What reasons has your insurance given for denials?

[AlfAteCats]

Hi! New to the board. 33 years old, about to have my first (and only! LOL) baby in July.

Backstory: I had braces from the 2nd to 4th grade. I also had 8 molars extracted to make room in my tiny mouth. This was not enough, because by the time I was in late elementary school, it was obvious my lower jaw was never going to catch up to my upper jaw. My parents had bad insurance and didn't fight for me to get jaw surgery - in fact, when the orthodontist told me I needed it, my mother made me feel bad for considering it (because she has the same jaw) and talked me out of it. I got a chin implant when I was 23, but it while it partially hides the cosmetic part of my deficiency, it doesn't help that I can't bite into things properly and I have to make an effort to keep my mouth from hanging open. My face is always sore from being tense. I have an overjet of 7mm and a 80% overbite. My two front teeth has hairline cracks from the stress of trying to bite into things.

Now I have what I thought was good insurance for the first time in my life and just had my first consultation with an orthognathic surgeon. He recommended advancing my lower jaw, shortening and widening my upper jaw, removing my chin implant (which is eroding my bone) and a genioplasty. I would have been totally fine covering the cost of the implant removal and genioplasty, by the way. My insurance denied it (twice) based on the fact that my condition is "developmental" and not "congenital". Uh... I was under the impression most bone irregularities WERE developmental. No one is born with a crossbite, for example (right?). Their criteria for fixing an overbite is 5mm - which only an adult would have. This just seems like a way for them to get out of covering it AT ALL.

So, now I'm going to get my company's HR and orthodontist to write a letter about the medical necessity of the procedure, and I'm going to write a letter about what getting this surgery (or not) would mean to me.

What objections did your insurance have to approving your surgery and how did you overcome them?

[MagnoliaMama]

I'm a worrier so I did a lot of (ultimately unnecessary) research on what to do when facing an insurance denial. Do you mind me asking which insurance company you have? Have you looked up their criteria for deeming the surgery medically necessary? Where are your measurements in comparison?

One of the most valuable things you can do is enlist your surgeon. They often know exactly what each insurance company needs to hear in order to approve. Try not to worry too much, from what I've read it isn't unusual to have to submit two or more requests before they ultimately cave in and approve it!

[snapdresser]

I concur with MagnoliaMama: A letter from your surgeon stating that you need this surgery and why it's appropriate for your case should go a lot further than a letter from you, your company's HR, or your orthodontist.

[Mart]

Whenever I see threads like this one concerning American health insurance cover I usually just pass it over without commenting, as I live in the UK where we have a national health service where everyone contributes through their taxes and the majority of health care is covered automatically without question.

But I feel compelled to ask.. why are the majority of Americans against a national health service when your insurance companies treat you so badly? I really don't understand this, but perhaps this is because I'm missing something?

It seems to me that insurance companies will fight you tooth and nail, and make up any reason they can possibly come up with just to avoid paying for your medical bills, which makes sense, as they're a business and spending their money on your health care is bad for their profit margins.

But the thing is I see this happening not just once but time and time again on these discussion boards. I've been following this forum for the last 9 years and I can't count the number of times someone has posted that their insurance provider is refusing to cover their medical costs.

But aside from just orthodontics I can't even begin to imagine what it must be like if god forbid one of you gets cancer and your treatment is delayed because the insurance company is fighting you over coverage.. it just boggles my mind.

Anyway rant over, sorry for the digression

[SantaBarbarian]

I have a PPO with Cigna provided by my employer. I've been given just about every reason under the sun for denying my surgery, but I ultimately got it approved. I'm still fighting on the back end of things.

Cigna requires that I meet two criteria: skeletal deformity and a functional impairment. They too use the 5mm overbite, but if I can't show that the 5mm+ overbite is causing a problem, then there's no medical reason to fix it. At first they said I didn't meet the criteria for the 5mm overbite. I had to return to my surgeon to have them take an X-ray to show that I did indeed have an excessive overbite. At this point, they acknowledged that I met the first criteria but not the second (which was having sleep apnea, in my case).

My surgeon wrote a letter of medical necessity and Cigna didn't care one bit. I think this is the first time that happened to him - he said normally Cigna will fight him, but he'll write the letter and talk to their doc on the phone and Cigna will ultimately approve the surgery. He did all this to no avail, saying that the types of questions Cigna's board-certified orthognathic surgeon was asking revealed his utter incompetence.

