Taking a New Job When You've Got Surgery Scheduled

[uncleezno]

That is good advice, too. Aetna and Anthem BCBS have identical guidelines for orthognathic surgery, down to the letter. That's encouraging! Also, Anthem states it covers genioplasty if it's done alongside the surgeries I would have.

Seriously, Sirwired, thank you SO much for your help!

[sirwired]

That is good advice, too. Aetna and Anthem BCBS have identical guidelines for orthognathic surgery, down to the letter. That's encouraging! Also, Anthem states it covers genioplasty if it's done alongside the surgeries I would have.

Seriously, Sirwired, thank you SO much for your help!

Ah! Anthem? Good. I have Anthem, and surgery that Cigna denied, Anthem approved with no hassle. Anthem denied me once, but that's because the Oral Surgeon's office forgot to include my measurements in their packet. Once those arrived, they approved in under a week.

That's no guarantee they'll cover your case, of course, but it's encouraging.

[uncleezno]

Thought I would give an update as tomorrow is my last day the current job and things are kind of slow, work-wise After reading everything over, I am definitely able to apply for pre-approval on day one of the new job. I have to get proof of continuation from my current insurer and give that to the surgeon's office, and then they forward everything along to BCBS.

I wasn't exaggerating when I said the approval criteria for Anthem and Cigna were the same - they literally are word-for-word identical, as if somebody at one insurer cut-and-pasted the text from the other. On top of that, Anthem states that it covers sliding genioplasty if it is requested in concert with orthognathic surgery, so that's good too!

The worst case scenario is I apply for pre-approval and get denied. In that instance I will take COBRA coverage (you have 60 days to apply for it after leaving your job and 30 days after that to make the first payment). COBRA isn't cheap by any means, but paying $1,250 a month for six months until I get the surgery is way less than paying for the entire thing out of pocket. So at worst I lose the increased earning potential at the new job for the first year, but I still get the surgery. And I was very up-front with the new company's owner about my surgery and the time off that I'll need, so we'll figure out a way to make it work.

Looking forward to a smooth transition at the new gig, and happy to report that one way or another I'll get this surgery covered!

[samoorelaw]

Thought I would give an update as tomorrow is my last day the current job and things are kind of slow, work-wise After reading everything over, I am definitely able to apply for pre-approval on day one of the new job. I have to get proof of continuation from my current insurer and give that to the surgeon's office, and then they forward everything along to BCBS.

I wasn't exaggerating when I said the approval criteria for Anthem and Cigna were the same - they literally are word-for-word identical, as if somebody at one insurer cut-and-pasted the text from the other. On top of that, Anthem states that it covers sliding genioplasty if it is requested in concert with orthognathic surgery, so that's good too!

The worst case scenario is I apply for pre-approval and get denied. In that instance I will take COBRA coverage (you have 60 days to apply for it after leaving your job and 30 days after that to make the first payment). COBRA isn't cheap by any means, but paying $1,250 a month for six months until I get the surgery is way less than paying for the entire thing out of pocket. So at worst I lose the increased earning potential at the new job for the first year, but I still get the surgery. And I was very up-front with the new company's owner about my surgery and the time off that I'll need, so we'll figure out a way to make it work.

Looking forward to a smooth transition at the new gig, and happy to report that one way or another I'll get this surgery covered!

If you get denied initially, I recommend you appeal it. I was denied but I appealed and won, and my policy (UHC) used to exclude orthognathic surgery automatically for ANY reason. Recently, they changed their position to state it would be covered if medically necessary, and thankfully, they agreed with my physician that it's medically necessary.

Also to the above poster who said that deductibles are rarely below $3,000, that simply isn't true: my deductible for the surgery was $2,000 and that was out of network: if it was in network, it would be $1,000.

Anyway, good luck on the new job and getting your new insurance carrier to cover it. Thankfully they are getting quicker with approvals/denials these days: I had my denial and answer approving the surgery after the appeal all within one month, so you may be able to go through the appeal process before having to elect for COBRA coverage.

[sirwired]

Glad to hear things are moving along, and I'm very glad I could help you understand how to get the pre-ex exclusion waived via the continuing coverage certificate (I'm still shocked the HR person didn't know about it; it's kind of a pretty basic part of employer group health coverage); it makes all the time I spend here worthwhile.

