Okay, so I am new to this board, but I figured that this would be a perfect place to state my problem and receive advice. And I know it's kind of long, so I apologize!
I was referred to an oral surgeon by my orthodontist and dentist to get my underbite/crossbite (class 3) checked out while I was getting my wisdom teeth extracted.
The procedure they assigned me for is Treatment Code 21141: Reconstruct Midface, Lefort I, Single W/O Bone Graft.
The oral surgeon said it was a routine procedure and that it was a very easy job and that all it would take is the pre-approval by the insurance (Anthem) and then we could go ahead with it.
However, these are where the problems started to occur. It took the doctor 4 months before he sent the papers to our insurance company, during that time I called regularly and talked with one of his secretaries that promised regularly to get on his case and remind him to send them. During this time, I got oral casts and x-rays to send to them. As they were talking to the insurance company, I received a letter in the mail from them stating my surgery and saying that they need to review if the services were medically necessary and that I need to send them x-rays and oral casts. So basically, I had to keep calling and bugging him to send all that stuff in for weeks. Keep in mind, half the time, the receptionist transfers me to some person that's supposed to deal with these situations but I'm almost always left at a voicemail that never calls me back.
So the few times I did get in touch with this person, I kept stating my problem to her and she kept getting on the oral surgeon's case about it. He finally did all the paperwork and sent it and I got my decision in the mail last week. Basically, I got rejected by them because they said that "I do not have difficulty swallowing, speaking, or chewing" and thus my requested procedure is cosmetic and not a covered benefit.
However, this is simply not true as I do have problems, especially with chewing foods which can be a huge inconvenience. I don't understand if my doctor said that it would be easy to get this procedure done, why he couldn't explain to the insurance company that this procedure is not cosmetic. Was it to simply get money from the consultation, give me false hope, and then try to drag this situation on until I forget about it? Because it sure seems like it.
And now I'm at a standstill on what to do, because my oral surgeon's receptionist transfers me to some other person who never answers and I do not know whether to expect success through an appeal, because it seems as if Anthem is doing whatever possible to not pay for this operation. I am considering getting this procedure done by a different oral surgeon, one I can hopefully communicate more to, and one that has good reviews that will not only fix my jaw so I can live normally, but also look normal. I might have to do this operation in Korea, where it is cheaper if this insurance thing does not fall through.
Sorry that this whole explanation was so long, I just wanted to give some background info on my situation and I wanted to know a few things. 1. Some good oral surgeons near the area of Washington, DC.
2. Whether getting rejected by insurance is normal and whether an appeal has a good success rate.
3. Anything else you'd like to add since I do not know that much about jaw surgeries!
Thanks so much in advance,
Daniel
Looking for advice on my Jaw Surgery Procedure
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Re: Looking for advice on my Jaw Surgery Procedure
Daniel,
My surgery was initially approved by United Healthcare around the time I started with braces (early 2010). Then it was mysteriously not approved 6 months later when I was ready for surgery and had selected another surgeon.
Ultimately what it took -- after literally 3 months of nothing getting done -- was a peer-to-peer phone conversation, between my surgeon and the doctor at United Healthcare who made the determination. My surgery was then approved as medically necessary. I got nowhere when I was doing all the go-between calls with the insurance company and the surgeon's accounting/office team. The reality is that as a patient you aren't terribly important in the current health care system. You need a surgeon who can diagnose your condition accurately and document everything to make a compelling case.
Based on what you posted, I'd say you have the wrong surgeon. Find someone else, explain your symptoms, and ask the surgeon to submit the paperwork. I suspect that a lot of people actually want jaw surgery for the cosmetic aspect of it -- which is fine, but I understand insurers wouldn't want to pay for that. You'll need a diagnosis of a medically necessary condition, and a surgeon who will actually follow through on the insurance side.
Good luck.
My surgery was initially approved by United Healthcare around the time I started with braces (early 2010). Then it was mysteriously not approved 6 months later when I was ready for surgery and had selected another surgeon.
Ultimately what it took -- after literally 3 months of nothing getting done -- was a peer-to-peer phone conversation, between my surgeon and the doctor at United Healthcare who made the determination. My surgery was then approved as medically necessary. I got nowhere when I was doing all the go-between calls with the insurance company and the surgeon's accounting/office team. The reality is that as a patient you aren't terribly important in the current health care system. You need a surgeon who can diagnose your condition accurately and document everything to make a compelling case.
Based on what you posted, I'd say you have the wrong surgeon. Find someone else, explain your symptoms, and ask the surgeon to submit the paperwork. I suspect that a lot of people actually want jaw surgery for the cosmetic aspect of it -- which is fine, but I understand insurers wouldn't want to pay for that. You'll need a diagnosis of a medically necessary condition, and a surgeon who will actually follow through on the insurance side.
Good luck.
Re: Looking for advice on my Jaw Surgery Procedure
Yes getting rejected the first time is expected even for the cases that clearly medically necessary. I would appeal it yourself, figure out your insurance's procedure for the appeal process and send them all your x-rays, pics, teeth molds, etc as well as a letter outlining the functional reasons for the surgery. Be stern in the letter, they need to know you're not pursuing this for cosmetic reasons as you already know.
Btw, the same thing happened to me and after I appealed it myself my insurance pre-authorized me for the surgery. I actually made a thread about it recently.
Btw, the same thing happened to me and after I appealed it myself my insurance pre-authorized me for the surgery. I actually made a thread about it recently.
Re: Looking for advice on my Jaw Surgery Procedure
Daniel,
I'm in Northern Virginia. I was approved and my OS office has become the "funnel" for all Class 3 procedures in the northern va/dc area. They sent everything in for me, all I had to do was wait. Most offices in the area have moved away from doing these types of procedures because they're just not as profitable and doing wisdom teeth or implants. It just doesn't pay, so I've been told. If you need a great OS office, I'd called Fairfax Oral and Maxillofacial Surgery. I'd ask for Dr. Smith or Dr. Theberge (doing mine) for a consult, they have a lot of practice and experience
I'm in Northern Virginia. I was approved and my OS office has become the "funnel" for all Class 3 procedures in the northern va/dc area. They sent everything in for me, all I had to do was wait. Most offices in the area have moved away from doing these types of procedures because they're just not as profitable and doing wisdom teeth or implants. It just doesn't pay, so I've been told. If you need a great OS office, I'd called Fairfax Oral and Maxillofacial Surgery. I'd ask for Dr. Smith or Dr. Theberge (doing mine) for a consult, they have a lot of practice and experience
Re: Looking for advice on my Jaw Surgery Procedure
Thank you guys for the responses! Sorry for getting back to you guys late, I'm still out of the country. I will let you guys know of any updates as well.
Also, another thing I've failed to mention was that I've had braces for about 2 years, and the completion of my braces treatment is contingent upon getting this surgery done, because of the required 6 months of braces needed, post-op. That is why I need to get this surgery asap, because the longer I wait to get it, the longer my braces treatment extends.
Also, another thing I've failed to mention was that I've had braces for about 2 years, and the completion of my braces treatment is contingent upon getting this surgery done, because of the required 6 months of braces needed, post-op. That is why I need to get this surgery asap, because the longer I wait to get it, the longer my braces treatment extends.