I had half a dozen sleep experts from three different institutions say that it was clear from my examination (namely, my profile) that I had severe sleep apnea. None of it mattered. All Cigna wanted to see was a sleep study that showed apnea. My problem was how they defined an apnea - I would stop breathing dozens of times per hour, but never for more than 10 seconds to count it as an apnea because I was sleeping so lightly in the test room.

I did have a third, at-home sleep study that showed the mildest apnea possible that could still be considered allowable for surgery (AHI of 5), For months, I asked Cigna why that sleep study didn't meet their criteria, and all they would say is "we checked with the medical director who has reviewed every page of every sleep study in detail and you do not meet the criteria; here are the criteria." (That's virtually verbatim what their response was.) I finally got my company's HR involved and they said that Cigna had to answer the question as it looked to them like I did meet Cigna's criteria. Only then did they come back and say "oh, that sleep study? The one that you've been asking about for months? The one we received via fax on June 23rd? Yeah, that one was never reviewed." [Jaw drop!!!!!!!!!!!!!!!!!!!!!!!!!!!]. I have this in writing too - it was all done via email. But my insurance plan is self-funded, meaning Cigna just administers the plan and my company ultimately pays for all the services. These kinds of plans are covered by a federal law called ERISA, and under that law, if I were to sue Cigna, it would have to be in federal court and I could not sue for damages, lost time, or suffering that their delays caused. The insurance companies have all the power. This is a terrible system and I very much want a single provider option!

They said that for them to review the sleep study (which they should have done the first time, let alone the second time), I'd have to file an appeal. But by this time I'd already used one of my two appeals, and even though they didn't do their job (and admitted that) during the first review or the second review, they were unwilling to give me an additional appeal. So I had one chance left to get it authorized. To ensure the best outcome possible, I scheduled an appointment with Dr. Pelayo at Stanford and had a fourth sleep study done. Stanford has pioneered the study of sleep and they knew how to design a sleep test space to ensure the best possible sleep for the patient while being connected to two dozen electrodes. I got a true positive result that showed severe sleep apnea in all sleep positions, which was a surprise to me as I thought I was actually ok on my side. After this, Cigna authorized my surgery.

Other tactics Cigna has used since my surgery to delay and reduce the amount of money I'm owed is to choose an arbitrary, very small number to pay, hoping that I would just accept what they did and not question it. They've also "mistakenly forgotten" to process all the procedures on a claim, or to "accidentally" mis-record the amount that the doctor has billed, etc. It's awful and you have to watch them like a hawk every step of the way.

[AlfAteCats]

Yeah... no. I am definitely not okay with this system and I vote accordingly. I can't speak for my brainwashed countrymen.

[quote="Mart"]Whenever I see threads like this one concerning American health insurance cover I usually just pass it over without commenting, as I live in the UK where we have a national health service where everyone contributes through their taxes and the majority of health care is covered automatically without question.

But I feel compelled to ask.. why are the majority of Americans against a national health service when your insurance companies treat you so badly? I really don't understand this, but perhaps this is because I'm missing something?

It seems to me that insurance companies will fight you tooth and nail, and make up any reason they can possibly come up with just to avoid paying for your medical bills, which makes sense, as they're a business and spending their money on your health care is bad for their profit margins.

But the thing is I see this happening not just once but time and time again on these discussion boards. I've been following this forum for the last 9 years and I can't count the number of times someone has posted that their insurance provider is refusing to cover their medical costs.

But aside from just orthodontics I can't even begin to imagine what it must be like if god forbid one of you gets cancer and your treatment is delayed because the insurance company is fighting you over coverage.. it just boggles my mind.

Anyway rant over, sorry for the digression [/quote]

[AlfAteCats]

I'm currently fighting with the practice's patient care coordinator to get her to help me file the paperwork that I have a functional impairment. I would say not being able to open my mouth enough to bite into a sandwich and having to eat a burger with a fork and knife is impaired. She's trying to say they do not assist with appeals AT ALL. I hate this woman.

[quote="snapdresser"]I concur with MagnoliaMama: A letter from your surgeon stating that you need this surgery and why it's appropriate for your case should go a lot further than a letter from you, your company's HR, or your orthodontist.[/quote]

[ZiziOConnor]

Mine rejected it on the basis that they don't pay for any treatment related to TMJ disorders.

And I was like, this isn't related to TMJ disorder. My TMJ is fine.

They were like, okay um we'll look into it.