As a random side-note, my wife got laid off from her job at the end of last month (she's already lined up a new one, and starts in a couple of weeks), and just last week we received the certificate of continuing coverage (along with the COBRA info), and we didn't even have to ask for it.

[uncleezno]

Well, here's a depressing update. I've been at the new job for three months and it's fine, but the new insurance company finally got around to reviewing the precertification request and they denied it for being medically unnecessary. Listening to the woman from Anthem BCBS blandly explain that it was completely denied and unlikely to change with an appeal made me want to throttle her. Not a fun place to be five and a half months in to braces.

[sirwired]

Well, your first step is to get the rejection in writing from Anthem; what you need from them is to learn specifically why they think the paperwork sent in by the Dr is insufficient to justify your case. Then, take the rejection details and a copy of the approval criteria back to your oral surgeon's office and work with their insurance person to assemble the paperwork needed to get the claim approved.

When I was denied, I incredibly had just walked out the door of the oral surgeon's office from my pre-surgery-consult. I turned right back around, asked for the insurance coordinator, she dug up the e-mail Anthem had just sent, saw what they needed (some measurements that were not included) and faxed them right away. I got my approval about five days later. I think I was just about as happy as the day I got into college!

The approval criteria are pretty clear, so if the OS office can provide proof you meet them, you should be able to get approved.

[uncleezno]

I called up Anthem. The whole thing was sketchy - I got one letter from them saying they were missing my entire information packet and couldn't make a decision, and then a letter from a few days later saying it was denied. They sent me my complete plan details, and it clearly states they don't ever cover jaw surgery to fix dental issues.

I am really angry with the benefits guy at this company - we had numerous phone calls on this topic before I took the job, and he never once mentioned that the exact thing I needed was explicitly not covered. I don't really have any recourse, unless I want to run around and try to get other doctors to sign off on me having TMJ (I don't) or can't breathe (I can).

The compassionate folks at the surgeon's office gave me a quote of ~$20k to get it done. So I guess I'm not getting it done, and I have to talk to the ortho about what we should do. Ugh.

[sirwired]

Hmm... the plan by my employer doesn't specifically call out orthognathic surgery at all, but does say that "dental" issues in general are not considered medical. The Anthem coverage policy then states that measurements off over a certain amount are considered "medically necessary".

So, in short, the reason I signed up for braces/surgery was to prevent gum recession from progressing further. But the reason Anthem approved it was because my jaw was far enough off for it to magically become a "medical" problem, and the recession and bone loss that were my reasons were irrelevant.

Yeah, it doesn't make a whole lot of sense to me either.

In short, if your case meets Anthem's medical necessity criteria, and your O/S can document it, it's not a "dental" problem any more.

[SoCalUniveristyLed]

So what happened?

I'm glad Samoorelaw gave insight : ) I was going to suggest Cobra.

I ended up switching jobs a month before I went in for surgery, but so I wouldn't have to deal with the possibility of being denied, I made sure my new employer had the same insurance (Kaiser). They did, and I was grateful. I was encouraged to sign up for Cobra if it didn't work out for whatever reason since I'd only be paying for it a couple months for surgery's sake.

I hope you at least appeal. I have come across people who didn't give up and in my opinion they'd sometime just approve to get you off their back, but if you don't try well then, they didn't have to pay for your procedure!

Good luck and don't give up.

[uncleezno]

So the end of the story is that Anthem rejected my appeal, and I'm waiting on the second, final appeal, which they'll also probably reject. My wife's employer is having open enrollment now, but the three plans they offer all specifically exclude orthognathic surgery.

My company is looking in to new insurance options for the coming year, but it's a tiny company, so benefits are an outsized expense, and I'm not holding my breath that any new options there will cover me, either. I even looked on the state's insurance exchange, and all of the plans on there also specifically exclude jaw surgery except in the case of reconstruction following an accident. Maybe I should just step in front of a bus?

I guess what will happen is that by the end of November I'll know for sure that the surgery won't be covered, and I'll talk to my ortho about undoing all the work he's done over the past nine months - my teeth look awful now, and if I'm not getting surgery, I'm not leaving them as they are now.


EDIT: Regarding my backup plan of taking COBRA coverage, by the time Anthem got back to me with their first denial, which took FOREVER, it was too late for me to pick up COBRA coverage. Can't wait until the day we finally have a single-payer system here and these awful companies go away.