Jaw Surgery Insurance?

[Nate92]

Hello everyone, I'm back.

So I'm gathering more information on my dental case. First, I want to expand my arch, even if it is just moving my teeth, but then I'm interested in bi-maxillary surgery. So! The big thing I want covered here is the bi-maxillary advancement. My insurance is Blue Cross/Blue Shield PPO. I called and my health insurance does indeed cover jaw surgery if it is medically necessary. I would like all of your's opinion on whether or not my case has a chance of being covered!

o What led me to question jaw issues was my physical appearance. My upper jaw seems pushed back. I have a very sunken mid-face, the skin from my nose to lip slopes back, my upper lip is undetectable, and a disproportionate nose. I also have a receding lower jaw. It has caused me to be very self-conscious.
o I have difficulty breathing through my nose, it has forced me to breath through my mouth most of my life.
o I am getting checked out for Sleep Apnea. I am constantly tired and anxious.
o I have jaw pain.
o I grind my teeth TERRIBLY at night.

The catch is braces fixed my teeth when I was younger. I had an overbite and the teeth were moved accordingly, so I seem okay. I almost wish I had kept my teeth where they were all those years so it was more blatantly obvious that my bite was messed up!

P.S. How do you get both upper and jaw surgeries covered as opposed to one?

[Chiara]

I work for said health insurance company. I got both jaws and my chin aug covered. You should look into the medical manual for which ever blue cross you are insured by and it will give you the requirements for jaw surgery. for example, I would be covered if my overbite was 4mm or more, mine was 8. the sleep apnea could work in your favor. I know that's one of the ways to approach lower jaw surgery and chin advancement. if it is purely cosmetic it will not be covered. get your diagnosis and go from there. good luck!

[azjaw]

I am having the same kind of surgery on Monday. It sounds like you might have a good chance of getting it approved. I have heard BCBS is one company that does approve it pretty often. I have Aetna and they did finally approve me. I would suggest being sure to find a surgeon who does a lot of this kind of operation. First of all he will be better at it if he is more experienced but also his staff will know what to do to get it approved.

I went to a surgeon who is in network with my insurance and his staff didn't seem to know what they were doing. It was a big hospital and the surgeon was in the ENT department so I think that is primarily what they were experienced in dealing with. The insurance rejected the pre-authorization and the appeal. The first time they tried to use the fact that I have sleep apnea but the insurance company said it wasn't severe enough. They would only do it if your Apnea-Hypopnea index was 25 or above and I am only about at a 10. The second time they just tried to get it approved on the basis of a skeletal deformity but they said my bite was functional so they rejected it again.

After that I decided to try with the surgeon my orthodontist originally recommended but who is out of network. I figured I might be able to do private pay with him since he does the operations in a surgery center instead of a hospital so it is a little cheaper. His insurance person was able to get it approved. I couldn't believe it.

[Nate92]

I am having the same kind of surgery on Monday. It sounds like you might have a good chance of getting it approved. I have heard BCBS is one company that does approve it pretty often. I have Aetna and they did finally approve me. I would suggest being sure to find a surgeon who does a lot of this kind of operation. First of all he will be better at it if he is more experienced but also his staff will know what to do to get it approved.

I went to a surgeon who is in network with my insurance and his staff didn't seem to know what they were doing. It was a big hospital and the surgeon was in the ENT department so I think that is primarily what they were experienced in dealing with. The insurance rejected the pre-authorization and the appeal. The first time they tried to use the fact that I have sleep apnea but the insurance company said it wasn't severe enough. They would only do it if your Apnea-Hypopnea index was 25 or above and I am only about at a 10. The second time they just tried to get it approved on the basis of a skeletal deformity but they said my bite was functional so they rejected it again.

After that I decided to try with the surgeon my orthodontist originally recommended but who is out of network. I figured I might be able to do private pay with him since he does the operations in a surgery center instead of a hospital so it is a little cheaper. His insurance person was able to get it approved. I couldn't believe it.

Hey azjaw: Thanks for the advice. Do you know how your surgeon finally got it approved? What changed?

[azjaw]

Hey azjaw: Thanks for the advice. Do you know how your surgeon finally got it approved? What changed?

I'm not sure of all the details. I'll see if I can talk to her next week and find out more. I know one thing she did was sent an image of my airway and emphasized how small it is.

[subu]

I have Blue Cross Anthem (CA). I was also approved quite easily for both lower and upper jaw. I only had the upper jaw moved 4mm, lower jaw was moved forward/rotated 15mm and I had a genio (had to pay out of pocket) moved 4mm. The insurance company saw that the genio was cosmetic even though my surgeon stated I was at very high risk of already having sleep apnea.

Some surgeon's office staff are better than others in getting approval. You need to check your insurance to see if there is a special exclusion against covering orthognathic surgery. 3 years ago, I had this issue with a different Blue Cross insurance company, but it was based out in Washington State and they had a special exclusion that I couldn't get around.

Ask your surgeon if your case is something that insurance would easily approve. I did. I was told my case was that severe he didn't see it being a problem.

[Alicia0913]

I also have BCBS and i believe my case is approved based on skeletal deformity. I don't really have a severe "functional problem" (i.e. I can chew food fine) but my surgeon did say he considers my case as medically necessary because my jaws aren't where they are supposed to be. Your case sounds a lot worse than mine with the jaw pain and sleep apnea.

I think you already have a good insurance, so it's all up to how the surgeon classify your case. GL!

[sarahfelldown]

[quote=Chiara post_id=427135 time=1368699603 user_id=17107]
You should look into the medical manual for which ever blue cross you are insured by and it will give you the requirements for jaw surgery. [/quote]

Thank you for this advice! I looked into BCBS's medical policies and it looks like my case would be deemed medically necessary based on their criteria and the measurements my surgeon forwarded to me. However, if you're still around on this board, I've got one question... In most of the policy documentation I could find online (I can't switch insurance until open enrollment, so I don't have a specific plan's statement of benefits/certificate of coverage I can refer to) that documentation lists orthognathic surgery as an exclusion except when treating an injury or congenital defect (my surgeon says mine was developmental, not congenital...which is another can of worms I won't open). So if something is listed as an exclusion in plan documentation, but your case fulfills the requirements listed in the medical manual to be deemed medically necessary, does that mean I COULD be covered?

Thanks!