Anthem BCBS and Orthognathic Surgery

[WVJordan]

I have Anthem BCBS through my employer and looked up their guidelines on Orthognathic surgery. They allow it if it is deemed medically necessary and they have a list of criteria. I meet the criteria by having a >5mm overjet. I called up the oral surgeon my Ortho recommended (in a neighboring state) and he asked what insurance I had. I told him, and he said most of our submittals to them come back declined. This goes against everything I have read online which says Anthem BCBS is one of the easier ones. I contacted a more local surgeon (same state) and he said they usually have no issues with them. Can anyone provide any insight? I am about a year away from surgery but now I am nervous my insurance won't cover it. Reading through their criteria, I seem to meet more than enough requirements for it to be medically necessary.

[snapdresser]

If you meet the criteria, then it's just a question of your surgeon sending them adequate information (and a nice statement that's clear and logical) to demonstrate that you meet those criteria. If they're too lazy to do that or unwilling to look up what information is necessary to send in, you may have to send in a lot of additional documentation after the first time it comes back rejected, or you could just find another surgeon who knows how to put in for insurance approval for the procedure properly. I had mine approved by BCBS the first time it was submitted. My surgeon put together a good write-up, tho. Good luck!

[EWUgal15]

Sometimes insurance companies don't like working across state lines. It really depends on the company and your plan. I speak from experience. I have Premera Blue Cross and my plan is specifically for Washington and Alaska. I live very close to Idaho, but not all of my benefits reach to Premera providers in Idaho. My surgeon operates in WA and ID...so my procedure is in-network where I live (Spokane, WA) but out of network if it's done in his Post Falls, ID office. I don't know how that works, but that's what the insurance/financial coordinator at the surgeon's office told me.

I recommend two things:
1. Try to reach out to sirwired (yes, I'm summoning you again because you're wicked smart). I know he had a jaw surgery and if I remember correctly, he worked with Anthem and it was covered.
2. Have your surgeon send a pre-authorization. Even though it may expire before your surgery if you send it a year in advance, the insurance coordinator with the surgeon will be able to file for an extension before it expires. I wish I had known when mine was going to expire so I wouldn't have to wait for a new one. If the pre-auth is denied, you should be able to find out why. It may be that even though the surgeon is an in-network provider, they aren't covered by your plan. It never hurts to try. You could probably fight a denial too.

[WVJordan]

Thanks for the responses. Hopefully the lady in PA (I'm in WV) was meaning that they deny a lot of out of state claims. But Anthem BCBS is based out of Pittsburgh I believe, which is where I want this surgery done, and considered in-network. Who knows. Hopefully someone can get it covered. I will no more after my consultation with the surgeon on the 8th.

[sirwired]

And again, I am summoned...

Anthem has a very well-defined list of criteria, and of those, they have one of the most open. (I previously had Cigna, which required some sort of major medical condition before they'd approve, no matter how bad your measurements were.) I was denied at the beginning, but that was just because the office forgot to submit my measurements. When they did that, I was approved in under a week.

As long as your medical plan covers orthognathic (not all medical plans do), Anthem should approve.

There's not really a need to submit for a pre-approval that's going to expire, because whatever your measurements are now, they are going to be worse by the time pre-surgical ortho is complete.

Anthem BCBS is a merger of a bunch of insurance companies; they are based in Indianapolis. They have consistent coverage criteria across the board, although the actual policies vary widely by state, employer, etc.

[chobbs7]

Besides Anthem, what insurance companies typically approve orthognathic surgery? I currently have CIGNA PPO, when looking at their requirements I am not sure I meet all of them.

My overbite itself is not that severe, however it is causing an array of dental problems. I have extreme crowding on my lower jaw and because of the crowding I have teeth that are growing from the very back of my mouth out of my jaw bone. Only the surface of the teeth can be seen. It is causing problems with my gums because of lack of space behind these teeth, and I will sometime bite or pinch my gums with my teeth. They can extract the teeth, but that is a temporary solution to a permanent problem.

[sirwired]

It sounds like you do indeed not meet Cigna's stated requirements, however, those are not set it stone. It might be worth it to consult with an OMFS (the consult should be covered) and try and suss out from either the doctor and/or their "Insurance Person" how likely it is they think they can get Cigna to approve.

Also, if you are just having a single jaw done, it may be possible to do it on an outpatient basis, which is way cheaper than inpatient surgery. However, not all surgeries can be done outpatient, and not all OMFS's will agree to it.

[uncleezno]

I also went through Anthem BCBS for my jaw surgery. Like SirWired said, it varies state by state and plan by plan. If you meet the guidelines for medical necessity, even if your plan doesn't cover maxillofacial surgery, I recommend trying for the preapproval and fighting them every inch of the way if they say no. Squeaky wheel gets the grease and all that.

[zigzimm]

Anthem guidelines: https://www.anthem.com/medicalpolicies/ ... 053349.htm

[zigzimm]

I am also going through anthem. Don't have preapproval yet, but hopefully will in the next couple weeks. I was told they will only cover $11-13K for an out of network doctor, who says he wants to charge $30K for Lefort 1, so I will have a lot to pay out of pocket. Still trying to figure it all out.

[kpw818]

This is all very encouraging. I have Anthem and my surgeon is in network. He wants to do double-jaw, which I'm wary of, but it looks like the process for approval may not be as tricky as I thought. I don't know my measurements off the top of my head, but I believe from what I saw on Anthem's requirements, I meet several.

I saw someone mentioned outpatient if only one jaw is operated on--is this common?

[sirwired]

This is all very encouraging. I have Anthem and my surgeon is in network. He wants to do double-jaw, which I'm wary of, but it looks like the process for approval may not be as tricky as I thought. I don't know my measurements off the top of my head, but I believe from what I saw on Anthem's requirements, I meet several.

I saw someone mentioned outpatient if only one jaw is operated on--is this common?

Outpatient LeFort's or BSSO's are not super-common. A lot depends on how comfortable the OMFS is with the idea. Really, it's only necessary if you can't get insurance coverage. It's a LOT of work for your caregiver if it's done outpatient; if insurance approves at all, they'll cover it as inpatient.

[EWUgal15]

My BSSO was an outpatient procedure and I had insurance coverage. I actually set an office record for how fast I got out and home that day.

[kpw818]

I saw the pre-approval, I would have a day long stay.

Looks like BCBC also automatically denied it, but it is listed as excluded under dental, not medical. Anyone has a similar issue?

[EWUgal15]

I saw the pre-approval, I would have a day long stay.

Looks like BCBC also automatically denied it, but it is listed as excluded under dental, not medical. Anyone has a similar issue?

Kind of. My dental is through a different company than my medical. Because my BSSO wasn't a covered benefit by dental, I went through my medical. It was reviewed by the dental review board of my medical insurance company, it was approved because I met the requirements for the procedure to be medically necessary according to the standard set forth by the insurance company. I got lucky I guess...