BCBS and unrealistic criteria

[madblogr]

I have BCBS Michigan and the pre-approved my surgery first but then after surgery denied paying the claim stating it was cosmetic. I spoke with surgeon since whole reason to get the jaw surgery was due to criteria backed by diagnosistic test results. Surgeon's office had it addressed and resolved that same week. Good luck with getting your appeal approved. If you have to, hopefully you have third party arbitration in your state for insurance billing issues.

[pechellaa]

My perseverance paid off! I sent my appeal in around Oct. 22, finally got a response today, and all services have been approved!
Since my bite is severe enough and I suffer from so many other issues, they basically disregarded the malnurishment part.
yyaassss!!

[pechellaa]

[quote="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 [/quote]

Hopefully you've had some luck! I feel like the "or" part of your policy could make things go much more smoothly than my case has. Even if it doesn't, definitely take your appeal process seriously. I've gone over nearly every post on this board (obsessively.. maybe..) and damn near most of them had luck after!

[madblogr]

My perseverance paid off! I sent my appeal in around Oct. 22, finally got a response today, and all services have been approved!
Since my bite is severe enough and I suffer from so many other issues, they basically disregarded the malnurishment part.
yyaassss!!

Awesome news, congrats on winning the appeal!

[shortcircuit]

Hopefully you've had some luck! I feel like the "or" part of your policy could make things go much more smoothly than my case has. Even if it doesn't, definitely take your appeal process seriously. I've gone over nearly every post on this board (obsessively.. maybe..) and damn near most of them had luck after!

Congratulations on your successful appeal!

It looks like a certain number of claims get denied initially "just because," I hope they're not playing games like what typically happens with product rebates but it sure looks like it sometimes. My case has been going nowhere for a while, I haven't even been able to get an OMS consult yet because of my crazy work/school schedule but that is coming as soon as the semester ends in a couple of weeks. Since they accept measurements only I don't anticipate any issues with that, I didn't clarify it during the ortho consult but I thought he said I have a negative overjet of >14mm which is far beyond a borderline case

I'm an engineer, so I expect lots of numbers during the OMS consult

Best of luck with your surgery, let us know how it goes

[snapdresser]

I'm an engineer, so I expect lots of numbers during the OMS consult

I'm an engineer too and found the numbers from my OMS consult pretty underwhelming until I got the VSP .pdf from my surgeon. THEN I got all the details

[shortcircuit]

Update: OMS says that he hasn't had any major issues with getting jaw surgeries approved through Anthem BC. He said that in my case he is going to submit the materials for the pre-authorization right away and then to let it expire, because it's easier to get it renewed once it's been approved, instead of taking the risk of a denial when already ready for surgery along with an unknown amount of delay.

The 14.4mm figure was something else (which I thought), I still have plenty of ammo though because my negative overjet is approximately -8mm and they accept any negative amount.

[sirwired]

It's important to know that there is no single "BCBS". The Blue Cross / Blue Shield Association is a loose collection of individual insurance companies spread out all over the country. They share a common physician's network, and that's about it. They have differing coverage policies that the "national" BCBS has nothing to do with.

Anthem BCBS has the "OR", other plans have the "AND. Speaking for myself, I was on Cigna (which was an "AND" carrier), was denied. Work changed carriers to Anthem, and the surgery was quickly approved.

[LyraM45]

My perseverance paid off! I sent my appeal in around Oct. 22, finally got a response today, and all services have been approved!
Since my bite is severe enough and I suffer from so many other issues, they basically disregarded the malnurishment part.
yyaassss!!

Awesome news!!!

[Lala082008]

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?

LyraM45: Wow, that's great to hear. I too have BCBS FEP, and reading the plan brochure I got worried because it doesn't even talk about covering jaw surgery because of discrepancies, TMJ, etc. Do you happen to know if the plan varies by state? Any info you have about getting the approval from them would be awesome. I have my appointment coming up in a few weeks, and after that my dr is going to submit the preapproval.

[snapdresser]

LyraM45: Wow, that's great to hear. I too have BCBS FEP, and reading the plan brochure I got worried because it doesn't even talk about covering jaw surgery because of discrepancies, TMJ, etc. Do you happen to know if the plan varies by state? Any info you have about getting the approval from them would be awesome. I have my appointment coming up in a few weeks, and after that my dr is going to submit the preapproval.

Yep, it varies by state. What state are you in? I have Empire BCBS FEP (New York) and had no issues at all.

[Lala082008]

LyraM45: Wow, that's great to hear. I too have BCBS FEP, and reading the plan brochure I got worried because it doesn't even talk about covering jaw surgery because of discrepancies, TMJ, etc. Do you happen to know if the plan varies by state? Any info you have about getting the approval from them would be awesome. I have my appointment coming up in a few weeks, and after that my dr is going to submit the preapproval.

Yep, it varies by state. What state are you in? I have Empire BCBS FEP (New York) and had no issues at all.

I'm in NC. I've tried like crazy to figure out what they'll cover, but the plan brochure is really vague. And when I tried calling the insurance company they had no idea what I was asking -- they actually told me I don't need prior approval, which I know is wrong.

[snapdresser]

I'm in NC. I've tried like crazy to figure out what they'll cover, but the plan brochure is really vague. And when I tried calling the insurance company they had no idea what I was asking -- they actually told me I don't need prior approval, which I know is wrong.

The plan brochures rarely address orthognathic surgery directly. BCBS NC has a separate document that states their specific policy pertaining to orthognathic surgery. Lucky day, I have a little experience with this so I was able to track it down. Here it is:
http://www.bcbsnc.com/assets/services/p ... urgery.pdf

Hope it contains good news for your case!

[Lala082008]

I'm in NC. I've tried like crazy to figure out what they'll cover, but the plan brochure is really vague. And when I tried calling the insurance company they had no idea what I was asking -- they actually told me I don't need prior approval, which I know is wrong.

The plan brochures rarely address orthognathic surgery directly. BCBS NC has a separate document that states their specific policy pertaining to orthognathic surgery. Lucky day, I have a little experience with this so I was able to track it down. Here it is:
http://www.bcbsnc.com/assets/services/p ... urgery.pdf

Hope it contains good news for your case!

Thanks very much. Do you think the criteria for BCBS NC are the same even if you have FEP? I have my surgeon's appointment on Monday -- so hopefully I'll get some good news about my surgery date then!

[snapdresser]

Do you think the criteria for BCBS NC are the same even if you have FEP?

Yes. I have FEP BCBS too, but I'm in NY. Good luck at your appointment! If you meet the criteria in that document, I wouldn't take 'no' for an answer, even if it means going to another surgeon.