Re: Pre-authorization declined

[Guest guest]

Hi nne,

That is ridiculous. It amazes me that they can decline you for a

procedure even if it is medically necessary because it is performed by

an oral surgeon.

Definitely start the appeals process. Here is a link to

Fiddlestick's website. She has some information on how to deal with

insurance companies and appeals

http://www.geocities.com/orthognathicinfo/insurancefaqs.html

[Guest guest]

Hi nne,

I'm & was scheduled for a phase I of two part surgey, phase I

being SARPE. My employer is changing insurances also eff 6/15 to

UHC. The first surgery would have been handled under my current

which is Principal. They even approved both procedures because at

the time we did not know we were changing plans. I found out Friday

UHC will probably not cover any of the surgery because they have

massive oral surgery exclusions & I should " probably go ahead with

the surgery and then their Medical Review Board of Nurses will deem

whether it was medically necessary or cosmetic. Despite all the

letters from my orthodontist, oral surgeon, & from Principal where

they approved it. So I am in limbo also. I will fight UHC to the

very end. So if you hear of someone being arrested for being a big

mouth against UHC, it is probably me. Because I will not let this

rest. I will get very TV station, every newspaper, every TV talk

show involved if I have to. I have massive bone loss in my jaws

because of the deformity since I was born. If I don't have the

surgery, in about 10 years, I won't have tooth left in my head. But

I guess they don't care. I will keep you posted. Good Luck.

> Hi everyone,

>

> I'm new to the group, I found it when looking for information on

> health insurance companies denying pre-authorization for this

> orthognathic surgery.

>

> I have been in braces since January 2002. When I made the decision

> to get this done, I was insured with Cigna, and checked into

> everything before I made my final decision. Well, I was laid off,

> and found a new job, UHC is my medical insurance. In February my

> surgical coordinator sent in the study models and everything needed

> for pre-approval via UPS. 3 weeks ago I called UHC and they claimed

> that they did not have anything. The surgical coordinator called,

> and they did not have anything. After a lot of back and forth we

> couriered the stuff to UHC again. 1 week later I got a letter from

> them telling me that this is not a covered procedure because it is

> done by an oral surgeon and dental procedures are not covered even

> if medically necessary.

>

> I'm at a loss as to what to do if they stick to that decision. I

> will of course file an appeal, I have appointments with my MD and

my

> Gastroenterologist to get letters detailing on how this is

effecting

> my health. I don't know if they will do any good, I am really

> depressed and desperate right now. Did I spend all this money for

> orthodontia for nothing? Was all this pain for nothing? I can't

> afford 30k for surgery, there is no way.

>

> Does anyone have experience with this? Maybe with UHC specifically?

>

> nne

[Guest guest]

nne--

See my post #38884 regarding my experience with UHC.

> Hi everyone,

>

> I'm new to the group, I found it when looking for information on

> health insurance companies denying pre-authorization for this

> orthognathic surgery.

[Guest guest]

-nne, I had to go through 3 appeals but finally won. Don't give

up. Make sure you get the terms of your policy, the definitions of

" medically necessary " , " exclusions, etc.' Look for " skeletal

abnormalities " . Seek an attorney who can help if you must. But

definitely don't give up. Hopefully your surgeon and ortho may be of

assistance.

Mine was denied because of medical necessity, but if you look close

enough into your policy, I'll bet you have a great chance. I felt

like you too, depressed, as I had started braces and thought what on

earth can I do now? I've already started this.

Hang in there and best of luck. Any help you need, just ask. Donna

-- In orthognathicsurgerysupport@y..., " ml_bowen " <mbowen58@m...>

wrote:

> Hi everyone,

>

> I'm new to the group, I found it when looking for information on

> health insurance companies denying pre-authorization for this

> orthognathic surgery.

>

> I have been in braces since January 2002. When I made the decision

> to get this done, I was insured with Cigna, and checked into

> everything before I made my final decision. Well, I was laid off,

> and found a new job, UHC is my medical insurance. In February my

> surgical coordinator sent in the study models and everything needed

> for pre-approval via UPS. 3 weeks ago I called UHC and they claimed

> that they did not have anything. The surgical coordinator called,

> and they did not have anything. After a lot of back and forth we

> couriered the stuff to UHC again. 1 week later I got a letter from

> them telling me that this is not a covered procedure because it is

> done by an oral surgeon and dental procedures are not covered even

> if medically necessary.

>

> I'm at a loss as to what to do if they stick to that decision. I

> will of course file an appeal, I have appointments with my MD and my

> Gastroenterologist to get letters detailing on how this is effecting

> my health. I don't know if they will do any good, I am really

> depressed and desperate right now. Did I spend all this money for

> orthodontia for nothing? Was all this pain for nothing? I can't

> afford 30k for surgery, there is no way.

>

> Does anyone have experience with this? Maybe with UHC specifically?

