I started my journey in Sept of 2005. I was told by the ortho I went to that I would need braces along with jaw surgery to help correct my bite. I got a consult a week later with an OS he recommended. In Nov of 2005 I get a letter from my insurance saying that my "BSSO, surgical splint, and skeletal fixation will be considered for payment." In Feb of 2006 my braces were put on and 16 months later my ortho and OS say I'm ready for surgery. YEA!! I set up a "tentative" date of Aug 22, 2007 while the surgery coordinator gets everything lined out with my insurance. I'm pretty happy because I can see the light at the end of the tunnel.
Well, today I receive a letter from my insurance saying that my policy "excludes benefits for any treatment for correction of malocclusion, protrusion, hypoplasia or hyperplasia of the jaws." I'm scratching my head wondering what policy were they looking at when I was pre-approved in 2005.
My ortho told me to begin with that if I couldn't have the surgery then he wouldn't recommend braces because I could end up in a worse condition as far as my bite goes. Well, guess what? It's worse! My teeth are straighter, but my bite is way off. I can't bite down or even chew without the inside of my cheek getting trapped between my teeth on the right side. I wake myself up several times a night with my teeth clenching the cheek and inside lip. I know I can't afford to pay all of this out of pocket, but I can't just be left like this either. It's a horrible pain. Has anyone else been pre-approved, denied, and then re-approved? I don't know what I'm going to do. I'm open to any and all ideas, suggestions, or comments.
Thanks in advance,
Pokergirl
Insurance benefits denied!!
Moderator: bbsadmin
I'm in the same situation as you. I have had braces for about 7 and a half months and I am very close to being ready. I was confident that I would be able to be approved because my father has good pulls in his business which I am covered under. I learned about 4 months ago that they would not cover my surgery and would never cover it. I am very confused as well. My Dad is searching for new insurance companies, because we would have a very tough time paying for this out of pocket
I'll admit I am SO nervous about being denied. My orthodontist told me to expect it on the first submission. She went on to say that it often takes three tries. She said she felt this was a ploy to get people to give up.
I'd contact both the surgeon's office and your ortho and ask for their help. I would also contact the benefits coordinator at work if that's applicable. I would look at the benefits package and see if it spells out that the surgery is not covered. Often times the refusal is more based upon how its submitted than what the procedure is. For example, I am not covered for some preventive tests. If the same test is given to diagnose an injury, its covered. Same procedure, same staff, different reason. It doesn't make sense, but its the game that's played.
Keep fighting. And good luck.
Mike
I'd contact both the surgeon's office and your ortho and ask for their help. I would also contact the benefits coordinator at work if that's applicable. I would look at the benefits package and see if it spells out that the surgery is not covered. Often times the refusal is more based upon how its submitted than what the procedure is. For example, I am not covered for some preventive tests. If the same test is given to diagnose an injury, its covered. Same procedure, same staff, different reason. It doesn't make sense, but its the game that's played.
Keep fighting. And good luck.
Mike
I wore braces (this time) for 1294 days or 3 years, 6 months and 17 days.
But who's counting?
Jaw Surgery June 1, 2009
Thanks for praying for me and thinking happy thoughts.
But who's counting?
Jaw Surgery June 1, 2009
Thanks for praying for me and thinking happy thoughts.
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BracesRacer
- Posts: 170
- Joined: Sun Feb 04, 2007 1:09 pm
This is a good time to chime in and say... I HATE INSURANCE COMPANIES they all suck and they all pull this crap to try to get out of actually insuring you like they are supposed to do... ugh! Okay I feel slightly better now... I hope mine goes okay. When I called the insurance company i was assured several times that it would be covered... I wanted it in writing but he could not provide that of course...
