Insurance Research Process & Recommendations

[aep4pDC]

Hi!

I will be having double jaw surgery early next year, and am starting the process of gathering information on insurance coverage. So, I was wondering what process you all used to determine what would be covered / not covered? I have the CPT codes and the related medical policy for insurance coverage, but it all still seems so subjective. For example, “Orthognathic surgery may be considered medically necessary for treatment of speech dysfunction that is directly related to a facial skeletal deformity, as determined by a speech and language pathologist (e.g., sibilant distortions, velopharyngeal distortion)”. My surgeon indicated in my initial consultation / write up that I have a skeletal deformity, and I met with a speech pathologist that indicated that I have speech dysfunction as a result of jaw position, so would I assume that I have met this criteria? There are other criteria in addition to this but I’m looking to make sort of a checklist to see what I have a write up for, or am missing.

I haven't called the insurance companies yet because I'm not sure what additional information they can provide me outside of what is indicated in the policy/coverage details, but maybe I should?

My surgeon does not participate with insurance but is willing to help me the necessary paperwork to get the most coverage possible. I have three different insurance plan options through my employer (BCBS PPO, Aetna PPO, Cigna PPO) that I can choose from so just looking for some guidance on how to do the in depth analysis to make a good decision for my pockets in 2017 . Any insight on your experience is greatly appreciated!

Thanks!

[sirwired]

A good start is Googling: "InsuranceProviderName Orthognathic Coverage Policy". That should give you the full details, including precisely which criteria you must meet. (Coverage outside those criteria is more difficult, but by no means impossible; you'll just have to file at least one appeal.)

NOTE: "BCBS" is not an insurance company; when Googling, you need to specify the precise BCBS affiliate your employer works with; they have different coverage policies.

I think I've seen two major "classes" of coverage policies: Skeletal discrepancy AND functional problem.... or Skeletal discrepancy OR functional problem. Cigna was an "AND" provider and denied me on round 1 (I had skeletal discrepancies, but no functional ones on their list.) I never appealed, because a year later my company switched to Anthem BCBS, which was an "OR" provider, and they approved easily.

[wcom939]

I would suggest doing research on the BCBS provider, they usually are the best bet when offered. I'm on bcbs throguh united, they are an "or" provider as well and even approved the genio for chin reconstruction after my surgeon appealed.

[LyraM45]

The insurance question is such a tough nut to crack because it's not cut and dry. Sure, you can get a plan that covers jaw surgery, but then if YOUR case will be covered is a question most of us can't answer. Hell, even your surgeon might have a hard time answering that. Each insurance company is different on what they deem medically necessary or not. Usually discrepancies over 5mm are considered surgery worthy by most insurances. Some of them want to see you try to remedy that discrepancy non surgically first though before approving surgery. If you are claiming sleep apnea they might make you show sleep study.

What is your bite looking like? How far are you off? When I went to surgeon/ortho they were all pretty unanimous saying I wouldn't be denied because my discrepancy was 8-10mm.

[kachalek]

I'm going through the same process and recently had my surgery (minus the genioplasty) pre-approved by my insurance company. I have Blue Cross Blue Shield of NE through an employer-sponsored plan.

The first thing to check is whether or not the insurance policy covers orthognathic surgery at all, as many policies exclude it entirely. You may need to check the 'Oral Surgery' section of your Explanation of Benefits if orthognathic surgery does not have its own section. If it IS a covered service, you then need to determine the qualifications for 'medically necessary.'

If your surgeon is willing to assist, it's often helpful to have them put together a pre-authorization letter to send to the insurance company, or at least have them assist you in drafting the letter. My surgeon did my letter for me, and included my measurements (my policy requires skeletal OR functional), the procedures to be performed, and the anticipated timeframe. The insurance company followed-up and requested my CT-Scan to confirm his measurements were indeed accurate, and approved the surgery itself and the hospitalization fees soon after. The entire process took about 5 weeks. My pre-approval is good for six months, and if I'm not ready for surgery by then, my surgeon's office will file an extension with the insurance company. It shouldn't be an issue, as long as my policy doesn't change in the next 6 months.

One helpful hint: My surgeon did NOT include the genioplasty in the pre-authorization letter because that is often a red flag (rightfully or not) for insurance companies that the procedure is cosmetic instead of medical. I am opting to do the genioplasty; however, I'm paying for it out-of-pocket and will be billed separately from both the surgeon and the hospital.

Good luck!