Did Insurance Help Pay for Your Surgery?

[JustMe]

Hi, Right now I'm between insurance companies and shopping around for a great policy from a good company.

I live in Arizona and realize that things vary greatly from state to state (and policy to policy), but in general
I have heard great things about Aetna, BCBS, HealthNet, and Cigna when it comes to coverage for orthognathic surgery.

So, if your insurance company covered all or a portion of your orthognathic surgery, would you please chime in here
and let us know which company it was? Also, did you have to fight to get them to pay up or was it a smooth process?

Thank you.

[samoorelaw]

United Health Care paid for mine but not without a long, hard fight (took two appeals). Good luck to you on getting yours covered.

[sirwired]

For me Anthem was good. Cigna's criteria were too strict. Check the individual coverage criteria before choosing.

Anthem required bad measurements OR a severe functional problem. Cigna required bad measurements AND a severe functional problem. "Teeth going to fall out in 20 years" wasn't going to cut it, even though my measurements were way off.

[glennstanzalone]

I'm in Arizona too. I've consulted with Dr. Sabol and he is contracted with BCBS. I have United Healthcare through my work and they won't cover jaw surgery at all. I'm going to buy BCBS insurance out of pocket to hopefully cover the costs.

[Lislap89]

Cigna covered mine completely other than the deductable and the genioplasty as that is deemed cosmetic.

[snapdresser]

BCBS is covering my LeFort I, BSSO, and genio. I was especially surprised about the genio, since most insurance considers it cosmetic. Something about a narrow airway and the genio actually helping to pull the tongue forward as well? All three were approved with the initial submittal from my doc, no appeals needed. I can't promise that your experience will be the same though! Not sure what my out-of-pocket expenses will be. I know I have a $200 copay for the surgeon (because the surgery will be in a hospital, not her office), 30% of the plan allowance for supplies, and $175 for the 1-day hospital stay that was approved. Braces weren't on the list of stuff my surgeon submitted, so I guess she's saying I don't need them. That'd be awesome if my out-of-pocket expenses are less than $1k...

[sirwired]

Generally braces wouldn't be submitted to insurance by the surgeon both because medical insurance never covers them nor would he be the one supplying them.

I don't think I've ever heard of orthognathic surgery without braces (except in cases of trauma, of course.)

[snapdresser]

I had assumed I would need braces too, but I don't have any issues with my bite and I think most posters on this forum have an open bite or other malocclusion, so maybe that explains it? Are the other people here getting the surgery without bite problems also getting braces?

[KaylaChristine]

BCBS of Kansas approved my surgery. My bite is pretty awful so it wasn't too hard getting it approved.

[snapdresser]

Sirwired, my surgeon confirmed that I don't need braces. Instead she's planning to use arch bars, and the elastics can attach to those. That seems to be standard operating procedure for when there are no bite issues.

[Kyngofpop]

I just got my approval from Aetna the other day for Reconstruction of Mandibular Ramus and Lefort 1. What I don't know is the amount they'll be covering. Following this thread intently.

[sirwired]

I just got my approval from Aetna the other day for Reconstruction of Mandibular Ramus and Lefort 1. What I don't know is the amount they'll be covering. Following this thread intently.

If your surgeon, hospital, anesthesiologist, etc. are in-network, then you'll simply pay according to whatever the benefits chart for your policy says you'll pay. (i.e. $200 deductible, 20% co-pay, flat $400 co-pay, whatever)

[nvmart]

Just took my 17 yo daughter to the surgeon today. Took molds and more film to determine the proper course. He said he believed the orthognathic surgery was medically necessary because my daughter has pain when she chews and demonstrated pain under exam, but it will be a fight. We have Cigna.

If we are ultimately denied, my daughter will be 18 during open season in the fall, so I could get her an individual policy with a carrier that has a more lenient policy towards the surgery.

My question is, would it hurt our case to start the braces before she is under a new policy? I am confused about the new pre-existing condition rules.

Thanks in advance!

[deathorglory]

I've got BCBS (California, I think, though I live in Washington) and I was approved without a hassle. You've got to check the medical plan pretty carefully - from what I understand, a number of plans will not cover it no matter what. What I did was call my insurance after I found out that it would be covered (looked through a bunch of pages online) to find out what criteria I needed to meet in order for it to be covered. I asked for the criteria to be faxed to me, which my insurance did with no problem (they can also email). I needed to meet two out of 3 criteria, which I did without issue. For me, my bite was outside the norm (up to 3mm - mine was 9mm) and I had a congenital defect (bottom adult biscuspids never came in). I think one of the other criteria was to have a medical issue that would be corrected with jaw surgery such as TMJ issues or sleep apnea. I'm not sure ... I checked on this a while ago before I even got braces. I know that the surgeon I was originally supposed to see had me answer a series of questions about my bite and chewing issues.

What I DO understand is that if there's no bite problems and no health conditions, the medical plans usually consider it to be purely cosmetic, which wouldn't be covered.

As for the braces and a new insurance plan, I'm not sure. I got my braces on March 7th 2014, had my initial consult with my surgeon on March 12th 2014, and the surgeon's office sent out papers to my insurance to make sure the surgery would be preapproved. Now, this was all super early, as I didn't have surgery until March 30th 2015 (I was kinda crazy about it being covered). I understand that most people are in braces well before the contact the insurance for surgery - I know that my orthodontist didn't even ask me to have the surgeon start the prior authorization for coverage until about 3 months before the surgery. I was deemed ready for surgery around December but had to have a series of wire changes before I could actually have the surgery itself.

Also FYI - most prior authorizations to be covered by the insurance (or denied, in some cases) usually take 6-8 weeks. I know because I harassed the crap out of my insurance (though I called them at 9 weeks because I hadn't heard anything, and apparently they forgot to mail out my approval letters, so stay on top of those guys!!!).

TL;DR - some insurances just won't cover it, but some have criteria to meet if it's a surgery they cover. Call and ask.

[snapdresser]

nvmart, I don't know how the individual plans address your jumping the gun on braces, but I would think the orthodontic treatment would be different if it's preparing for the surgery vs orthodontic treatment alone. Getting the orthodontics to prepare for a surgery might be risky if you don't know whether or not insurance will approve the procedure. Since the insurance probably won't cover orthodontics anyways, jumping the gun on that part shouldn't affect whether or not the surgery is approved, I don't think. Getting the surgery without prior approval is another thing lol

snapdresser