Oh Pokergirl, I am so, so sorry - but keep trying!!! There are many people on this board I've read the same situation applies to and they finally were approved after several tries. I'm scared to death of getting turned down as well although my policy explicitly "says" it will cover it in my benefit handbook. I know it's not much of a consulation, but thank goodness for companies like Capital One who will finance a lot of things medically if you have no other choice. That would suck, but sometimes you have to invest in yourself, I will be thinking about you and sending good vibes your way. And Monia, yes, I thought about going out of country as well for surgery years ago to Costa Rica before I got this particular job and insurance plan, but just couldn't bring myself to do it - but that doesn't mean it might not be worth it. I'd just be really, really careful, which I know you will.
pokergirl,
I do sympathize with you! I also was denied and just two weeks prior to surgery. I called the insurance company and they said very matter-of-factly to send in additional info to support my functional problems. Even my OS's office was unfazed. They do the reconsiderations all the time. I wrote a letter detailing my problems and the office manager sent in that and additional evidence of crossbite. A week later, I got a letter that my surgery was approved for the next 30 days.
However, it does make a difference what your insurance carrier covers specifically. Because they were considering payment in 2005 may not mean that they would have covered it. However, your OS should have cleared this for you. I'm sure they must be working on it.
I hope it works out in your favor!
Lo
I do sympathize with you! I also was denied and just two weeks prior to surgery. I called the insurance company and they said very matter-of-factly to send in additional info to support my functional problems. Even my OS's office was unfazed. They do the reconsiderations all the time. I wrote a letter detailing my problems and the office manager sent in that and additional evidence of crossbite. A week later, I got a letter that my surgery was approved for the next 30 days.
However, it does make a difference what your insurance carrier covers specifically. Because they were considering payment in 2005 may not mean that they would have covered it. However, your OS should have cleared this for you. I'm sure they must be working on it.
I hope it works out in your favor!
Lo
I too was denied
I got preapproved and got braces as you did based on the first ok. AFter SARPE surgery my claim was denied because they "assumed" it was for TMJ. I had SARPE ('05) and Orthognathic surgery (06). My initial consult with the OS was because I wrenched my jaw eating something. After reviewing my mouth, he asked me if I had breathing issues and snoring. I had a sleep study and it was determined I had sleep apnea. My OS appealed the claim and I also talked it over with my insurance rep at work. They didn't understand what was happening. I've heard others that have the initial claim denied and have to appeal. I think ins just tries this to see if they can get out of paying. Keep trying. And, do some research on the net. There are lots of reports on how oral health affects you in other health issues, like your heart. Why ins thinks your mouth isn't part of your body is beyond me.
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mamabracito
- Posts: 93
- Joined: Sat Apr 22, 2006 11:39 am
pokergirl,
I'm not sure were you are from and i know this isn't 100 percent the same but I'm from Canada. When my ortho told me that the pain in my head was caused by a jaw disfunction it was the answer to my prayers. I had been suffering for sooo long. Then I asked the big question...does OHIP cover it. See OHIP in Canada covers most medical expenses including hospital stays and doctor visits. My ortho told me that they do not cover it unless it is causing me pain. I called OHIP to see if they would cover me and they told me no because it was classified as plastic surgery. I got my doctor and ortho to send in notes with proof that it was causeing me server pain and discomfort but to no arrival. We finally got an agreement when they said they would pay for my hosiptal stay but I had to pay for my sugeon to do the actuall work. So in the end I only have to pay $3000 for the sugeons work. That doesn't include the braces which OHIP refused to pay for they are $6000.
Don't give up because even though I didn't go though insurance problems if you keep pestering and proving that you need this hopefully they will help you out. The government finally came though for me in the end. I hope your insurance company does too.
I'm not sure were you are from and i know this isn't 100 percent the same but I'm from Canada. When my ortho told me that the pain in my head was caused by a jaw disfunction it was the answer to my prayers. I had been suffering for sooo long. Then I asked the big question...does OHIP cover it. See OHIP in Canada covers most medical expenses including hospital stays and doctor visits. My ortho told me that they do not cover it unless it is causing me pain. I called OHIP to see if they would cover me and they told me no because it was classified as plastic surgery. I got my doctor and ortho to send in notes with proof that it was causeing me server pain and discomfort but to no arrival. We finally got an agreement when they said they would pay for my hosiptal stay but I had to pay for my sugeon to do the actuall work. So in the end I only have to pay $3000 for the sugeons work. That doesn't include the braces which OHIP refused to pay for they are $6000.
