Health Insurance Coverage

[vaguy79]

I have a class 3 cross bite. I am in my early 30's. Besides not being able to open my mouth very wide and the occasional popping, I have learned to live with it. However, it seems to be getting worse. I wore braces in my early teens for 5 years. When I was around 23-24, I went to about 9-10 orthodontists regarding the movement of my teeth and crooked smile. Half of the orthos, said I needed Orthognathic surgery and the other half said they could probably fix it with just braces.

I have health insurance through work with United and it seems like the consensus is that United does not cover Orthognathic surgery. I've read Kaiser is pretty easy with coverage. Before I presume further consultations/actions and create a documented pre-existing condition, would it be beneficial to change to Kaiser and then go to the doctors or try my luck with United?

Thanks!

[mc2001]

I have United and mine is covered. They will deny it at first but if you can show the medical necessity on the appeal you can get it approved. Keep in mind this is only if your plan covers orthognathic surgery, some employers plans do not cover it.

[bmueller]

I have Coventry and it is covered. You need to get the CPT codes (ID codes for the procedures) and then call the insurance company to see if those are covered or not. You may have to prove medical necessity before it will be approved. That will require consultation with an Oral Maxillofacial surgeon.

[sirwired]

Ask your HR dept. for a copy of your health plan. It will detail if your employer excludes orthognathic surgery. It's totally up to your employer; the insurance company will cover whatever your employer pays them to cover.

(As a side-note, my employer has two documents; the first is just the cheesy "Quick Reference Sheet" with basic info on deductibles and co-pays. A separate, more formal, document has all the details on specifically what is and is not covered.)

[vaguy79]

On my Certificate of Coverage it states this under the list of exclusions:

Upper and lower jawbone surgery except as required for direct treatment of acute traumatic Injury,
dislocation, tumors or cancer. Orthognathic surgery and jaw alignment, except as a treatment of
obstructive sleep apnea. This exclusion does not apply to Benefits as described under Dental
Services - Anesthesia and Hospitalization and Temporomandibular Joint Services in Section 1:
Covered Health Services.

Going to Benefits Covered under Dental Services references this:
4. Dental Services - Accident Only
Dental services when all of the following are true:
 Treatment is necessary because of accidental damage.
 Dental services are received from a Doctor of Dental Surgery or Doctor of Medical Dentistry.
 The dental damage is severe enough that initial contact with a Physician or dentist occurred within
72 hours of the accident.


So it looks like it is excluded from my employer coverage which is disappointing as I don't pay anything for my health coverage.

[Alicia0913]

Sounds like Kaiser is the way to go for you. =( Wouldn't try to fight your current insurance if it's specifically listed as an exclusion

[batwing]

I know you asked this a couple weeks ago, sorry about the late response!

I have UHC through my employer as well, and have a similar exclusion. There is a financial coordinator in my surgeon's office who deals directly with the insurance company. What she found was that if I met at least two conditions (it was a documented physical deformity and a functional disorder, mine was insufficient mastication) that it would be reviewed by my insurance in more detail as an exception to the exclusion. TMJD was also a specific exclusion in my plan as jaw surgery is considered experimental treatment for it under their definitions.

Once my insurance company found my paperwork (which they lost for over a month), including the letter of medical necessity which showed the diagnoses above, I had my approval in about a week-- even though I had heard horror stories about UHC and swore it'd be rejected.

Another option the financial coordinator gave me was to try to get my response from UHC before my employer's open enrollment period. We have two different insurance plans. She said if I were rejected by my insurance, we could switch insurance during open enrollment and try with the new insurance. So that may be an option for you, too.

[samoorelaw]

I have to chime in here. I also have United Health Care through my employer and I was denied three times because first, orthognathic surgery was automatically excluded. When I learned that the new health plan for 2014 stated they would cover the procedures if it was "medically necessary, I tried again in December 2013 and was denied because I had not proven it was a medical necessity. I then appealed this second denial and was denied yet again two days later (yes, TWO DAYS) because "x rays did not substantiate diagnosis."

THEN out of the blue, I received another letter yesterday saying they have re-reviewed the appeal and have reconsidered and will be covering my surgery, even though my plan states they will only cover it if it's to correct a traumatic injury, congenital defect, TMJ, or obstructive sleep apnea, none of which I have! I am not going to question it, and it's only to be covered out of network, but that is certainly better than nothing!

Goes to show that you should NEVER give up and keep trying.

[vaguy79]

Thanks for the update. My employer switched insurance carriers this year, so now I am with BCBS. I recently made an appointment with the oral surgeon and will proceed from there.

[samoorelaw]

Good luck to you. Everthing I've read about BCBS says that they are way more likely to cover orthognathic surgery than UHC: it's almost a miracle to get UHC to cover this surgery or ANYTHING for that matter, which is why I couldn't be more shocked and happy that they are finally doing the right thing.