Help!! regarding insurance approval!!!!!!!!!!!!

[tybceo25]

So i finally see the ENT doctor in which i waited 6 months to see thinking he would be the one declining or approving my request for surgery. And all he ends up doing as handing me a sheet with the following information.

1. Letter from requesting oral surgeon or DDS
2. Pertinent medical history relating to the surgety request
3. Reports of diagnostic testing and examinations
4. Results of clinical examination, and how it relates to the proposed surgery.
5. Conservative treatment modalities that have been attempted with the outcomes over minimum of 2 years.
6. Panoramic and Cephalometric tracing completed within the last 3 months, showing the preoperative position and projected post-op position of the facial bones with measurements and method of analysis included.
7.Recent study models of the teeth, including index bite to properly articulate the models in the pre-treatment position.
8. Facial and occlusion photographs within last 3 months

Which is pretty much a requirement list that i am supposed to give to my orthodontist to complete to build me a case to be submitted to my medical group for approval.
ENT doctor said he was going to do his part on this side whatever that means and how surgery's are expensive and insurance want any reason to deny them. But thinks he can get me approved.


So s this not a lot of info to ask from my ortho? I mean he did request to try and get surgery but all he has done is put on my braces. does he even have the knowledge to help me with this?
I have already seen multiple doctors and a physical therapist and they all basically my bite was terrible and only surgery could help me.

So what should i do? Just hand the paper to the ortho?gather some info beforehand?Have a oral surgeon do it? anything helps?
I want my report to be bullet proof so it decreases my chances of getting declined.

I am in California and my medical group is sharp stealey and insurance is Health net if that helps

Any piece of info helps.

[fatbaby9]

Hi,

You sound like you aere facing the same problem as I soon will be - trying to get money out of these bloody insurance people! I'm in South Africa but face similar problems. Basically you need to call up all the doctors and specialists you have seen regarding this problem and get them to give you copies of all the notes, tests and recommendations that they made. Then you would give all this to the person making the appeal (your surgeon I presume) Now I dont know if thats allowed in the USA. I'm originally from the UK and every patient is entitled to view their medical records at any time. I dont know if the same rule applies to you guys. I'm working for a general surgeon in South Africa and I know that he's very shifty about giving people copies of patient notes - He'll only send the notes he wants them to see!
You just need to call them all up and explain your situation I guess.
Mind you, I , as the surgeon's secretary have to do all that for a patient, so maybe your surgeon's secretary will do all the calling up for you!
You need every scrap of information possible. The more info that you can get to prove that your condition is a real medical problem and is compromising your day to day life, will strengthen your case from what I can gather. Good luck!

[nineeyes]

I think your ortho would be willing to help you along in getting whatever you need for insurance approval for the surgery. Though you may want to check in with your oral surgeons office to see if they can do it for you (if they have staff that are used to dealing with insurance companies) or at least help you gather all the info you need to make your case.

I am in California too, but I have Blue Shield. It seems all the paper work in getting approval was handled by my Oral Surgeons office. After I was ready for surgery I had another consult with the surgeon and about 3 or 4 weeks later I got the pre-authorization letter from my insurance company. Unfortunately I don't really know what they did or what they sent, so I don't have any specifics. In the end I had the surgery and haven't had any big insurance issues come up.

[tybceo25]

I think your ortho would be willing to help you along in getting whatever you need for insurance approval for the surgery. Though you may want to check in with your oral surgeons office to see if they can do it for you (if they have staff that are used to dealing with insurance companies) or at least help you gather all the info you need to make your case.

I am in California too, but I have Blue Shield. It seems all the paper work in getting approval was handled by my Oral Surgeons office. After I was ready for surgery I had another consult with the surgeon and about 3 or 4 weeks later I got the pre-authorization letter from my insurance company. Unfortunately I don't really know what they did or what they sent, so I don't have any specifics. In the end I had the surgery and haven't had any big insurance issues come up.

Thanks for taking your time to help me out.
Who recommended you to your Oral Surgeon? Was it through your insurance? or your orthodontist refereed him to you?
I would like to see a oral surgeon now to help me with my case but i need to know what im getting myself into.
I dont want to have to pay for all the appointments before hand out my pocket and be in a hole and then have my insurance deny my surgery.

Thanks.

[geordie999]

My insurance is Aetna (HMO) in California though every insurance is different. My story is that I first went for one of those free consults with my orthodontist who outlined the range of problems that I had and various treatment options - one of which was surgery. I then authorized the orthodontist to take x-rays and do the analysis which cost several hundred dollars but which they then deducted from my full treatment plan if I chose to go with them (which ultimately I did). With the analysis in hand I went to the oral surgeon that my ortho recommended (the one that does difficult cases like me;-)) who then explained what he was going to do - essentially staggered surgeries over the coures of two years, that cost about $50 if I remember correctly. Finally, when I said that was willing to undergo surgery the surgeon sent me more information, which along with the info from the ortho, I took to my primary care provider who got me pre-approved for my first surgery which I had last May. Hope this helps.

[tybceo25]

My insurance is Aetna (HMO) in California though every insurance is different. My story is that I first went for one of those free consults with my orthodontist who outlined the range of problems that I had and various treatment options - one of which was surgery. I then authorized the orthodontist to take x-rays and do the analysis which cost several hundred dollars but which they then deducted from my full treatment plan if I chose to go with them (which ultimately I did). With the analysis in hand I went to the oral surgeon that my ortho recommended (the one that does difficult cases like me;-)) who then explained what he was going to do - essentially staggered surgeries over the coures of two years, that cost about $50 if I remember correctly. Finally, when I said that was willing to undergo surgery the surgeon sent me more information, which along with the info from the ortho, I took to my primary care provider who got me pre-approved for my first surgery which I had last May. Hope this helps.

Thank you very much for your help.

So The Surgeon only charged 50 $ beforehand to build a case for your insurance to review?

[Rodney008]

Not sure if this is typical, but my doc could not get a straight answer from my insurance. They basically could not tell me whether or not it was covered, and could only make that determination after it was precertified. So the doc just submitted the paperwork for the surgery to take place in 6 weeks (really I had over a year left in braces). The insurance got back to him and said it was covered. So at least now we know.

[boatsink]

I had Healthnet HMO in California. The surgeon's office said I will not get approved due to the "insignificance" of my case...given their experience with Healthnet HMO. Because of this, I waited 1 year and switched to Kaiser. I was approved for surgery on the same day I was assessed by the oral surgeon, which was day 5 as a new enrollee. Goodluck! The insurance part is quite time consuming and stressful!

[nineeyes]

Thanks for taking your time to help me out.
Who recommended you to your Oral Surgeon? Was it through your insurance? or your orthodontist refereed him to you?
I would like to see a oral surgeon now to help me with my case but i need to know what im getting myself into.
I dont want to have to pay for all the appointments before hand out my pocket and be in a hole and then have my insurance deny my surgery.

Thanks.

I did have to pay for the initial consultation appointment for my Oral surgeon which was around 200 or so, but will likely vary depending on who you see. The consultation should give you the opportunity to ask all the questions you want and, while it costs money, it may be beneficial to consult with more than one OS as they may give you different answers as to what your case will require.

The OS I saw was recommended by my Ortho as he had worked with him in the past, I had a PPO so I didn't need a referral and just went directly to him. I live in Southern California and had my surgery at the UCLA dental school, one of the teachers there was the one who was recommended and ended up performing the surgery.