Don't give up because even though I didn't go though insurance problems if you keep pestering and proving that you need this hopefully they will help you out. The government finally came though for me in the end. I hope your insurance company does too.
[url=http://www.TickerFactory.com/]
July 18, 2006 Speed Braces on both Top and Bottoms!
July 30, 2007 BSSO, Le Fort 1, SARPE, and something else Surgery lol!
Thanks to everyone who has responded. I really love this site. All of the support that everyone gives to each other is just wonderful!
I am in Texas and being self-employed I pay quite a bit for my insurance premium each month. I do intend to appeal this and I do intend to drive them absolutely crazy with phone calls and letters. My husband says I put the a$$ in ten-a$$-ity. LOL! I am also going to check on maybe going to Costa Rica for the surgery if all else fails. I've never been there and I'm sure by round 15 with the insurance company I'll need a little vacation (or a padded room with a straight jacket.)
Anyway, thanks for the replies. I'll let everyone know how it goes.
I am in Texas and being self-employed I pay quite a bit for my insurance premium each month. I do intend to appeal this and I do intend to drive them absolutely crazy with phone calls and letters. My husband says I put the a$$ in ten-a$$-ity. LOL! I am also going to check on maybe going to Costa Rica for the surgery if all else fails. I've never been there and I'm sure by round 15 with the insurance company I'll need a little vacation (or a padded room with a straight jacket.)
Anyway, thanks for the replies. I'll let everyone know how it goes.
I came across this article. Lets not give up!
http://www.cnn.com/2007/HEALTH/07/19/pa ... index.html
http://www.cnn.com/2007/HEALTH/07/19/pa ... index.html
My surgery coordinator filed an appeal on my insurance's denial and I got a letter today stating that benefits are still denied. The letter states, "Your policy is a True Individual Major Medical policy. Benefits were approved for the proposed surgery on Nov. 17, 2005 in error. The Texas State Mandate does not apply to True Individual Medical plans."
What do they mean it was approved in error? I spend $3,000 in braces, $1,000 for wisdom teeth extraction, and another $500-$800 for x-rays, models, molds, pictures, etc., and I'm worse now (I feel like) than when I started this journey all because someone approved it in error? Are they kidding me?
My husband talked with our insurance agent about it, who is also a family friend. Our friend said that Texas passed a law within the last two years that basically says that insurance companies don't have to cover this type of procedure if they don't want to. And God forbid if they do anything they don't want to!
Our friend said he's going to do everything he can to get it covered since I was approved for surgery before any of this crap was passed and even told us to expect the first appeal denial.
What is everyone's impression on this? Has anyone heard of such? Should I be looking for a good attorney?
Pokergirl
What do they mean it was approved in error? I spend $3,000 in braces, $1,000 for wisdom teeth extraction, and another $500-$800 for x-rays, models, molds, pictures, etc., and I'm worse now (I feel like) than when I started this journey all because someone approved it in error? Are they kidding me?
My husband talked with our insurance agent about it, who is also a family friend. Our friend said that Texas passed a law within the last two years that basically says that insurance companies don't have to cover this type of procedure if they don't want to. And God forbid if they do anything they don't want to!
Our friend said he's going to do everything he can to get it covered since I was approved for surgery before any of this crap was passed and even told us to expect the first appeal denial.
What is everyone's impression on this? Has anyone heard of such? Should I be looking for a good attorney?
Pokergirl
Wow, your situation really stinks as the lead up costs to surgery, as you point out, are huge. I got a letter when my surgery was approved that clearly listed the procedures that would be covered with a code and the length of the hospital stay that would be covered. Did you get a letter that was that specific? If so it might be worth taking it a step further. However, it also seems worth checking out what kind of policy was approved in Texas. Does your friend mean that any insurance company operating in Texas doesn't have to cover the surgery if they don't want to????