Orthognathic Surgery Preauthorization

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BlazingBlue
Posts: 2
Joined: Sat Dec 29, 2018 11:08 pm

Orthognathic Surgery Preauthorization

#1 Post by BlazingBlue » Sat Dec 29, 2018 11:11 pm

I’ve been in braces for a little over 18 months and am scheduled to have double jaw surgery in April or May of 2019. My oral surgeon and orthodontist have been somewhat vague on whether they believe my insurance provider will approve the request for preauthorization. I’ll list what I’ve been diagnosed with below along with the surgical plan and guidelines for approval of orthognathic surgery from my insurance provider. We have yet to submit a complete preauthorization request. Not listed is my orthodontist documenting that I have abnormal wear on several teeth. I have stated to both my orthodontist and my oral surgeon that I don’t feel breathing through my nose is as easy as it should be. I don’t have seasonal allergies but always feel like my nose is somewhat what congested. I’ve read that nasal breathing isn’t the easiest with somewhat who has what I have. I’m also a mouth breather at night and routinely wake up with dry mouth. Since my teeth have begun aligning with braces, I’ve developed a more pronounce underbite and find it difficult to bite through pasta, onions, tomatoes especially if they’re on a burger or sandwich. I’ll also sometimes pull cold cuts and lettuce out of a sandwich instead of biting though them. I didn’t have this problem before braces. Are there any dos and don’ts when submitting a request for preauthorization? From what is listed below, does it look like something that would be authorized for medical necessity and NOT something that’s just for cosmetic reasons?

Orthodontic Findings:
Class 3 Malocclusion
9mm Negative Overjet
3.5mm Maxillary Incisor Show at Rest
100% Incisal show at full smile
Maxillary midline centered on facial midline, mandibular midline 1mm to right of facial midline
Bilateral posterior crossbite

Skeletal Findings:
Maxillary Hypoplasia
Mandibular Hyperplasia
High narrow palate vault with restricted maxillary transverse dimension

Surgical Plan:
3 Piece Lefort 1 Osteotomy
BSSO Setback
Intermediate Surgical Splint
Final Surgical Splint

Insurance Providers Guidelines for Orthognathic Surgery
http://blue.regence.com/trgmedpol/surgery/sur137.pdf

kplatt2010
Posts: 260
Joined: Sat Jul 07, 2018 6:26 am

Re: Orthognathic Surgery Preauthorization

#2 Post by kplatt2010 » Sun Dec 30, 2018 10:07 am

Good Morning Blazing Blue,
It will not be you that obtains the pre-authorization but your surgeon. If for whatever reason; you are denied, the surgeon will be the one to write the appeal. You can check on prior authorization approval by calling the pre-certification number on the back of your BCBS card.

I would respectfully suggest too; once you've received the prior authorization, request a copy for your records. Also; keep the EOB statements for a couple of years too and here is why.

I had MMA surgery on July 11, 2017 with prior authorization. I had the surgery at Brooklyn Methodist in NYC(BTW avoid at all cost). Following surgery I had a few hiccups with oral surgeon being underpaid and their office having to send payment back and then jump through hoops to be paid correct amount. The attending overseeing Intensivist (while in step down intensive care unit); who billed me, was apparently out of Network. This resulted in me having to fill out special paperwork for an appeal so that the provider could be paid in-network. I finally wrote a letter to the hospital asking them why they would be a preferred BCBS facility, yet have an overseeing intensive care unit doctor who is not a preferred BCBS provider, when they are the area trauma center and patients do not have a choice. The hospital wrote back that they would cease that pursuit.

Fast forward EIGHTEEN MONTHS LATER and I receive a bill from anesthesia provider asking for $7K as the insurance company is asking for their money back. Rationale listed on statement was they were not authorized (WTF??!!). I looked through BCBS portal and their is no documentation of any sort of action and so I'm hoping and praying that this is some sort of clerical error. I've emailed BCBS regarding the matter including my original prior-authorization, EOB statement paying anesthesia provider, and the bill from anesthesia. I'm going to call all parties on Monday but what a headache and stress that I don't need. Someone is getting a can of whoop a$$ come Monday morning.

The cherry on the sundae is the fact that I had to undergo a 2nd procedure (rhinoplasty, septoplasty) because the anesthesia folks deviated my septum.

So lessons learned and message to share to all ** Save All Paperwork For a Few Years..**
Karla

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