Preapproval DENIED. Advice on the appeal process?

[TXcourtney04]

Hello. I'm new to this site and I'm hoping there's someone out there who can help.

Back-story: I was in braces for 8 years as a child to fix what ultimately couldn't be fixed with braces alone. I am now 26 and in need of orthognathic surgery.

My dentist, 2 orthodontists, and my oral surgeon have all told me that this jaw alignment procedure is necessary. After having my surgeon send in a letter of medical necessity and waiting 10-12 weeks, I found out today that my preapproval was denied because my insurance plan (PPO with Blue Cross Blue Shield of Texas) apparently does not cover orthognathic surgery after the age of 19.

Am I just out of luck with this? I plan on submitting an appeal regardless. Does anyone have any experience with this kind of situation? Any advice on the situation or appeals process would be greatly appreciated. Thanks. [/b]

[funkyrhodes]

Hey there! I had my share my insurance woes. I have a PPO with Cigna and they denied me...twice. Even my oral surgeon didn't think I had a chance of getting approved and suggested I change jobs! Eventually I had to appeal before a panel, and even then I didn't get approval for the genioplasty (I'm getting my upper- and lower-jaw worked on).

I say...yes, submit the appeal and plead your case. It also helps to have as many professionals on your side present ON PAPER why you need this surgery. I wish the best of luck!

-George

[switchblades]

I find it odd they won't pay for orthognathic surgery for over 19...most surgeons won't even do surgery until that age! Perhaps that's why they wont cover it...it's kind of silly if you ask me.

I don't know much about the Texas program, but I have Atlantic Blue Cross in Canada and I'm thinking they won't cover any of mine, even though I'm still under my mother's health plan (I'm a student) and considered a dependant.

Good luck!

[masher]

Continue to appeal and work with your dr. to see what can be done. I've been fighting my insurance company for just about a year now and have made some progress. They even claimed that the only reason my wife needed the surgery was because she had the pre-work done and removed teeth and braces. IMHO, the current medical and insurance system needs to be taken to the wood shed.

So far the biggest help has been me writing a long letter our our HR VP about the situation. I'm in a special situation as my current company would be lost without me and if I quit they would be in a world of hurt. They actually changed the policy from a flat denial to something that would cover it. Over course they left in vague language that allows them to decline the coverage.

GOOD Luck and keep fighting! A lot of us have unfortunatly felt your pain and in a lot of ways it is worse than the pain from the medical treatment.