Metal Mouth Message Board

I am investigating going forward using Drs. Gunson and Arnett, but have some questions about total out of pocket costs for folks with Cigna insurance. So far Cigna has suggested that they would cover 15,000 of the surgery fee's - which sounds about right given a likely maximum allowable cost of 22,000 or so. But would anyone be willing to share either here or via pm with me about how much Cigna covered for your anesthesiologist and hospital stay?
Kind regards,

Hey Wickl,

I, too, am going with Arnett/Gunson and I currently have Cigna PPO with my employer. I may or may not be switching jobs this summer though and am waiting until I get settled to move forward.

Please let me know what you find out as I am interested!

Btw, how did you find out that they would cover $15,000 of the surgeon's fees? That's pretty good for Arnett/Gunson, I would be very happy if I got that much covered.

Anyway, good luck and I hope to hear from you!

Dan

My Cigna PPO covered 100% of my hospital stay and anesthesia...sill fighting them to cover more of the surgery.

asmileconnectsus - this is great news, and very helpful! Thank you! As well as for your wonderful, painful and joyful blog - I suspect that there are many many others out there like me who have read and benifited from your openness and commitment to share your experinces.

Dan, the insurance folks at the office work with Cigna to get kind of preauthoization from Cigna. They send in your models and your case information to confirm that it is indeed a medical necessity and then start haggling on price. The trick is that Cigna has an unpublished, unshared figure in mind for what the maximum allowable expense is for your particular surgery. The doctors office needs to 'guess' what that figure is and then pitch their surgery at that rate to get Cigna to cover it (this is all based on my observation, and may not infact correlate to what's going on in any way, shape or form: please don't sue me:) Trouble is most agents at the insurance company will not take more than a couple 'guesses' before just denying it. All in an attempt to help keep costs down I imagine. Anyway - from the way I figure it Cigna was willing to accept a figure around 21000 for surgery fees for my case - leforte 1 with bone graft and is then covering 70% of that fee since it is out of network, leading to the 15000 figure. The math may not be right if they also subtrack my out of pocket maximums first, but I doubt that they are accepting more that 23000. Hope this helps!

Yes Wickl, that does help, thank you! And don't worry; I won't hold you to that! Hehe. My quote from Arnett was just under 53k so having to pay 38k for the surgical fees would be a dream come true! I've been going over the insurance requirements to get coverage for medical necessity and I just need to prove sleep apnea so I'll be getting a sleep study done this spring.

I've heard though, that even though Cigna may not have a direct exclusion of orthognathic surgery, your company through which you have your plan may have such an exclusion. I don't know how to find this out. I don't feel comfortable discussing my upcoming surgery with HR at my company and when I called the insurance company to talk about coverage in general, the woman on the other end didn't really seem to know what orthognathic surgery is (she kept pronouncing it "orthoganic" lol). Any advice there?

Dan

Dan, I'd call Drs. A&G office and ask for help with insurance questions - they seam to have their game down. If nothing else, they should be able to tell you what the procdure number is for your case - turns out there is a semi standard catalog of procedures - There is a partial list posted below based on my search for your reference. With this code handy you should be able to get better help from Cigna when you call in and talk with them. (It's a lot easier than learning to say orthognathic


Orthognathic Surgery Codes: (including, but not limited to the following)
CPT Copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Procedure Codes:
21110 - Application of interdental fixation device, non-fracture or dislocation
21125 - Augmentation, mandibular body or angle; prosthetic material
21127 - Augmentation, mandibular body or angle; with bone graft
21141 - Le Fort 1 single piece
21142 - Le Fort 1 two pieces, without bone graft
21143 - Le Fort 1 three pieces, without bone graft
21145 - Le Fort 1 with bone graft
21146 - Le Fort 1 two pieces
21147 - Le Fort 1 three or more pieces
21150 - Le Fort II, anterior intrusion
21151 - Le Fort II, any direction, requiring bone grafts
21154 - Le Fort III, requiring bone grafts without Le Fort I
21155 - Le Fort II, requiring bone grafts with Le Fort I
21159 - Le Fort III, requiring bone grafts without Le Fort I
21160 - Le Fort III, requiring bone grafts with Le Fort I
21188 - Reconstruction midface, osteotomies (other than Le Fort type) and bone grafts
21193 - Bilateral Vertical Osteotomy (reconstruction of mandibular rami, horizontal, vertical, C or L
osteotomy without bone graft)
21194 - Bilateral Vertical Osteotomy (reconstruction of mandibular rami, horizontal, vertical, C or L
osteotomy with bone graft)
21195 - Reconstruction of the mandibular rami and/or body, sagittal split, without internal rigid fixation
21196 - Sagittal Split Osteotomy with rigid fixation
21198 - Mandibular Osteotomy
21206 - Osteotomy, maxilla, segmental
21208 - Osteoplasty, facial bones; augmentation
21209 - Osteoplasty, facial bones; reduction
21210 - Graft, bone; nasal, maxillary or malar areas
21215 - Graft, bone; mandible
21247 - Reconstruction of mandibular condyle with bone and cartilage autografts

Kind regards, Wickl

Thank you Wickl for the very thorough reply! I really appreciate it!

