When your insurance denys your Orthognathic Surgery...

[skittley80]

Hi all.. Well I haven't posted here in a long time.. I started my braces journey in July of 2006 in preperation for Orthognathic surgery. I met with a surgeon at that time and went through the whole insurance bit and got my surgery approved. At the time I was still married to my ex and was on his insurance. At the end of 2006 my divorce went through and I then got insurance through my work. The company was the same that the insurance was through so I didn't see the need to notify anyone of the change since I didn't need to see my surgeon for awhile because my teeth were no where near ready. Well I met with my surgeon last month at the request of my orthodontist because I am now getting close to needing surgery. I told them of my new insurance and they sent in everything to get the approval and it came back denied. Apparently on the policy at my work there is an exclusion that states it will not cover orthognathic surgery for anyone over 19.. I'm 27 So basically my only option is to purchase a policy on my own. Has anyone ever done this? My surgeon suggested Blue Cross of Maryland or Allied Health. He said with his other patients the surgery got approved with these two companies. Does anyone know if this idea is feasible.. how long the waiting periods are and how much it would cost? Also, does anyone know of any other options? Thanks alot!

[badbite]

I am sorry to hear what you are going through. I have Blue Cross (I in in central PA) and they paid for my SARPE. I was told by the OS to consider it a big Christmas present if it was covered, so I guess I was lucky. My husbands's office even said it most likely would not be covered, but it was without any appeals. I am keeping my finger's crossed that the policy does not change this year. I am very hopeful they will cover the "big" operation.

Good luck, there may be a waiting period if you can get the new insurance, and get them to cover it. Also they may may consider this a pre-existing condition now (since the braces and already trying to get it covered). Just something to think about.

[phil]

skittley80,

Here's some irony for you: most people UNDER the age of 19 should NOT have orthognathic surgery, since their bones have not stopped growing.

My opinion--you need to call that insurance company again--they might be trying to pull one over on you! Why would a policy have a statement like THAT which makes no sense? Oh, excuse me, I forgot who you're dealing with...

[Arvensis]

Here's some irony for you: most people UNDER the age of 19 should NOT have orthognathic surgery, since their bones have not stopped growing.

True story, they wanted to do surgery when I was 16, said I was done growing. I grew 3 inches from 18-20.

Sucks if insurance doesn't pay, but I paid out of pocket for mine. I'm 25, 26 actually in a few weeks, and realized I didn't want to live the rest of my life unable to eat crunchy cereal or living off pasta. Life goes on I guess, I'll be broke for a bit but at least I'm eating well.

[skittley80]

skittley80,

Here's some irony for you: most people UNDER the age of 19 should NOT have orthognathic surgery, since their bones have not stopped growing.

I already tried explaining this to them but the person on the phone didn't care to hear it. She said it's an exclusion and there is nothing she could do about it.. I don't understand insurance companies.

[Arvensis]

yup, if it's excluded they're not even going to examine whether it is medically necessary or not, it's just a big fat no. At least, that was my experience.

[allisonh]

Hello,

I had a similar situation. I just moved up to Oregon from CA. I had health insurance coverage in Ca, under the company I worked for. But, since moving to Oregon, health insurance was a MAJOR issue, so I wanted to warn you. I was denied from 3 insurance companies because they found out I had been seeing an oral surgeon and had a pending surgery in Ca and because I had TMJ. I had put it as a pre-exhisting condition on my first application, but on my other apps, I had lied, and was still denied. I finally got lucky and lied my way into an insurance company, and then found out there is a waiting period, and despite the waiting period, it still would not have been covered. There are not many, or really any private pay (as in not through a company or group policy) that will cover jaw surgery, unless you live in a stat with state mandated TMJ coverage laws (check here http://www.tmj.org/insurance3.asp). Unfortunately, Oregon is not a state with mandated TMJ coverage. My last quote was 25-30,000 for my surgery. Meanwhile, I am on a soft food diet and have a really hard time with speech since my teeth are now straight, and has severely exacerbated the gap between my upper and lower teeth, and the fact that my jaw joint is severely damaged.... Anyone seen Sicko?

[allisonh]

Oh, and im also at risk of losing my insurance coverage now because I lied about having TMJ, and they may cancel my policy... leaving me blacklisted for insurance companies.

Be very very careful.. It shouldnt be this difficult, but, unfortunately, it is.

[iBorg]

I'm stunned to find West Virginia in the list. That makes my mind set a lot easier. I'll admit I'm more than a tad worried about whether or not my surgery will be covered.

Now how to get it covered? If you're in group coverage talk to your group plan administrator. Ask what we need to be done to be covered. Appeal on the grounds that it is not for appearance but functional. Finally combine the surgery with sinus surgery and use the sinus surgery to pay hospital expenses so you only have to pay doctor's fees.

I hope something works for you.

Mike

[Arvensis]

Finally combine the surgery with sinus surgery and use the sinus surgery to pay hospital expenses so you only have to pay doctor's fees.

This is what I did!! I had a septoplasty along with my upper jaw surgery, and insurance paid for the hospital, 80% of the anesthesiology, etc.

A WORD OF CAUTION TO EVERYONE THOUGH: my new current nightmare is that the surgeon wrote "rhinoplasty" in the chart during op in the hospital, so while Rhinoplasty was never the diagnosis code used by the surgeon's office, now my anesthesiologist (whose billing is controlled by the hospital, by the official surgical record) is filing for "rhinoplasty" for that portion. His little error in writing rhinoplasty instead of septoplasty? ... probably going to cost me AT LEAST 340 dollars, but could be upwards of 1500 dollars if they deny entire septoplasty anestethesiologist portion... assuming insurance doesn't pitch a holy fit over the whole thing now and try to argue something else was cosmetic too.

Not. Happy.