Insurance Approval Question

[smylex]

Does anyone know how difficult it would be to get a prior approval from Blue Shield of California for orthognathic surgery, and what my primary care physician should tell the insurance company? She was at a loss of what to tell them when I went in for the referral today and it's the only thing setting me back on getting this started.

The last time I had my underbite measured was back in 1988 when I joined the US Navy at the age of 17 and it was 8 millimeters then. (I'm 39, now.) I can't remember the last time I was able to bite through my food with my front teeth and this underbite is now starting to cause other dental problems. Add to this, I'm also getting tired of the psychological effects this is having since people (including one dentist I had just met 10 minutes before) are constantly telling me that it makes me ugly.

Has anyone dealt with the insurance companies so I know what to tell them on appeal if they deny my request? I can afford the braces, but I can't afford the surgery as I have no credit to get a loan.

[Phantom Muse]

Goodness, that certainly is not kind to tell you that you your bite takes away from your appearance. Don't give that dentist a second thought!

I have Blue Cross/Blue Shield insurance in Illinois, and when anyone in my family needs something done, I simply call them directly myself and ask about what they will cover (based upon the doctor's diagnosis). I have been surprised at what they have covered (a portion of a dental implant for my husband - but not the thingy he needed to wear while waiting for the initial part of the procedure to heal, a portion of braces for my daughter, etc.) The representative has always been good about giving me as much information as I requested. In fact, on one occasion, our dentist's receptionist used the information I had gathered ahead of time to adjust the claim she submitted to the insurance company so they would cover more of the procedure. She said so much of what they do can be categorized in different ways depending upon the insurance company.

Perhaps do the leg work for your physician, and then ask that she make a claim based upon this information. If she was at a loss to help you initially, this can only help to secure coverage.

Good luck!

[Sunny]

Smylex ... I agree ... give that dentist a wide birth ... and anyone else who chooses to be so rude.

We, along with the surgeons, do most of the communicating with our patients insurance companies. The information is often being given verbally by their orthodontist and followed by a letter with all the technical jargon they require. I think you need to talk to the orthodontist you choose to make sure this is done correctly.

If you're wanting to check if you have cover to have surgery for this or that ... I think a phone call asking for that information should be sufficient. Then ask for the information to be emailed or snail mailed to you.

It's very important when dealing with insurance companies to be speaking the same language ... and that can be a major challenge. Good luck!

[smylex]

Looking over my medical insurance coverage, it says that it is covered in the case of medical necessity, though I'm responsible for the orthodontic portion and I can afford that thanks to the orthodontist I have picked. However, I was told that I would need prior approval to get the referral to the OMS. I've already spoken to the representative on the phone and she told me that with the things I had described to her, it will probably be approved.

It's probably the waiting and not knowing that are the hardest parts to deal with since I've been dealing with this for so long. I'm just trying to figure out what it is that my physician needs to tell them. She's seen my cephalometric x-ray (which I also have posted on my off-site blog) and is on my side, she's just at a lack of what to tell the insurance company.

[mikeg]

Hi THere. Too bad you didn't have it fixed while in the navy. It would of most likely been totally covered.

You will need to find a surgeon that really knows how to work insurance companies for approval. With today's healthcare system, it is becoming harder and harder to get these procedures covered. It is very unfortunate.

I have seen VERY SEVERE underbites/overbites that were not covered by insurance, so the patient had to take out a loan.

I also agree, don't let anyone tell you your bite makes you ugly or your appearance.. screw them.... If it bothers you that much, you may be lucky enough to get insurance to cover it, but don't count on it.

Good luck and keep us posted.

[kellieam1]

Smylex, there are "magic words" that your primary care doctor (not an orthodontist) needs to use to get this procedure medically covered. I have Blue Cross in Texas (as a state employee) so to get my son covered by my medical insurance, his pediatrician had to get the referral. It was a four-page letter, basically saying that the surgery was medically necessary. We got the referral and then when we went for the initial visit with the oral surgeon, Blue Cross sent me a bill for the full amount. I said "No, no, no, this is a covered visit." They corrected the billing. So, you definitely still have to watch. My son's orthodontics are covered by my dental insurance, so we're dealing with three doctors; luckily, they are easy to work with.