Hey guys,

For those of you with Cigna, did you have a sleep test to confirm sleep apnea for coverage? I'm looking over the requirements to have the surgery deemed "medically necessary" and you need to have 1 skeletal deformity and 1 functional impairment (from their lists). I have the skeletal deformity, and functionally I am scheduled to have a sleep study done to confirm sleep apnea which my ENT doctor is sure the study will confirm I have due to my tongue obstruction and small airway (3mm).

But I am wondering for those of you who got coverage through Cigna, what was your functional impairment? Here is a list from their requirements for medical necessity:

- persistent difficulties with mastication and swallowing after causes such as neurological or metabolic diseases have been excluded
- malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity
- speech dysfunction directly related to a jaw deformity as determined by a speech and language pathologist
- myofascial pain secondary to facial skeletal deformity that has persisted for at least six months, despite conservative treatment such as physical therapy and splints
- airway obstruction, such as obstructive sleep apnea, documented by polysomnogram, when BOTH of the following criteria have been met:
- criteria for positive airway pressure (PAP) met and individual has proved intolerant to or failed a trial of PAP
- individual has failed prior less invasive surgical procedures or has craniofacial skeletal abnormalities that are associated with a
narrowed posterior airway space and tongue-base obstruction

Thanks for your time! I will let you know how my sleep study goes

Dan

treevernal,
I got coverage through Cigna, alhtough went out of network. I will ask this week when i go back what the office submitted. Where did you find this list? do you know if it is for all Cigna plans or specific to yours?

Thank dtdtdt, I would greatly appreciate that! I believe it is for all Cigna plans. I have a PPO open access plus.

Did you have a sleep study done?

Also, did you guys with Cigna have to pay the total amount for surgical fees then wait to be reimbursed or did they cover a certain amount then you just paid the difference? I've heard it can go either way depending on insurance companies.

I hope I don't have to pay all up front then wait for reimbursement!

Thanks again!

Dan

$15,000! Wiki, you and the other Cigna holders have just been invited to the chocolate factory. I wish I had the Cigna golden ticket! I'm with Anthem. At first I was ecstatic when Anthem approved me, then Gunson's surgical coordinator informed me that the allowable amount was still unknown. Come to find out the allowable amount can be as low as my $2500 deductible. How is this possible?

Hi, I talked to OS office today about Cigna and learned some new to me things. This might not be news to you so ignore if you choose!

I showed the list of complicating conditions listed earlier in this thread to see how they had coded me, as I didn't think i had any of those situations. The women in office said that this varies by policy and some Cigna polices do not require another situation or use a list like this, but just need to see a skeletal deformity (love that word). For many Cigna policies there might be specific requirements to first do sleep studies or splints or other procedures first. For others they do not have these other requirement prior to give ok to surgery. Instead, Dr just send in his notes and the models and they make a decision from there. She said again depending on Cigna policy it can be denied first and then appealed. MY own policy did not have very stringent requirements. She told me it is very frustrating when the dr and the Cigna agree a surgery is necessary but a policy specifically says not covered, and this is more common than you would think.

Cigna is covering my in network hospital at 100% as well as anesthesiologist. The out of network surgeon and assistant surgeon (fyi - the assistant charged 7k!) will be covered at 70 percent.

My question back to you guys is does your policy have a maximum allowance for out of pocket? Mine does, so this 70% will be capped at 4K. Is this the norm?

I too was expecting a bill of around 50 k down to say 35K before all of this started.

I forgot to add that no Treevernal i did not have to pay all this upfront. The office said for cigna they have you pay some and then wait for the rest to be sorted out by insurance. It is only for those who do not get coverage that they work out a payment plan with a hefty upfront payment.

My Cigna denied at first, acknowledging that I met the requirements for the skeletal deformity, but stating that I didn't have a "functional" deformity. My surgeon sent a bit of a nasty gram back stating their definition of "functional deformity" was vague and not quantative, only qualitative, and therefore, should have no basis for nonpayment. I have appealed and am waiting my 30days for a reply. Which should be by April 10th or so. I believe I have made a good case for myself (If I were them I'd pay )

I paid for the surgery out of pocket---that part is a long story, but I was surgery ready in Canada in Sept. but due to wait list took my US Ex-patriot international insurance, which happens to be Cigna...and went to Seattle. The surgeon has very low negotiated private pay fees--the total I paid for surgeon fees, hospital, and anthesthia was roughly 8K. Which I am now trying to get back from Cigna----I submitted, it got rejected, but some genius over there flipped my surgeon fees {which say oral surgery (?dental), but are coded for orthognathic surgery (medical)} over to my dental, which promply paid the $3500 claim like a dental claim (80/20, up to the yearly dental limit of $1500)---now normally I would call them kicking and screaming, but they could continue to deny it as a medical claim I suppose, so I am taking my $1500 which they directly deposited into my bank acct and calling it a day---so I am out about 6K, of which $350 was deductible and my max out of pocket for the policy is $1500---so I expected to pay about $1850 anyway....so if I can squeeze any more $$ out of cigna I'd love it, I'll update after I hear back from them after my 30day appeal process. Insurance is almost as frustrating at the Canadian wait list (which I would still be on )