BCBS and unrealistic criteria

[pechellaa]

I'm new to this board, and desperate for help.

My name is Chelsea, I'm 22 and have had my braces on for about 2yrs and 4 months. This entire time I've been setting up for surgery to fix my class 3 malocclusion (underbite) and fighting with insurance companies the whole way. I have a 9-10 AP discrepancy, with my lower jaw 4mm to the left as well. I've had problems eating since I was a child, and have also started choking on food due to not being able to properly chew or chewing until the point of exhausting my facial muscles. Also suffering with symptoms associated with tmd, but those aren't quite so severe, so it has been included much in my records or to the insurance company.

I'm insured thru bcbs ppo of Montana. For me to be covered, it needs to be medically necessary. So my plan says.... significant functional impairment, defined as persistent difficulties with mastication and swallowing as manifested by inability to incise and/or chew solid foods, choking on incompletely masticated solid foods, damage to soft tissue during mastication; malnutrition; significant weight loss; failure-to-thrive
AND an AP discrepancy of 5mm or more.

My preauthorizaton claim has been denied TWICE. Once for old records and most recently, because I'm not suffering from malnurishment; significant weight loss or failure to thrive. But I fit all other criteria! There's no logical reason that I would be suffering from those 3 things, ive found ways to adapt throughout my entire life. But I'm in pain, and I have so much trouble eating; there has got to be some way around this. Anyone ever had a similar experience? Or some advice on my next move? Currently working on my appeal...

[snapdresser]

You need a good letter from your surgeon. The insurance people at your surgeon's office SHOULD be good at drafting up exactly what they need to say to get it approved (calling out which criteria you meet and saying that they consider it medically necessary). Your words alone might not do the trick. You shouldn't have to go through this alone tho... If your surgeon's office is worth their salt, they should be handling it.

[pechellaa]

They have done this; the first denial, they did a peer to err review. after the second denial the insurance advisor for their office said there was nothing left for them to do.
:c

[pechellaa]

[quote="pechellaa"]They have done this; the first denial, they did a peer to peer review. after the second denial the insurance advisor for their office said there was nothing left for them to do.
:c[/quote]

[snapdresser]

They have done this; the first denial, they did a peer to err review. after the second denial the insurance advisor for their office said there was nothing left for them to do.
:c

If you meet the criteria and the insurance advisor hasn't been able to adequately communicate that to your insurance, then the insurance advisor should be out of a job. You should complain to your surgeon. That said, what do they say when you call your insurance and ask what the issue is? In my experience with BCBS the telephone reps are super knowledgeable and trying to help the customer, not screw them (tho maybe that changed with Obamacare?).

[pechellaa]

[quote="snapdresser"][quote="pechellaa"]They have done this; the first denial, they did a peer to err review. after the second denial the insurance advisor for their office said there was nothing left for them to do.
:c[/quote]

If you meet the criteria and the insurance advisor hasn't been able to adequately communicate that to your insurance, then the insurance advisor should be out of a job. You should complain to your surgeon. That said, what do they say when you call your insurance and ask what the issue is? In my experience with BCBS the telephone reps are super knowledgeable and trying to help the customer, not screw them (tho maybe that changed with Obamacare?).[/quote]

I've called a couple times and they do sound helpful but i usually get the same kind of answers to all my questions. They repeat back the denial letter, explain how to find the policy's, and how to appeal.

[kpw818]

I had trouble with BCBS in Colorado. I meet their measurement requirements and they denied it flat out. Appealed once, denied again. Got a new job and new insurance. Surgery is in two weeks.

I think it is ridiculous how problematic the insurance companies are for this surgery. Even some minor issues can turn major after several years. It was so frustrating being told that my medical issue wasn't worth their time. Really wasn't happy with them. I can literally not chew on the majority of my teeth, save for the two back on the left side (my bite slides off on the right side due to crossbite).

I hope you get things sorted out. I would say check out another insurance company, if you can. Or, work with a different surgeon who might provide a stronger case.

[snapdresser]

I had trouble with BCBS in Colorado. I meet their measurement requirements and they denied it flat out. Appealed once, denied again. Got a new job and new insurance. Surgery is in two weeks.

Wow, that's nuts... I got mine approved by BCBS NY first try, but my letter was drafted by one of the top surgeons in my area. This was in early 2015. Crazy to think that experiences vary so much.

[LyraM45]

I know it varies from state to state, but I had zero issues with BCBS federal employee program. I was measuring 9mm with discrepancies in every direction possible though. Like, my surgeon didn't even bother doing a pre auth for me until 2 weeks before surgery because they knew it was going to go straight through. Are you sure your surgeon has sent everything? And you're not below any of their magic numbers for anything?

