Insurance policy: supporting language for surgery coverage

[Ann9]

Hi everyone, I am new here and will be having Orthognathic surgery this year. I am searching through my insurance policy contract to see if it is a covered procedure, but it does not mention this surgery specifically.
My orthodontist gave me a CPT code,21141, which is for reconstructive midface surgery:lefort I. A representative in the insurance benefits department (BCBS) told me it was covered if medically necessary, but I don't think this person is familiar with this type of surgery.

I am sure that that code is covered in certain circumstances, but maybe not for something like this. For example, to correct a congenital defect or from trauma,etc.

Has anyone gotten coverage as an adult if the policy listed the coverage for this procedure to cover a congenital defect?

If your insurance did or is covering this surgery, how was it stated in the contract? Was it covered under oral surgery specifically or under reconstructive surgery?

Thank you, and I look forward to reading this board!

[mollycat]

I haven't solved this question myself, but have learned a few things. Some insurance policies have specific measurements they use to decide if it is necessary (From Aetna's orthognothic policy posted online: "Maxillary/mandibular incisor relationship: overjet of 5 millimeter (mm) or more, or a 0 to a negative value (norm 2 mm)" or "No vertical overlap of anterior teeth greater than 2 mm") Even if your insurance doesn't share their specific policy, it may be similar. I also got a little insight from one insurance person I talked to. She said that it would be more likely to be covered if it caused a functional problem (i.e., you had trouble eating because of it). I think this may be especially convincing if your molars can't chew properly.

An aside: My issue is more biting than chewing, so I'm concerned about my current coverage, but hope to learn more soon. The first oral surgeon I saw was concerned about my insurance covering it, because he hasn't gotten them to cover anyone. I'm not sure if I should be encouraged or depressed by his next statement: "if they cover anyone, they'll cover you"

Good luck!
Molly

[Ann9]

Thank you for your response,Molly.I'm sure I would qualify based on measurements, but I'd be concerned about proving a functional defect also. Good luck to you too.

[sirwired]

Who's your insurance provider? Over the course of my odyssey, I had two different ones (ostensibly providing the same plan provided by my company.) The first, Cigna, required proof of a functional defect in order to approve; I didn't think it could be done, so I put a hold on my plans. My employer then switched to Anthem BCBS, and their coverage required either a functional defect or measurements out of bounds. I had no major problems getting approval.

The coverage policy for your particular insurer will determine approvability. To make things even more fun, if you work for a large employer running what is called a "self-funded" plan, they may override any coverage decision by the insurance company, no matter which criteria they use. Also, it is possible to convince the insurance company to go outside their coverage criteria, or you can do so on appeal.

[Alicia110613]

Hi Ann!

I also have BCBS, and remembering back then reading up the contract/policy when I was in the process of deciding whether or not to go through with the surgery.

My insurance policy had a section on "oral surgery" and states that orthognathic surgery is covered only if it's "medically necessary". Also look into the "exclusion" section - mine did not have a specific exclusion for orthognathic surgery, except requiring that it be medically necessary.

I didn't have TMJ or any serious jaw pain - but I couldn't really fully utilized my front teeth to bite on things due to the poor bite - not that it affected my eating much. In any case, I didn't have a serious functional issue. My surgeon, however, says that he considers correcting underbite/overbite a "medically necessary" procedure and I think he may have described the problem as a skeletal deformity in the insurance pre-approval process.

Note my surgical movement was only about 5mm or so... not a clinically severe case. But BCBS approved it and covered at 100%.

If your policy does not have a specific provision excluding ANY orthognathic surgery, then you have a good chance of getting at least some coverage. It may also depend on how your surgeon classifies your case.

Good luck!

[kpw818]

Whew. I'm glad to hear that BCBS covers. From what I read, my policy doesn't exclude, and I meet medically necessity based on the measurements of my crossbite (I also have an open bite/underbite). I do have pain and clicking in my jaw. My problem is that there isn't a surgeon who preforms the surgery specifically in-network, so even if it is covered, it is still only covered to a percent. If anyone has experience with that, I would love to hear it.

[sirwired]

Most policies have a provision that if there is no in-network provider that can do the work within "X" miles, then you can simply pick your surgeon, and he'll be covered at in-network rates. But absolutely work this out with the doctor and insurance company ahead of time.

I will say that for me, the surgeon was nearly the cheapest part (the hospital was pricey), but he was with the Dental School (a professor, not a student), and not private-practice.

[treichow]

I also have BCBS. The procedure I had done was a LeFort 1 also. The insurance originally denied because there was not proof of a functional defect like eating. The Oral Surgeon then did a "Peer to Peer" conversation with the insurance company doctor and it was approved. I believe that the difficulty chewing and the pain were the things that got me approved-- I had an extensive list of doctor/dental appts. to prove this. I guess they didn't get that information in the original request, which is why it was denied. My measurements weren't that bad. Good luck!