Metal Mouth Message Board

(this is long, sorry!) My orthodontist yesterday gave me my referral to an orthognathic surgeon, he says I'll either be getting Le Fort I or SARPE. He thinks Le Fort I is more likely, but the surgeon will be the one who knows for sure. I have about a year until I need surgery to figure out insurance and all that fun

I have United Healthcare, and I've been looking at their policies. They only pay for orthognathic surgery if you meet these conditions:

A jaw deformity resulting from facial trauma or cancer

OR

A skeletal anomaly of either the maxilla or mandible, that demonstrates a functional medical impairment such as one of the following:

Inability to incise solid foods
Choking on incompletely masticated solid foods
Damage to soft tissue during mastication
Speech impediment determined to be due to the jaw deformity
Malnutrition and weight loss due to inadequate intake secondary to the jaw deformity
Obstructive sleep apnea or airway dysfunction


Orthognathic surgery would not be covered because it is considered unproven treatment due to a lack of evidence of improved functional clinical outcomes in peer reviewed, published medical literature, for the following symptoms:

Myofascial, neck head and shoulder pain
Irritation of head/neck muscles
Popping/clicking of temporomandibular joint(s)
Potential for development or exacerbation of temporomandibular joint dysfunction
Teeth grinding



My main issues are discomfort, TMJ, popping/clicking, and it's a major possibility that I'll experience bone loss in my right side, the right side of my mouth is caving in. My Orthodontist says he will work with the insurance because he believes it is 100% medically necessary in my case, and thinks the surgeon will agree. I don't have the issues such as trouble chewing, I do have a slight lisp but I've never had speech therapy or anything for it. So I have a gut feeling the insurance is going to deny this a few times before I get approved (if I get approved!)

My insurance doesn't even have an orthognathic surgeon in its network, and my cost is 60% for out of network.

Let's say by some miracle they approve the surgery. The hospital it will be done at (Riverside in Columbus, OH) is in my network, so standard cost is 80% after my $200 deductible is met with a max out of pocket expense is $3000.

If everything were preauthorized and covered, would I pay 20% of hospital costs and 40% of the physician fees because he's out of network? Or 40% both hospital and surgery? OR, can the insurance refuse to pay EVERYTHING (including hospitalization) because it's not a covered surgery? This is something I'm obviously very worried about, because I've heard of 3 day hospital stays costing between $60,000 and $80,000

Also, has anyone gone the route of seeking speech therapy to "prove their case" to the insurance? I've had a messed up jaw my entire life, I get tongue twisted and I'm aware of my slight lisp, but it's not at all something I would have ever considered therapy for.

if you have insurance there is no way hospital fees could be 20gs a night.

most insurance policies have complication clauses that state you have to pay 1,000-1,500 for every night you stay at the hospital if you have complications.

just run this by your insurance and see what they say.

[quote="CaliforniaKid"]if you have insurance there is no way hospital fees could be 20gs a night.

most insurance policies have complication clauses that state you have to pay 1,000-1,500 for every night you stay at the hospital if you have complications.

just run this by your insurance and see what they say.[/quote]


Are you saying that if the surgery isn't covered, that the insurance company would still cover the hospital stay but not the surgeon's fees? If so, that would be a huge burden off my shoulders!

Jaw surgery is excluded from my coverage unless you have cancer, an injury, or apnea/chewing problems/significant speech impediment. I don't have any of those, but I do have my face basically caving in on the right side and TMJ on my left. I looked at my policy's fine print, and they even go so far as to exclude jaw surgery for the purpose of correcting cleft palate/cleft lip, which really shocked me!

I've been working with some of the same insurance issues, and my surgery will also be done at Riverside. My insurance is a bit different as they will cover the surgery, but there was only one in-network surgeon that is within 30 miles. I'm not a fan, so I'm going out of network. I'd wait to see what the surgeon says and then talk to the person who is in charge of billing and filing insurance claims. They were extremely helpful, and I'm in the midst of fighting to get my surgeon an in-network waiver. The surgeon may deem it medically necessary for one of those reasons that are covered by your insurance being able to see what the future issues of your jaw are.

I was told by my insurance company that my hospital bills would be covered b/c the hospital was in-network, but not maybe some of the surgeon's bill b/c he was out of network. I did get an advocacy group involved, which was helpful. The insurance company was able to give me exact quotes for amounts for the in-network doctor vs the out-of-network doctor.

Just keep fighting for it...

helpingsmile wrote:I've been working with some of the same insurance issues, and my surgery will also be done at Riverside. My insurance is a bit different as they will cover the surgery, but there was only one in-network surgeon that is within 30 miles. I'm not a fan, so I'm going out of network. I'd wait to see what the surgeon says and then talk to the person who is in charge of billing and filing insurance claims. They were extremely helpful, and I'm in the midst of fighting to get my surgeon an in-network waiver. The surgeon may deem it medically necessary for one of those reasons that are covered by your insurance being able to see what the future issues of your jaw are.

I was told by my insurance company that my hospital bills would be covered b/c the hospital was in-network, but not maybe some of the surgeon's bill b/c he was out of network. I did get an advocacy group involved, which was helpful. The insurance company was able to give me exact quotes for amounts for the in-network doctor vs the out-of-network doctor.

Just keep fighting for it...

Thanks helpingsmile, that's helpful. My orthodontist and regular dentist are both saying it's medically necessary, and the ortho said he saw no reason for the surgeon NOT to deem it necessary and that they've gone rounds with insurance before. This is nerve-wracking for sure! I have about a year to figure this out, so at least that's on my side.

Are you seeing Smeltzer? My insurance has one oral/maxillofacial surgeon listed within 30 miles, and he's a pediatric specialist at Nationwide Children's... uh I am pretty sure I can't go that route

lots of insurance companies exclude orthognathic surgery because of the costs. every doctor i have met said it was medically necessary but as long as my jaw is "functioning" insurance forbids it.

im in california, so everything is probably more expensive here than in ohio.

also - i had speech therapy as well and my insurance did not care. they just looked at the xrays and said it wasn't bad enough.

you can as the poster above "just keep fighting it" but i honestly would not count on it if your insurance is very explicit about orthognathic surgery.

i "fought" my insurance for 7 years and got nothing. i even changed my insurance. but UH may be different.

Smeltzer is who I am seeing. I got my braces the other day, and my ortho said he just did a surgery on a girl from their office and did an amazing job. So that made me feel great. I also really like my ortho. Good luck. Let us know how it goes with insurance.