Insurance Concerns

[KaylaChristine]

I'm currently waiting to hear back if my health insurance will pay for my double jaw surgery. I have a Class III malocclusion (underbite). My teeth are 10 mm apart from meeting. My upper is also in complete cross-bite. The surgeon estimates that my upper jaw will be moved forward 4-5 mm and the bottom one moved back 4-5 mm. I'll also have my upper jaw widened during the surgery.

I have Blue Cross Blue Shield of Kansas. Orthognathic surgery is covered if it's deemed medically necessary. Has anyone else here had BSBS of KS and gotten the surgery approved? I'm so worried they'll deny it. There's no way I can get it done if they don't approve it.


Also, if the insurance approves the surgery---is my out of pocket cost typically just my max out of pocket for the year?

[sirwired]

I Googled "BCBS Kansas Orthognahtic" The coverage policy was the fourth link. (The server was down, but the cached Google copy came up.)

If you meet the criteria in that policy, it'll be covered, if not, it'll be a battle. (BCBS's policies I think are all the same, and more liberal than Cigna's and some other providers. BCBS says Functional Impairment OR Measurements more than X off... many other policies say Functional Impairment AND Measurements off)

Make sure your OMFS sends in your measurements... mine forgot, but as soon as they did, it was approved quickly.

[KaylaChristine]

Thanks for your help! The policy you're referring to is BSBS of Kansas City, but I imagine they're probably similar in guidelines. I'd like to think I'd get approved with my measurements alone.

I told myself I wasn't going to share any pictures of my awful bite unless the surgery was approved...but eh it doesn't really matter if I do or don't.

Attached is my x-ray and a couple pictures of my bite....it's awful I know

[deathorglory]

I have Anthem BlueCross and I was afraid my surgery wouldn't be covered (lower jaw only, 8mm recessed) but I made sure that my surgeon knew what the criteria were for me to be approved and, even before my consult, I looked to make sure that I met the criteria. At 10mm of underbite, I don't think you'll have a huge problem with getting approved. I think my criteria was that I'd have to be at least 5mm off from perfect to be approved.

I got approved, so I think you'll be fine

[boodles8]

I also was approved with Anthem BC/BS, though not in Kansas. I had mandibular setback only. My measurements were actually asymmetric, 4mm on one side, 1mm on the other, to total 5mm. The asymmetry could have contributed to approval, but with 10mm movement needed in total, I think you'll be fine.

[KaylaChristine]

Thank you both! I feel a little more optimistic now


Since both of your surgeries were approved---could you tell me if the amount you had to pay for the surgery was your max out of pocket for the year for your insurance? My max out of pocket each year is $4000 and I can come up with that in time....but if it's anymore I'm not sure I'd be able to.

[sirwired]

It was nowhere near my max for the year. My LeFort I, IIRC, was about $2.5k out of pocket, including all prep and follow-up visits, x-rays, etc.

[deathorglory]

I haven't actually had my surgery yet! I'm on track for it to happen in February.

When I called my insurance to ask about the price, they said that since I have a maximum out of pocket expense, no matter how expensive the surgery is, all I'll end up paying MAXIMUM is $4000 (which is my maximum out of pocket for in network coverage). She did say, though, that while she didn't have access to how much it'd cost me (because it's something to do with the doctor's contractual obligations with the company or something), what she found from older price guides (or whatever they're called), it looked like it'd cost me well under my maximum out of pocket. Something like $1.5k for the surgery itself, maybe another $500 for the hospital fees? She said it looked like I'd be out something along the lines of $2.1k.

I would suggest putting aside your maximum out of pocket of $4k. It won't be over that, no matter what the surgeon and hospital want to charge you - why else would it be called the maximum out of pocket?

[KaylaChristine]

Thank you both so much for your help!

deathorglory-- I feel a lot more at ease now, thank you! I don't really think it would cost any more than my max out of pocket--but I'm a worrier by nature and I fear the worst. I'd love for mine to cost less than the $4k so I could apply the remainder to my outrageously expensive braces lol. Good luck with your surgery btw!!

It's now been a full week since my surgery consult....hopefully I'll hear back from the surgeon's office about insurance approval within the next two weeks.

[deathorglory]

Just an FYI since you're a worrier (don't worry - me too!)...

...the insurance approval usually take 6-8 weeks. And then if you're like me and haven't heard back at 8 weeks, you immediately call the insurance to harass them about why you haven't heard back. Turns out, my insurance approved me at 4 weeks but then didn't send any of the paperwork out to either me OR my surgeon. After I called, they sent it out with no problems

I've talked to my insurance like a bajillion times about this surgery, ever since I decided to get it. I had my surgeon's consult a full 5 days after I got my braces on...that should tell you how annoying I am as a worrier

I'm sure you'll do fine - like the other poster said, 10mm is a lot of movement, so I doubt you'd have to worry about the surgery being approved

[KaylaChristine]

I thought it normally took around that long but the receptionist at the surgeon's office said about 3 weeks. I'm hoping she's right because I hate waiting. And wow you had 4 more weeks of worrying that you needed, that sucks!

I'd like to think I'll have no problems getting approved but I'd hate to be too optimistic.

[deathorglory]

I thought exactly like you did! Hahaha! Even after I bugged my insurance company to send me the requirements for the surgery, and even after I knew I had about 8mm of movement possible in my future surgery, and knowing that the requirement was to be outside the "norm" of 5mm, I still worried about approval.

I went through each stupid requirement and knew I met them all and I still obsessed about it.

And yes, 4 extra weeks. ...those weeks sucked the worst because I kept thinking "Well if they're taking this long it means they're DEBATING it which probably means they'll deny it!" But no, I was approved. If you've only got 3 weeks to wait, great for you!!!! Keep us in the loops, would ya?

[KaylaChristine]

I just logged into my BCBS account online and there is a claim for $12,035 from the surgeon. It's still being processed & doesn't list the patient responsibility amount yet. Is it safe to assume the surgery is approved? I haven't heard back from the surgeon's office yet. I'm probably going to wait to give them a call until it's finished processing. Does the surgeon usually submit a 'dummy claim' so to speak to see if the insurance approves it? I'm not really sure how it all works and it seems a bit weird to see an actual claim on there.

Haha I haven't bugged the insurance yet. I imagine if I have to wait much longer that I'll be calling them.

It's so hard not to obsess about it all!

I'll definitely keep posting updates!!

[sirwired]

Maybe that's how your local insurance handles it, or how they log a pre-approval request... I know mine certainly didn't charge until after the surgery.

I'd just sit tight and wait until you hear from somebody.

[deathorglory]

I've never heard of them submitting a claim before the surgery itself...! I'd personally call the insurance and ask about it...mostly because I'm crazy and want to know everything haha!