In what way were you "functionally impaired"? Need help with an unhelpful office and insurance.

[AlfAteCats]

Ugh. I am still trying to obtain approval for my surgery from insurance (widen/shorten upper jaw, length lower jaw, remove chin implant which is eroding my bone and lengthen chin).

I got rejected the first time in writing. Then I was rejected after my doctor did a peer-to-peer with the insurance company's doctor. The office said it was because my insurance only covered corrective surgery for "congenital" (present at birth) jaw problems and not "developmental" (problems that present themselves with growth) jaw problems. Then I called the insurance company yesterday and they said it wasn't the case at all - it was because there wasn't enough evidence of a "functional impairment", even though I met the measurement criteria for needing the surgery. It has to be both.

Well, I'm functionally impaired. I have a 7mm overbite. I can't bite into an apple or a sandwich. I can't keep my mouth shut and lips together without focusing on it, and my face is always tense from it. My front teeth have hairline cracks in them from trying to bite into things. I don't know what else we are supposed to say to the insurance company. This is not functional! The patient care coordinator at the practice is NOT helpful and expects me to go it alone with appeals. I'd rather just switch practitioners at this point.

Any help with how to "prove" to the insurance company that I am functionally impaired would be greatly appreciated. Basically - what do they want to hear and how do I prove it to them?

[EWUgal15]

That's really a tough spot. I had a nurse tell me to use statements like "It affects my work" or "It prevents me from sleeping at night" to get insurance companies to loosen up a bit. I don't know how well "I can't eat without a straw" would fly but it's definitely a quality of life issue and that should be enough with your measurements to push you over the edge. Best of luck to you!

[sirwired]

That's really poor on the part of the insurance coordinator at your Dr's practice; dealing with insurance appeals is part of his/her job.

[MagnoliaMama]

Ugh. I am still trying to obtain approval for my surgery from insurance (widen/shorten upper jaw, length lower jaw, remove chin implant which is eroding my bone and lengthen chin).

I got rejected the first time in writing. Then I was rejected after my doctor did a peer-to-peer with the insurance company's doctor. The office said it was because my insurance only covered corrective surgery for "congenital" (present at birth) jaw problems and not "developmental" (problems that present themselves with growth) jaw problems. Then I called the insurance company yesterday and they said it wasn't the case at all - it was because there wasn't enough evidence of a "functional impairment", even though I met the measurement criteria for needing the surgery. It has to be both.

Well, I'm functionally impaired. I have a 7mm overbite. I can't bite into an apple or a sandwich. I can't keep my mouth shut and lips together without focusing on it, and my face is always tense from it. My front teeth have hairline cracks in them from trying to bite into things. I don't know what else we are supposed to say to the insurance company. This is not functional! The patient care coordinator at the practice is NOT helpful and expects me to go it alone with appeals. I'd rather just switch practitioners at this point.

Any help with how to "prove" to the insurance company that I am functionally impaired would be greatly appreciated. Basically - what do they want to hear and how do I prove it to them?

Most plans have fairly specific language outlining what their parameters are in their view. Have you gotten a copy of your plan's exclusion language as pertains to Orthognathic surgery? If so, mirror back to them their own words as you explain yourself.

I also agree wholeheartedly with sirwired. This could be a sign that your practice might be less than competent. I would feel very uncomfortable with that if I were in your shoes. I lucked out on the insurance front since both of my plans approved from the get go. My surgeon IS a peer reviewer for one of the plans, so it would have been awkward if they denied their own expert's opinion, lol.

What insurance company/plan do you have and have you consulted with any other in network OMFS offices near you?

[AlfAteCats]

Most plans have fairly specific language outlining what their parameters are in their view. Have you gotten a copy of your plan's exclusion language as pertains to Orthognathic surgery? If so, mirror back to them their own words as you explain yourself.

I also agree wholeheartedly with sirwired. This could be a sign that your practice might be less than competent. I would feel very uncomfortable with that if I were in your shoes. I lucked out on the insurance front since both of my plans approved from the get go. My surgeon IS a peer reviewer for one of the plans, so it would have been awkward if they denied their own expert's opinion, lol.

What insurance company/plan do you have and have you consulted with any other in network OMFS offices near you?

[/quote]

I have Humana (a group plan through my employer).

Thanks for the advice. I got my policy out and dissected it (thank you, English degree!) and I think I've found a way to make them cover me. It's intentionally tricky language. Scumbags. I wrote directly to my surgeon and copied his PCC on it and asked him to make the changes to pander to their policy language. Just writing her is not getting me anywhere.

I talked to my orthodontist's office, who have worked with this surgeon extensively, and HE is great, but there is high turnover of his staff so they are unknowledgeable. She was so unhelpful, offering zero advice and guidance about how to prepare my appeal. I don't know anything about this. I have never done this in my life before and ANY advice was good advice. After I get this approved, I need to figure out who her boss is and talk to them about it.

[AlfAteCats]

That's really poor on the part of the insurance coordinator at your Dr's practice; dealing with insurance appeals is part of his/her job.

She argues it's not and she's getting back up from their billing coordinator. It's like she is just trying to get out of helping me.

[sirwired]

Does this OMFS not do much orthognathic? Because arguing with insurance about approval is par for the proverbial course with orthognathic...

I'd say "barely able to chew" qualifies as a "functional impairment" but somebody needs to translate that into text the insurance will accept, and that somebody isn't you.

[AlfAteCats]

Does this OMFS not do much orthognathic? Because arguing with insurance about approval is par for the proverbial course with orthognathic...

I'd say "barely able to chew" qualifies as a "functional impairment" but somebody needs to translate that into text the insurance will accept, and that somebody isn't you.

The surgeon does a whole lot. Steven Roser at Emory. His new patient care coordinator is just awful. I'm tempted to "tell" on her.

And totally agree about the functional translation. I have an issue with my ability to bite, not chew.

[AlfAteCats]

Wow. I wrote the surgeon and his PCC last week, asking for changes to the language of my pre-authorization packet, and I have received no response. Not even an "We're on it." I wrote the PCC today to ask how long it would take - no response. It's time to get my records and switch practices. I don't even know how that will affect the appeal process with my insurance.

[AlfAteCats]

I'm switching practices. I took hours of my time researching my insurance company's coverage language and sent them EXACT instructions on how to alter the language of my packet so I could have the best chance to win my appeal. They not only did NOT change anything on my packet, but they also sent me a letter of necessity stating that I have a speech impediment (a complete lie!). We don't need to LIE to win and get this covered, just pander to the insurance company's language. I'm SO DONE.