Metal Mouth Message Board

I have been pursuing this surgery now for 2 years and 7 months. I had SARPE in Jan. 08, and have had my breaces since. I was just told my my surgeon the OUr area of Blue Cross is no longer approving Orth. sugeries. I am now at a point where I can not bite ANYTHING, and can't chew most things becuase of my deformed jaw. I have no clue what to do!!!!!!

Can you speak to the surgeon whom you had in mind to explain your situation?

Did Blue Cross pay for the first one? If they did, and your surgeon submitted a COMPLETE treatment plan that clearly outlined that you would need a second surgery, then you'd likely still be covered.

If you aren't so lucky to have what I listed above, you're going to have to appeal. Your surgeon is going to need to submit records that indicate your issue is of medical necessity. This will include a written diagnosis along with a slew of records (x-rays, models, etc).

Your insurance company just can't say "we're not covering Procedure X" - If medical necessity can be demonstrated then you're likely to win. I just warn you that it may be a time consuming and painful process.

My only advice is to fight like hell and don't give up. Insurance companies rely on people just giving up...don't!!

Best of luck to you.

-Chicago29

So sorry to hear of your woes, badbite

I don't know how the US system works, but what chicago said certainly rings true for me. My treatment plan was approved up front as a complete package. You may yet find that that's the case for you and they can't exclude something they've already agreed to.

Failing that, keep on fighting!

Really hope it works out for you. Let us know.

THanks, I am using the same surgeon. He is really good and got my SARPE coverd with no problems. I don't know if he submitted a full plan which included my second surgery or not. I go see him today, so I'll let you all know.

The executives at Wellpoint/BCBS are bastards, but I read one post that said if you push hard enough on any plan for medical necessity, you can get it covered. Good luck!

So sorry to hear this badbite! I can offer you no advise about insurance because the UK system has the NHS- but just do what everyone else has said and keep pushing for it. Best of luck

I would also imagine that if you had a certain plan, under which they would approve the surgery for medical necessity, they can't just change the plan on you. Even if new plans wouldn't have the same coverage, your plan should remain the same during any contracted period.

Well I saw the surgeon. He did submit the entire plan before my first surgery (back in oct of 07), which was paid for without any trouble at all. There been been no changes in insurance since that time. I have a copy of the letter from BCBS that clearly states they do not cover orthognatic surgery after the date of Oct, 1, 2010. My policy period doesn't end until Dec. 31. I guess I will be in for a huge battle. Where should I start?

So if I've understood you correctly the insurance company has contacted your surgeon to say they won’t cover orthognathic surgery from 1st October. In other words the surgeon has received a general letter about the general situation. That, presumably, is the letter you have a copy of.

BUT have they specifically said they won’t cover YOUR surgery? If they’ve already approved your plan and there’s been no change then I don’t see how they can go back on it. Maybe the first step would be for you – or your surgeon – to contact your insurers asking them to confirm that your already approved treatment will nonetheless continue as planned and agreed.

Sorry if I’m just being naïve here. Hopefully others with more wisdom will chime in. What did your surgeon have to say about it?

I'm a bit naive on this stuff. When did you get that letter?
If you started a procedure and it was submitted by the surgeon a couple of years ago, I would think that the letter is probably for new cases. They can't change their mind as to what's covered mid treatment--you've already gone down a path based on it being covered. Usually when they change a policy like that it's for new cases.

I think you have a really strong case regardless. Just keep fighting them. I have a feeling you will be okay.

That‘s how I see it too, almost50. I may not know anything about US health insurance, but I like to think I recognize weasel wording when I see it.

My assumption is that the insurers have sent a letter which says something like “We regret to inform you that for reasons of blah blah blah this company will no longer be able to offer coverage for orthognathic surgery procedures as of October 1st 2010.” Which in itself is perfectly true. But it conveniently neglects to mention that existing contracts have to be honoured. The hope being that patients will wring their hands and go away in the belief they’re not covered any more.

To be absolutely fair, there may be no such intention on the insurers’ part. That’s why I was asking if it’s a general letter to the surgeon that badbite has seen. The insurers may simply be informing the surgeon of their new policy, and he’s mistaken it for meaning existing cases too. Well, you never know…

The letter was sent to him when he called the insurance company about me. There is another patient with Capital Blue Cross who was approved and now the insurance won't pay after the fact. The treament plan origanally sent to the insurance abck on Oct. of 2007 only asked for authorization for the first surgery, but it outlined the entire plan.

The surgeon submitted the preathorization as if they never got that letter.

I don't know....... The surgeon's office just called me to say that is the insurance won't pay the surgery will be at least $30,000. They are going to try and help me fight the insurance company though.

Sorry, badbite, not ignoring you but don't know enough about it to offer any tips. Sounds amazing to me that a person can have a contract for services, and commit to a course of action based on that contract, only for the other side to turn round and say they've unilaterally changed the terms. Even worse when your health is at stake!

Good to hear your surgeon is on side, though. Don't give up!

YAY! I have been fighting with my insurance, and I got them to extend my approval until the end of the year (when the contract renews). Anyone in PA; I filed a complaint with the PA insurance commisoner who helped me get the the FAIR outcome I needed. Looks like my surgery will be Novemeber or December. YAY!