[kpw818]

I had trouble with BCBS in Colorado. I meet their measurement requirements and they denied it flat out. Appealed once, denied again. Got a new job and new insurance. Surgery is in two weeks.

Wow, that's nuts... I got mine approved by BCBS NY first try, but my letter was drafted by one of the top surgeons in my area. This was in early 2015. Crazy to think that experiences vary so much.

Yeah I think it varies by state and by plans within the state (depending on the organization). I don't know how Colorado BCBS is outside of my former workplace. It is crazy though--wish things were just standard across the companies (at least!)

[wcom939]

I got approved by BCBS NY (Empire Plan) on the 2nd try, my surgeon or his staff knew exactly what to write and originally they denied it claiming that the jaw cant and misalignment needed to be as a result of a birth defect or accident. BCBS approved it on appeal, I didnt have to do anything my surgeon or his staff did all the communication.

One thing to point out is that not all BCBS plans are created equal, most BCBS plans have an underlying company that manages them. In my case the underlying company was United Healthcare, but I believe in other states you might have Anthem, Aetna, or Kaiser underwriting them. Each of these insurance companies has their own rules for what constitutes the need for this surgery.

Ultimately if your surgeon or his staff are experienced they should be able to communicate with the insurance company effectively the need for the surgery as long as it's not for a pure cosmetic reason.

My surgeon for example even got BCBS to approve the chin genioplasty because my bottom jaw was shifted to the right 2 mm and empire decided to cover it, in the end I didnt need the genioplasty but they still covered it in the event it was performed.

What I would first do is see who the manager of your BCBS plan is, if it's Anthem or United they should be pretty easy to deal with, if it's Aetna or Kaiser I hear they are harder to deal with.

[Marchi31]

kpw818, I hope your surgery went well today!!! Prayers your way
If you don't mind me asking, which city in Colorado are you doing your surgery at? Im also from Colorado & have BCBS so reading your posts kinda scared me now. My surgery is not till some time next year, but would b nice to b mentally prepared for any insurance issues..Im in the position now where I can switch jobs too if needed all depending on this surgery. And do you know what is the earliest my surgeon can start issuing claims to the insurance prior to surgery. I am just 1 month being in braces, have ways to go but still..
Wish you an uneventful recovery, & no rush replying to me back, take care of yourself first!!!

[shortcircuit]

Following this with interest; I have Anthem BC PPO in California and their medical policy for orthognathic surgery has pretty much the same language, except for the lovely word "OR" instead of "AND," so it looks like measurements will hopefully be sufficient. I did e-mail them recently and they said that the surgery is a covered benefit under my insurance plan, of course getting them to actually approve it seems like a completely different ballgame

[LyraM45]

Following this with interest; I have Anthem BC PPO in California and their medical policy for orthognathic surgery has pretty much the same language, except for the lovely word "OR" instead of "AND," so it looks like measurements will hopefully be sufficient. I did e-mail them recently and they said that the surgery is a covered benefit under my insurance plan, of course getting them to actually approve it seems like a completely different ballgame

Funny you bring in Anthem BC because I can speak about them too. I have Anthem BC in CA as secondary to my BCBS and they also covered me no questions asked. It's the PPO option, I think. So between BCBS primary and Anthem BC secondary in CA, both chipped in full on for me no questions asked. Between the two I've been out very little for my surgery (less than $1000 for surgeon, anesthesia, hospital, etc).

[shortcircuit]

Following this with interest; I have Anthem BC PPO in California and their medical policy for orthognathic surgery has pretty much the same language, except for the lovely word "OR" instead of "AND," so it looks like measurements will hopefully be sufficient. I did e-mail them recently and they said that the surgery is a covered benefit under my insurance plan, of course getting them to actually approve it seems like a completely different ballgame

Funny you bring in Anthem BC because I can speak about them too. I have Anthem BC in CA as secondary to my BCBS and they also covered me no questions asked. It's the PPO option, I think. So between BCBS primary and Anthem BC secondary in CA, both chipped in full on for me no questions asked. Between the two I've been out very little for my surgery (less than $1000 for surgeon, anesthesia, hospital, etc).

Great to hear a success story, I'll be on the hook for quite a bit more in my case because I have just the Anthem BC with a $3500 yearly out of pocket max. My "sentencing hearing " is this coming Friday.....if they say I'm going to need a SARPE to even get started, then I'm going to be hitting that twice given the typical timespan between that and a LeFort, plus another issue of whether or not there are any OMS's around here who are in-network on my plan.