So, that's where things are right now.

[snapdresser]

She's trying to say they do not assist with appeals AT ALL. I hate this woman.

Wow She sounds terrible! Perhaps she thinks she's overworked and underpaid? I wonder if asking your surgeon directly if they'd help with the appeal would help light a fire under her. I suspect the surgeon would be more likely to be congenial and agree to help you out and therefore sign the patient care coordinator up for more work than the patient care coordinator would be herself Then you can tell her "the surgeon said you'd help me file the appeal". Maybe it's worth a shot? Good luck!!!

[joecinq03]

Sounds like you need to find a new surgeon. Filing an appeal is very routine for any surgeons office which handles jaw surgery cases and this is a big red flag to me.

[AlfAteCats]

The funny thing is, the surgeon I'm seeing is literally the best in my part of the country. People drive hours and come in from out of state to see him. His administrative staff (a lot of whom are new due to turnover) are pretty awful. Specifically just her. I think I need to work with someone else in the practice.

[quote="joecinq03"]Sounds like you need to find a new surgeon. Filing an appeal is very routine for any surgeons office which handles jaw surgery cases and this is a big red flag to me.[/quote]

[SantaBarbarian]

The funny thing is, the surgeon I'm seeing is literally the best in my part of the country. People drive hours and come in from out of state to see him. His administrative staff (a lot of whom are new due to turnover) are pretty awful. Specifically just her. I think I need to work with someone else in the practice.

Alf I feel for you... I'm 33 as well and we welcomed our first child into the world in February. I also had an underdeveloped jaw and went through two surgeries to removed a total of 4 premolars and 4 molars while growing up.

I hate to ask... does your underdeveloped jaw also cause sleep apnea problems? While my jaw was highly underdeveloped, I did not have the problems you mentioned in your original post. I have, however, had severe sleep apnea since I was a teenager and just didn't know it until about 4-5 years ago.

May I ask who your surgeon is? I've worked with three surgeons in California (one at UCLA, one at Stanford, and one in Santa Barbara; I ultimately had surgery with Dr. Gunson in Santa Barbara) and all three were surprised at how difficult my insurance was being (first one - the one at UCLA - was unsuccessful getting Cigna to authorize the surgery) but they did ultimately get Cigna to authorize it.

I forget what I wrote in my earlier post on this topic... but my recommendation is to look up your company's policy on jaw surgery and provide all the information they need. For me, it's the first link that appears when you google "Cigna jaw surgery policy":
https://cignaforhcp.cigna.com/public/co ... urgery.pdf
For Cigna, it's Coverage Policy Number 0209 ("CP0209" for short).

While I disagree with many of the criteria Cigna uses (they completely exclude Upper Airway Resistance Syndrome [UARS] for example), they do make it clear what criteria you must meet. You might have to google a few terms to understand WTH they are talking about, however.

You're probably already aware, in general, you must have a skeletal deformity (e.g., overjet of "just" 5 mm - sounds like you meet that criteria) combined with a functional impairment (Cigna's first bullet on this topic, on page 2, is "persistent difficulties with mastication" - sounds like you'd meet that criteria no problem).

Cigna's policies are pretty similar to policies from other insurance companies I looked at. If anything, I think you can count on Cigna's policies to generally be pretty strict. So "all" you should have to do is show Cigna you meet that criteria. For me, for the skeletal deformity (overjet of 5mm or more), Cigna required a "lateral cephalometric X-ray with tracings." This is essentially a side X-ray with someone drawing lines to represent your bones. Cigna only accepted the X-ray and the tracings that measured the overbite from my bone. And even then, they still rejected it for reasons unknown (well, we all know: they wanted to deny the surgery by any means possible). When pressured during an appeal and I pointed them to the specific information that was provided via a fax from UCLA on a specific date (I had a copy of the fax), they relented on that criteria. Proving my functional impairment (sleep apnea) was the most difficult part because I had three false negative sleep studies and they refused to look at the sleep study that showed there was a problem, despite the fact that they'd told me that they had reviewed "every page of every sleep study in detail" multiple times.

Good luck... I hope they've authorized it for you by now!

[SantaBarbarian]

P.S.

To be frank, the service by the staff at UCLA wasn't great (too many patients, not enough staff), but they never once said they weren't willing to file the appeal; it just took them a long time to do so. It's obviously your call if you want to continue working with the office you've been working with, find another provider, or try to submit the paperwork yourself.