BSSO (which extends the bone all in one shot, is easier on you, and has a lower complication rate) would probably be sufficient. And your ortho should be able to tell you if he feels you should see the OMFS prior to starting treatment.

I hadn't known of BSSO surgery but just looked into it. I have to say ... I'm not too keen on it just because I'm having plates screwed into my mouth ! DO seem a lot more natural. Oh! And could this be performed on my upper jaw as well? Or are you just talking about lower.

Do you have any pictures of your teeth?

What kind of pictures would you like? You mean x-rays or pictures I can take? Because I don't have x-rays yet.

Even if your teeth line up below the limits for medical necessity, I would think that the rethongenia of your jaws would be outside of "normal" and qualify you anyways.

Yeah? That would be a relief . I'd imagine there has to be some other appropriate way to tell.

If you can prove sleep apnea/breathing problems then "medical necessity" for double jaw advancement shouldn't have anything to do with proving a teeth discrepancy rather an airway insufficiency.

Either way, I reccomend going to the OMS before starting treatment so you have a good idea of what the surgery plan will be and find out for sure if your insurance will cover it.

Do you think I should schedule an appointment with an OMFS I like? Or should I wait for my orthodontist appointment. I haven't seen my orthodontist yet.

The OMS will file for a pre-authorization, basically the insurance will confirm that they are willing to cover the procedure based on medical necessity. That should put your mind at ease. Be sure to have your ENT and sleep study results available for the OMS to see as well. You want to make sure the surgical plan will fix all of your problems including breathing.

What can an ENT recognize that the surgeon could not? I just want to ask my ENT these questions.

[bmueller]

Pictures showing how your bite/teeth line up like this from mine (below). Even though my front teeth only had an overjet of 1-2mm because I had teeth pulled and incisors tipped back, the molar relationship was 4 mm class II.

If picking a specific surgeon is the most important to you, I would do that first. They can reccomend you to an orthodonitst they work with. You can probably pick OMS and OD seperately, but I think it will be alot easier if they already work with each other.

The ENT can identify the cause of your sleep apnea or airway problems. Sleep apnea or snoring can come from a variety of problems. If it is from having too small of an airway (visible in x-rays or CT scans) the ENT may reccomend your jaws be moved even more forward than if you don't have airway problems. This will affect how the orthodontist moves the teeth and how the surgeon moves the jaws. Everyone wants your final product to produce the right proportions on your face as well as functionality.

[sirwired]

A BSSO (or any standard orthognathic surgery) uses a few grams of standard medical-grade titanium plates and screws; the same they'd use if you broke a bone and they needed to set it with pins. In Europe, they are commonly removed after healing, in the US, they usually stay in permanently. (Pretty much nobody is allergic to the stuff; they're utterly inert.) Most (all?) upper-jaw procedures are of the variety called a "LeFort I" usually "segmented". (Don't be scared if you Google "LeFort I"... the same term is used for purposeful surgery and accidental trauma along the same part of the face.) LeFort I's also use plates and screws.

[Nate92]

I'm just trying to find the best way to go about this. All the choices!

Can you guys tell me what is the downside if I go with both the surgeon and orthodontist I like, but they haven't previously worked together? Is there that much contact between them that it would be critical for them to have?

Pictures showing how your bite/teeth line up like this from mine (below). Even though my front teeth only had an overjet of 1-2mm because I had teeth pulled and incisors tipped back, the molar relationship was 4 mm class II.

If picking a specific surgeon is the most important to you, I would do that first. They can reccomend you to an orthodonitst they work with. You can probably pick OMS and OD seperately, but I think it will be alot easier if they already work with each other.

Ugh, I am just trying to find out the most cost-effective way to going about this. I just spoke with the surgeon that I like, he says that a consultation is $145. Should I meet with him and be referred to an orthodontist? I like my choice now, I think.

I think choosing the surgeon is most important to me. Not just because of the procedure, but because I need to find one that will work with me on getting insurance to cover my jaw surgery! That is a lot more important to me than covering braces. Covering braces will also be a lot harder to get covered than jaw surgery on my plan right now, too.

The ENT can identify the cause of your sleep apnea or airway problems. Sleep apnea or snoring can come from a variety of problems. If it is from having too small of an airway (visible in x-rays or CT scans) the ENT may reccomend your jaws be moved even more forward than if you don't have airway problems. This will affect how the orthodontist moves the teeth and how the surgeon moves the jaws. Everyone wants your final product to produce the right proportions on your face as well as functionality.

Can an ENT take x-rays or CT scans? And so I should probably go see him after my sleep study then?

A BSSO (or any standard orthognathic surgery) uses a few grams of standard medical-grade titanium plates and screws; the same they'd use if you broke a bone and they needed to set it with pins. In Europe, they are commonly removed after healing, in the US, they usually stay in permanently. (Pretty much nobody is allergic to the stuff; they're utterly inert.) Most (all?) upper-jaw procedures are of the variety called a "LeFort I" usually "segmented". (Don't be scared if you Google "LeFort I"... the same term is used for purposeful surgery and accidental trauma along the same part of the face.) LeFort I's also use plates and screws.

Thanks for the suggestion, sirwired. I will be sure to keep BSSO in mind. DO takes the plates out after the bone has been expanded, it's similar to SARPE for the palate it seems.

[sirwired]

I'd meet with the orthodontist first; he's going to have a better idea of what needs to happen to your bite, and based on that, what he needs the oral surgeon to accomplish to meet your orthodontic goals. (He'll put it in the referral letter.) Most US orthodontists do not charge for the initial consult, but prior to seeing the oral surgeon, you will need "full records" taken (impressions, pictures, a panorex, and P-A and lateral cephalograms), which the ortho will charge you for; mine were $300. (If you later choose a different ortho, you can take most of the records except the models with you.) You take photos and x-rays with you to see the Oral Surgeon.