[smylex]

Thanks for the info kellieam1.

Part of the thing that irritates me is that I don't even know if I can even get the referral for the consultation with the OMS because my primary care physician doesn't know for sure what to tell the insurance company - she's never had to deal with this kind of thing before. I don't care to have to spend another $150+ (this doesn't count x-rays) to have the surgeon's consultation only to find out this isn't medically necessary. That's my primary concern. I'm pretty sure that my case may actually qualify and that's based on every dentist that has seen me as a patient or that I've worked with telling me that because of the severity, my underbite could only be corrected with surgery.

[smylex]

Good news today.

I called in to schedule an appointment for the consultation and told them that I would pay out of pocket if necessary. When I told the assistant what was going on with my referral and that I hadn't heard back about anything, she found out who my medical group was and checked through their website. I received the good news that I've been approved for my referral and I have my appointment for my consultation in 4 weeks.

So now, in addition to the dull pain in my TMJs, my cheeks hurt from smiling all day! I think I can live with that, though.

[Phantom Muse]

Smylex - Glad to hear it!

[mikeg]

great news... Keep your blog here as you go through this journey to help encourage others who are on the fence.

Good luck

[smylex]

Thanks mikeg.

Actually, I've started a miniature blog here since I'm keeping my main blog at smylex9.blogspot.com. That blog goes much more in depth with what I'm going through. Check out the blog I've started here if you want to see the cephalometric radiograph and outline I got. Reactions to the x-rays have been pretty interesting from my co-workers.

[saba360]

I've been in braces for almost 8 months and am hoping to have my surgery in June (fingers crossed!) I'm seeing a great surgeon at UCSF and have student health insurance through BCBS CA.

My surgery is mandibular advancement. I've done a little research and the two things insurance wants to know before approval is 1) is there a functional problem? and 2) is there a structural problem? Both of those elements have to be present.

The link below gives precise definitions of what Anthem (this is what BCBS is called in CA) counts for each of these:

SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery

I'm 28 now and was first told I would need surgery when I was about 10. As far as steps go, this is exactly what I've done so far:

1) Went to 3 orthodontists all of whom independently agreed I would need a combination of extractions, orthodontics and surgery to solve my problem.
2) Picked an orthodontist
3) Obtained a referral to see an oralmaxiolfacial surgeon that was in-network but submitting to the insurance rep at my school a letter from my orthodontist, molds, and x-rays.
4) Saw the surgeon my ortho recommended
5) She did a work-up and basically told me that the way the insurance approval goes, she does not guarantee that I will be covered for the surgery, but in her opinion it is medically necessary situation. She told me the insurance will review your case before you've had orthodontic work, but they really don't approve them that early because your case for medical necessity is strongest after you've had orthodontic work.
6) Leap of faith. Trusting my (amazing) doctors' expertise and reps I went with what they had to say and got started on extractions, braces, etc.
7) Saw my surgeon at the 7 month mark, she says I'm almost ready. She's going to get started on my insurance work.

Anthem reviews all pre-service medical claims within 5 days of receipt and will call your doctor w/in 24 hours of making a decision. If the first person rejects it based on the #'s, it goes to a reviewer who has the same title as the clinician requesting the procedure (so if the standard claim rep rejects my oralmax surgeon's request, it automatically goes to the insurance's oralmax surgeon reviewer-a peer review in other words) who will call to discuss your case with your provider. Your surgeon should be familiar with the criteria the insurance co uses to make their decision.

That's alotta info! But I hope it helps. Good luck, you won't believe how quickly the whole thing goes once you get started!

[saba360]

Aaaand here's to scrolling to the bottom before writing a lengthy reply!

[smylex]

Thank you, saba360! This is exactly what I've been looking for.

I think I'll be covered as a medical necessity since I fall under #4 (masticatory dysfunction or malocclusion) as well as several of the discrepancies listed, i.e. maxillary/mandibular incisor relationship, open bite, Maxillary/Mandibular anteroposterior molar relationship discrepancy and others, as well as the constant ache in my TMJ and the muscles in that area. I'm still waiting for my consultation with the surgeon. That appointment is in 3 weeks from today.

What doesn't make sense to me is step #5, especially since I've read that many insurance companies will deny a claim if orthodontic work has already been started.