Please Help! In a lot of pain!

[Rebecca]

Hi Everyone-
I live in Columbus, Ohio and have a very severe overbight (13mm)- as far back as I can remember, I have jetted my lower jaw forward to compensate. If I do not posture my jaw, I am unable to breath easily, cannot talk, and cannot chew. Unfortunately, our jaw joints were not meant to be clenched forward 24 hours a day and thus, I have been developing nodules of ripped/swelled/spasmed muscle tissue along my jaw line. I am getting braces on for the third time this thursday and am distraught as I was just contacted by my oral surgeon with the bad news that my insurance consideres orthognathic surgery as a benefit exception. As you can imagine, if I wait much longer, I have been told that I can look forward to prosthetic jaw joints . Any suggestions on getting insurance to pay for an exclusion if the procedure is clearly medically necessary? If I do have to pay out of pocket, does anyone know about how much it might be for everything including hospital/anesthesia fees(UPMC Presbyterian Hosp)? If you have to finance with the hospital for an outstanding balance, are there interest fees? How can you get a drug rep to donate screws/plates?
Please help!
Thanks, Rebecca

[AZWILDCATS]

Wow - wish I knew what to say. I had to go to my corporate Human Resources department for our insurance to pay to repair my broken jaw because it broke in the joint and all the medical codes were for TMJ disorder, which is not covered.

My husband in now going through a similar issue. He had a pilon fracture of the ankle four years ago, had three surgeries to try to fix it. Now, he needs ankle replacement and insurance is denying it - saying it's experimental.

The one thing I have found is, squeaky wheel gets the grease. Appeal Appeal Appeal. File formal complaints with the Ohio Department of Insurance. Do whatever you can.

[iBorg]

Ask your surgeon and your orthodontist's insurance folks to look over your plan. There may be exceptions based upon breathing issues or sleep apnea. While most insurance companies exclude insurance coverage for "cosmetic surgeries" they may cover the same surgery if it is deemed medically necessary. Good luck with the insurance process. For many of us the outcome is worth the battle.

Mike

[OzzysMom]

I'm so sorry you are going through all that and I feel your pain. I suffered almost daily tension headaches for 6 years before my surgery.
There are many people here with stories about how they fought and won with their insurance companies over covering surgery. If you do a search, I'm sure you'll find a lot of info.
In my case, I was labeled uninsurable so I went to Costa Rica for med tourism and paid less than half the cost...It's always an option if you don't have insurance coverage.

[jul]

Sorry you have such bad news. I'm w/ Mike if you have difficulty breathing, sleep apnea or being at risk for respiratory failure treatment is probably a covered benefit. Ask you medical doctor not your OS about that. I would ask OSU oral surgery dept if they have any programs for pt who do not have ins coverage. Many teaching institutions do or have a reduced cost for cash payers. It's worth a phone call and they have very good OS there.
Good luck

[Rebecca]

Hi Again-
Spoke to my husband yesterday about paying out of pocket for the surgery if it is denied after appeal under the impression that it would be about 30k total....then spoke to the OS assistant today who basically laughed (said hospital fees alone would reach 75k plus 13k for the surgeon and I would have to have every penny in advance)- guess that won't be an option. I know the OS is itching to do the surgery as every dentist, orthodontist, and oral surgeon have basically put me on parade as a freak of nature due to my ability to posture my jaw almost an inch forward at all times(imagine clenching your jaw in a certain position every second of every day for years and years....painful, but I can't function unless I do). Apparently, no one has ever seen anything like it (man I'm sick of hearing that). So far no private practice OS will touch my case, and I am now seeing a physician at the University of Pittsburgh (I went to Ohio State too, but I like my Dr. at Pittsburgh a little better).
Since my out-of-pocket plan has been shot down, I now plan on applying for appeal by presenting letters of medical necessity from my PCP, dentist, orthodontist and some random person off the street if I have to. In the back of my mind I am thinking that I am lucky to have a husband that will be an anesthesiology resident at the University of Michigan next June....that has a dental school....who's oral surgery department accepts UofM insurance for orthognathic surgery under certain circumstances. The only hold up.....another year of pain, another year with braces!
Will keep you updated, Rebecca
PS- whoever started this web site is amazing...it feels better to just get this off my chest, thanks for all of your kind words/advice

[chicago29]

Rebecca,

I am sorry to hear of your pain (both physical and emotional). What you are experiencing on the insurance front is a shame. Given what you are telling us, there is absolutely no reason you shouldn't be able to get treatment based on medical necessity.

I don't understand why your surgeon doesn't submit a treatment plan to your insurance and explain why the procedure(s) is/are medically necessary. This is standard practice, and this is not something YOU should have to do. The oral surgeon's office should have treatment coordinators that know how to work with insurance and what the "magic words" are to ensure the point comes across that the procedures are not cosmetic but are required for legitimate medical reasons.

Talk to your surgeon and tell them what you are telling us. If that isn't enough to get them to submit a plan and explain your medical needs, then you need to find a surgeon that CAN help you.

And by the way, if all of this was already done, APPEAL. And then appeal again...and again if you have to.

Best of luck.

-Chicago29

[iBorg]

Rebecca:

I was quite surprised to be approved on the first go round with my insurance company. My approach was to attack the submittal as if it was my final appeal. You MUST be proactive. Your insurance WANTS you to abandon this procedure as it is very expensive. With that said, what insurance are you trying to get to cover it? Medical or dental? This is a medical procedure and will only be covered by medical insurance. Since it is a medical procedure examine what medical issues this is causing. They could range sleep issues (normally caused by a small airway) which I doubt you have. You may have either significant sinus or inner ear problems. That may lead to coverage. You may also may have digestion issues due to the inability to properly chew your food.

Think about your personal health. Is there anything out of the ordinary that this treatment may help? At the bare minimum, you should have grinding issues. Are they severe enough to require splints and the like to prevent excessive tooth damage. That my be enough to be covered.

Pause....you need to recollect your wits. Ask your ortho to look at your insurance and see if they see clauses in your medical insurance that may be covered. If they do, pursue that possibility.

Finally you mention that your surgeon's office seems to not care about helping with your insurance. Something is wrong there. If they hope for you to spend the amount of money this surgery requires, they need to be proactive to help you get as much insurance as possible. As my ortho says, there are two type of people who need this surgery, those covered by insurance who get it and those who end up with a compromised outcome.

If you're willing to travel to Lexington, Kentucky I highly recommend my surgeon, Joesph Van Sickels at the University of Kentucky.

Mike