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[ams288]

So I'm a 23 yo recent college grad. Whenever people asked what the first big purchase I was going to make once I got a full time job was, I always said my teeth. I've been very self conscious about them for a while. I got a job in Ann Arbor, MI and moved here. So once I started working last September, I began looking into what I could do about my crowded teeth.

At first I really wanted Invisalign, because I did NOT want to sacrifice 2 years of my social life to metal braces. So I asked my dentist, and she said for my level of crowding and my underbite, Invisalign wouldn't work. So she referred me to a couple of orthodontists. I had never really paid attention/realized the significance of my underbite before. Once she said this I started researching and realized just how bad my underbite is.

The first orthodontist said with a class III underbite like mine, the only real solution would be braces and surgery. By this point I was becoming more open to the idea of braces. They quoted me a price of $7500 for the braces, in addition to whatever surgery would cost. (Ann Arbor is notoriously expensive because most of the orthodontists are really good and also teach at the University of Michigan). So they referred me to an oral surgeon so I could figure out if my health insurance would cover jaw surgery. I have Cigna through work, and apartently Cigna is just awful about covering this type of surgery. So back in November I went and got evaluated by an oral surgeon (who is about an hour away from where I live, the only one who is "in-network" for Cigna). He said that I would definitely be a good candidate for the jaw surgery. So I assumed they would submit the paperwork to see if Cigna would cover it and I'd hear back.

Well, I didn't hear back from anyone. I (naively) assumed that it was just taking a long time to get approval. I got a call a couple of weeks ago from the oral surgeons office asking if I'm still interested and if I'd gotten my braces yet. I said I was still interested, but I was waiting to hear if the surgery was covered before I took any action. I guess they never submitted anything to see if it would be covered. So the billing lady gave me some billing codes and I called Cigna, and they said those surgeries would be covered, I just have to have it precertified and have the doctor's office send x-rays and pictures to prove it's necessary. Apparently my Cigna plan is really good, because both the billing lady at the doctor's office and one of the Cigna reps I talked to on the phone said this surgery isn't usually covered. So right now I'm waiting to get it precertified, and once I know for sure it is, I'll get the braces.

I also recently got a second opinion from another ortho. This orthodontist said the same thing (braces and jaw surgery), but quoted me at about $5900. Her husband is an oral surgeon (but due to insurance coverage I can't use him), so I would feel very comfortable going through this procedure with her. So once I get the 100% okay from Cigna, I'll get the braces. I'm excited to get started. The way I look at it, the sooner I get the braces, the sooner I can get them off.

[kellyb]

hey, thanks for sharing and wishing you all the best with the insurance and the braces journey. have you decided if you will be getting ceramics or metal?

[sirwired]

Still make sure you get that pre-cert. While some Cigna plans do indeed cover orthognathic surgery (most don't, as employers don't like to pay for that option), Cigna applies very tight approval criteria to those surgeries. (If you are interested in what those precise criteria are, just Google "Cigna Orthognathic".)

Basically, unless you have major uncorrectable TMJ, problems chewing so bad you are losing weight, or uncorrectable sleep apnea, they don't like to cover.

I wasn't able to even consider orthognathic surgery until my employer went from Cigna to Anthem BCBS. (Anthem BCBS will also cover it if your bite is just plain awful.)

[ams288]

Oh, trust me, I won't be taking any action until I'm 100% certain that Cigna will cover this. I don't trust insurance companies at all...

I've seen that Cigna documentation that says you have to have a skeletal deformity as well as a functional impairment in order to be covered, but as I understand it doesn't apply to all Cigna plans. I don't really have a functional impairment (not yet, at least), but the rep I spoke to said based on the diagnosis code and the medical billing codes that the billing lady gave me I would be covered.

[ams288]

[quote="kellyb"]hey, thanks for sharing and wishing you all the best with the insurance and the braces journey. have you decided if you will be getting ceramics or metal?[/quote]

I didn't really discuss this with the orthodontists I met with, I just assumed I'd be getting metal, which I'm fine with. I don't even know if you can get ceramics when you're going to be having jaw surgery??

[sirwired]

You can get ceramics when getting jaw surgery, but surgeons generally much prefer metal because they are not as brittle when they wire your jaw shut during the operation.

[ams288]

I'm still waiting to hear back from the oral surgeon's office. Starting to get frustrated with them. I told the billing lady that the Cigna rep said it just needs to be precertified and that it looks like my plan would cover it, and I've yet to hear anything back.

I have another orthodontist consult next Monday. This ortho also teaches at the University of Michigan, and spends some of her time in the hospital there. There are some oral surgeons at the University hospital who are considered to be in-network for Cigna now, so I may just ditch the first oral surgeon and start all over with them.

[ams288]

Finally heard back from Cigna about jaw surgery.

It was denied. The reason they gave for the denial was a pre-existing condition clause in my plan. Since I haven't had Cigna for a year yet, they won't cover the surgery before that time. The Cigna rep I called said that if I can prove I was continuously covered before I got Cigna (I was), then the clause wouldn't matter and it might be covered. She wasn't sure (they're never sure about anything when I call them).

We're trying to figure out if that's the only reason they denied coverage, or if when I provide them with a Certificate of Creditable Coverage they'll just pull some other reason out of a their butts to deny it.

And I had two more orthodontic consults. The first went really really well. She was very thorough and detailed everything, and gave me a quote of $5000, which is great for this area. She said she usually charges more for surgery patients, but my case seems pretty straight forward so she wouldn't have to do that. I'll definitely go with her if I can ever work out the Cigna issue...

The second was not so great. She said that she'd probably have to do extractions to fix my level of crowding (the other 3 orthos never mentioned extractions and seemed to think that my crowding would be pretty easy to fix with braces alone). Then they charged me $50 for the consult. That was annoying, all the other ones were free.

[NICURN85]

Good luck with your journey and hopefully the insurance company will take another look and agree to let you get your surgery. Braces are my first BIG PURCHASE also since graduating from college. I went for my consult today and will be getting started in about a month after getting this one cavity filled.

[ams288]

STILL trying to get Cigna to approve surgery.

Got the pre-existing condition issue taken care of, then they denied it because they didn't have the proper documentation from the doctor's office. The doctor's office sent it everything they asked for, then they denied it for the pre-exisiting condition thing again (which was a mistake, Cigna admitted). So I got my company's HR dept involved. They got ahold of their people at Cigna to "expedite" this process and I should hear back within the next couple of days whether or not it's actually approved.

[jamsession]

Hope you get approval soon! Its great to get going on treatment!