Metal Mouth Message Board

My daughter has been in braces for almost three years and is at the point where they are ready for double jaw surgery. Originally, three years ago, the oral surgeon said to expect our insurance company would deny initially, but we would have the surgery covered in an appeal. Now that we are there, the oral surgeon has changed his story and said it is unlikely the insurance company will pay for it at all. This week, we got a final denial from the insurance company. Every denial has a different reason. This time they said the pictures submitted were too old. We are out of appeals unless we do an external review. Our dentist this morning suggested we try working with a different oral surgeon's office and see if we have more success with the insurance company. I guess I am bothered by the oral surgeon wanting to give up already and am concerned he did not send in more recent pictures, giving them an excuse to deny. Our insurance is Aetna.

jnkrim wrote:My daughter has been in braces for almost three years and is at the point where they are ready for double jaw surgery. Originally, three years ago, the oral surgeon said to expect our insurance company would deny initially, but we would have the surgery covered in an appeal. Now that we are there, the oral surgeon has changed his story and said it is unlikely the insurance company will pay for it at all. This week, we got a final denial from the insurance company. Every denial has a different reason. This time they said the pictures submitted were too old. We are out of appeals unless we do an external review. Our dentist this morning suggested we try working with a different oral surgeon's office and see if we have more success with the insurance company. I guess I am bothered by the oral surgeon wanting to give up already and am concerned he did not send in more recent pictures, giving them an excuse to deny. Our insurance is Aetna.

Sorry to hear about your issues, and I really have no solution but to hang in there and try all avenues. I was initially pre-approved for both of my jaw surgeries (SARPE and MSDO) which were done at separate times in the year and then within a month or two afterwards the insurance company refused to pay the claim stating it was cosmetic (which it is not). However, it seems like this is fairly common with insurance companies and jaw surgeries. I was ramping up for a fight with them (we have one appeal and then have to bring it to the State for the next, and final, appeal) when I mentioned it to my surgeon and he had his billing people on the phone that day with the insurance company both times and both times the insurance company paid. I still have one to two more surgeries so hopefully my luck won't run out. His office definitely know what they're doing and he said they see this all the time, standard operating procedure for the insurance. BTW, my insurance is BCBS. Good luck with your case!

Thanks! After talking with the orthodontist (who has not been involved with the ins. co., just the oral surgeon), they think we just need to wait six months and try all over again. It's crazy there is so much denial over this surgery, my daughter is starting to have trouble eating with her bite issues now. She can no longer chew with her mouth closed

I was approved for lower and denied for upper. 8 went through appeals process and finally got approved after appeals were denied by an external review after insurance issued final denial. I needed both jaws done to get the correct result but it took a long time to get there. If your surgeon is not supporting you in the process you mat need to find a new surgeon who does deem the procedure medically necessary and is willing to go to bat for you.

Hate to here about this. Have you had any luck.