>

>

[Guest guest]

hi dolfan,

I live in texas and i had united health care and i was approved for

the surgery with no problem at all. actually i was very surprised it

went so smoothly since i see how so many people get rejected. i had

my surgery in janurary and they paid 100 percent of everything.

I have heard that with this procedure each state has its own rules

about this surgery. i hear that in texas its easier to get approved

here than some other places.

i would certainly continue trying or maybe you can work something out

with your surgeon and the hospital to negotiate the price of the

surgery if you pay out of pocket.

good luck.

mike.

-- In orthognathicsurgerysupport@y..., dolfan11661 <no_reply@y...>

wrote:

> -nne, I had to go through 3 appeals but finally won. Don't

give

> up. Make sure you get the terms of your policy, the definitions of

> " medically necessary " , " exclusions, etc.' Look for " skeletal

> abnormalities " . Seek an attorney who can help if you must. But

> definitely don't give up. Hopefully your surgeon and ortho may be

of

> assistance.

>

> Mine was denied because of medical necessity, but if you look close

> enough into your policy, I'll bet you have a great chance. I felt

> like you too, depressed, as I had started braces and thought what

on

> earth can I do now? I've already started this.

>

> Hang in there and best of luck. Any help you need, just ask. Donna

> -- In orthognathicsurgerysupport@y..., " ml_bowen " <mbowen58@m...>

> wrote:

> > Hi everyone,

> >

> > I'm new to the group, I found it when looking for information on

> > health insurance companies denying pre-authorization for this

> > orthognathic surgery.

> >

> > I have been in braces since January 2002. When I made the

decision

> > to get this done, I was insured with Cigna, and checked into

> > everything before I made my final decision. Well, I was laid off,

> > and found a new job, UHC is my medical insurance. In February my

> > surgical coordinator sent in the study models and everything

needed

> > for pre-approval via UPS. 3 weeks ago I called UHC and they

claimed

> > that they did not have anything. The surgical coordinator called,

> > and they did not have anything. After a lot of back and forth we

> > couriered the stuff to UHC again. 1 week later I got a letter

from

> > them telling me that this is not a covered procedure because it

is

> > done by an oral surgeon and dental procedures are not covered

even

> > if medically necessary.

> >

> > I'm at a loss as to what to do if they stick to that decision. I

> > will of course file an appeal, I have appointments with my MD and

my

> > Gastroenterologist to get letters detailing on how this is

effecting

> > my health. I don't know if they will do any good, I am really

> > depressed and desperate right now. Did I spend all this money for

> > orthodontia for nothing? Was all this pain for nothing? I can't

> > afford 30k for surgery, there is no way.

> >

> > Does anyone have experience with this? Maybe with UHC

specifically?

> >

> >

[Guest guest]

I would like to thank everyone who responded to my e-mail. I am so

frustrated right now, but I will beat this. I will take them to court if I

have to. I know that I have lived 40 years with this, but I am not willing

to live with it for the rest of my life.

I found a sentence in the covered health services section of my health plan

that should be the one that gets this taken care of, I think:

Surgery and anesthesia in a hospital ... for a covered person who has one or

more medical conditions and requires admission to a hospital or alternate

facility and general anesthesia for dental treatment (if provided under the

direction of ap physician or dentist and not the treatment of dental

disease).

Doesn't this say that if someone is sick and needs dental treatment in a

hospital it is covered?

Sigh ... the way they write these, so confusing.

nne

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[Guest guest]

--

That is a tiny bit confusing. It says you have to have one or more

medical condition(s). How is medical condition defined? I think

maybe an attorney can help decipher that more. I just don't know.

Good luck, Donna

- In orthognathicsurgerysupport@y..., " MARIANNE BOWEN " <mbowen58@m...>

wrote:

>

> I would like to thank everyone who responded to my e-mail. I am so

> frustrated right now, but I will beat this. I will take them to

court if I

> have to. I know that I have lived 40 years with this, but I am not

willing

> to live with it for the rest of my life.

>

> I found a sentence in the covered health services section of my

health plan

> that should be the one that gets this taken care of, I think:

>

> Surgery and anesthesia in a hospital ... for a covered person who

has one or

> more medical conditions and requires admission to a hospital or

alternate

> facility and general anesthesia for dental treatment (if provided

under the

> direction of ap physician or dentist and not the treatment of dental

> disease).

>

> Doesn't this say that if someone is sick and needs dental treatment

in a

> hospital it is covered?

>

> Sigh ... the way they write these, so confusing.

>

> nne

>

> _________________________________________________________________

> MSN Photos is the easiest way to share and print your photos:

> http://photos.msn.com/support/worldwide.aspx

>

>

> [Non-text portions of this message have bee

[Guest guest]

I dunno about the definition part, but my surgeon put a lot of

emphasis on " correcting a skeletal dysplasia. " I'd think your stomach

trouble would be enough, but who knows the minds that govern

insurance policies?

Good luck!

Cammie

> > [Non-text portions of this message have bee