Monday, December 10, 2007

Insurance Woes ...

And so the process begins … my OS’ office submitted the paperwork to insurance at the end of July. After much back and forth between the insurance company, my OS’ office and my OD’s office to receive X-ray, molds, etc., I finally received a response on September 20th, stating coverage denied. The most disturbing part of the denial letter was that my case was reviewed by “a physician reviewer specialized in general surgery”. The surgery was deemed cosmetic because the physician specialized in general surgery did not feel that the proposed procedures would alter my documented symptoms.

So thus began my appeal. Since my meeting mid-July with my treatment coordinator, I had begun to do extensive research on the surgery as well as insurance. I pretty much expected a denial letter, so I wanted to understand what insurance companies look for to make sure that my appeal was as complete as possible. Two sites (The orthognathic surgery support site on Yahoo and the Archwire site) have been very helpful to me in understanding what patients go through, the risks involved, the rollercoaster of emotions through this process, the ins-and-outs of the insurance process (thanks Shayna :)), and tons of questions to ask my OS and OD on how specifically things apply to my situation.

I learned the following relative to the appeal:

*Request review by an Oral and Maxillofacial surgeon specialized in these procedures, they are the only professionals qualified to make a determination in your case.
*Outline that the condition is caused by a congenital deformity and the purpose of the procedure is to control pain and minimize further deterioration.
*Send a letter from your OS, your OD, and yourself (it is best if these letters arrive together)
*Establish medical necessity. Outline all problems that have been caused by your malocclusion (in my case, wearing of the condyles, TMJ dysfunction, lower incisor wear, migraine headaches).
*Illustrate the potential complications if you do not have the surgery (such as tooth loss, further degeneration of the condyles, increased TMJ dysfunction, continuation of migraines)
*Explain that you understand that the surgery may not cure TMJ dysfunction, but correcting the malocclusion may lead to improved symptoms.
*Show that non-surgical treatment (conservative treatment) was unsuccessful.
*Make reference to any other health professionals you have visited to improve symptoms (migraine specialist, chiropractor, etc.)

The letter from my OD was brilliant. It was very detailed and addressed many of the points listed above. My OS’ letter was much shorter and to the point, but it did the trick! I received the approval on November 9th for my upper and lower jaw surgeries. The genio was denied (this was expected) along with the temporary anchoring devices, which were considered “unbundled” from the main surgery.

1 comment:

Anonymous said...

Hi, Stephanie,

I am writing a letter to the state insurance commissioner to try to get BlueCross/BlueShield to change its coverage to include orthognathic surgery, which currently is denied outright.

Would it be possible for you to e-mail me your doctor's letter that you mentioned was brilliant?