Insurance/pre-approval

[earthpart20]

Evenin', folks.
I'm new to the board. Here's my story in a nutshell. I used to do all kinds of bike tricks (standard bike, not a motorcycle) many years ago and one day the chain on my bike snapped and the bike flung me face-first into the concrete. Since then, my jaw/chin have healed improperly shifting my jaw to the left. I had braces for almost two years at the time and was months away from getting them off. They said that if I hadn't had braces at the time of the incident, I would have lost all of my teeth. Anyway, with the jaw shift my teeth have also shifted out of position. I consulted the same orthodontist I had before about this and went to the oral surgeon that he generally works in conjuction with. The surgeon says that I'm best off getting aetna medical insurance (looking into getting the gold plan ie. 1000 PD) and says that I can get the insurance up to 3 months in advance of the surgery and the orthodontist says I need 9 months of orthodontics before the surgery. The orthodontist's secretary is now asking me if I have been pre-approved for the surgery. I'm pretty sure the surgeon said that he works with aetna and can sign off on the pre-approval himself. I'll call the office monday morning to make double-sure. Anyway, I wanted to know what insurances you guys on this board have had and how smoothly everything happened. I don't want to get through the orthodontics and then be stuck when it comes time for the surgery because of any financial issues and/or not being approved. I also wanted to know if it's even possible to get pre-approved for surgery if you don't have coverage from the provider you're getting approval from at the time. Thanks in advance!

[sirwired]

Every insurance plan is different. You need to do a couple of things:
- Ask your employer for your policy text. Look in it for the word "orthognathic"; if it doesn't appear at all, that is a good sign. (Some policies call it out specifically to exclude it, although there is usually a trauma exception to the exclusion, which you might fit.)
- Read the following document, present it to your surgeon, and see if your case fits their criteria. http://www.aetna.com/cpb/medical/data/1_99/0095.html

If you meet the criteria, your surgery should be approved without much hassle. If you don't, it'll be more work, and may or may not be approved.

[Alicia110613]

Certain Kaiser and BCBS plans also cover orthognathic surgery, although every plan is different depending on what your employer decides to include, etc.

It sounds like your surgery is more likely to be qualified as medically necessary because of the accident? However, I don't think you can submit a "pre-approval" until you're actually covered under that plan.

[earthpart20]

Well, the surgeon told me that he works in conjuction with aetna and can sign off on the preapproval himself. I'm just waiting for him to get back to me because I'm pretty sure that's what he said. He basically just told me to get the aetna plan 3 months in advance of the surgery and everything else should be fine. Aetna said that with their gold plan the surgery will be out of pocket 2,500 plus the monthly premiums which is 440 a month for me. I just need to call them tomorrow and find out is hospital stays/anesthesia are covered. I don't bother with insurance through my job because it's terrible insurance and it wouldn't cover anything I need and I'd be stuck in their plan for X amount of time for no reason. Side note, does anyone know of any job who would provided aetna 1000 PD gold plan through their employer? That'd make things so much easier lol.