Re: I just LOVE the insurance hassle....not!

[Guest guest]

Thanks, Cammie,

1st) Yep, it's the medical unfortunately.

2nd) I will do that. The girl I am dealing with at the surgeon's

office doesn't seem to have much experience with CIGNA. Maybe

someone else there can help me.

3rd, 4th and 5th) Great ideas, I will try that.

This is so frustrating, and I can choose to say " forget it " and still

register for classes this semester until Monday. (I took this

semester off for the surgery). I am just ready to do that. But then

again that is what they are hoping on. I don't want to get the

braces taken off in August (like they were supposed to be) without

getting the surgery done, because then I know I will never get it

done. I also don't want to end up keeping them on for an extra year!

Ok, enough whining, I will just have to deal with whatever happens

and go on. I will keep you all posted,

> > Hi Everyone,

> >

> > Just a quick question. Has anyone ever gotten approval for this

> > surgery even though it is specifically listed under general

> > exclusions in your policy? I have just under 3 weeks to go

before

> a

> > surgery date of 1/27, which my husband's COBRA coverage was

> supposed

> > to cover. The insurance company is still giving me the

runaround,

> > and then of course, January started, and now our out of pocket

max

> > for the year is $6000 instead of $3000, so I have to pay an

> > additional $3000 for my surgery if it is even approved. (Out of

> > network surgeon (there are no in-network surgeons in my area),

he's

> > only covered at 65%, and the hospital is at 85%) So....(are you

all

> > following me here:-)?) my insurance plan through my employer

> starts

> > on Feb. 1st. It specifically excludes " Orthognathic

reconstructive

> > surgery " . I spoke to the insurance agent, and he told me that

> > sometimes even excluded things get covered. He has offered to

help

> > in any way possible. I just don't know whether to go through

with

> > the surgery in January (if it even gets approved), or to save the

> > $6000 and wait until February to try.

> >

> > Anyone have any suggestions, or experience with this?

> >

> >

[Guest guest]

I did - orthognathic surgery was specifically not covered under my

policy. I found a way around it and used reconstructive surgery as

my angle instead (which was a covered surgery) and gave supportive

evidence why I needed to have this done and why what I was doing was

reconstructive. My insurance company also said that even though a

plan specifically excludes something doesn't always mean that they

won't cover it under every circumstance - each case is individual

and if you have a good case - very likely that you can get it

covered - I had to go through the appeals process, write a few

letters, make a million phone calls and send in x-rays and molds.

Use your agent - get a copy of the plan and find out what they do

cover and see if something fits what you are planning on having done.

> Hi Everyone,

>

> Just a quick question. Has anyone ever gotten approval for this

> surgery even though it is specifically listed under general

> exclusions in your policy? I have just under 3 weeks to go before

a

> surgery date of 1/27, which my husband's COBRA coverage was

supposed

> to cover. The insurance company is still giving me the runaround,

> and then of course, January started, and now our out of pocket max

> for the year is $6000 instead of $3000, so I have to pay an

> additional $3000 for my surgery if it is even approved. (Out of

> network surgeon (there are no in-network surgeons in my area),

he's

> only covered at 65%, and the hospital is at 85%) So....(are you

all

> following me here:-)?) my insurance plan through my employer

starts

> on Feb. 1st. It specifically excludes " Orthognathic

reconstructive

> surgery " . I spoke to the insurance agent, and he told me that

> sometimes even excluded things get covered. He has offered to

help

> in any way possible. I just don't know whether to go through with

> the surgery in January (if it even gets approved), or to save the

> $6000 and wait until February to try.

>

> Anyone have any suggestions, or experience with this?

>

>

[Guest guest]

I must say, that with my upcoming surgery less than 2 months away,

this board has been great AND terrible at the same time. Kidding of

course. The experiences I've read have been so informative...however,

this business with the insurance claims are miserable. My surgeons'

office just called for pre-cert on Tues 1/6. I have UHC and based on

what I've read, I'm almost expecting them to DENY me (upper & lower).

However, after reading my coverage manual, the exclusion reads as

follows: " Plastic surgery, reconstructive surgery, cosmetic surgery,

or other services and supplies that improve, alter, or enhance

appearance, whether or not for psychological or emotional reasons,

EXCEPT TO THE EXTENT IT IS NEEDED TO IMPROVE THE FUNCTION OF A BODY

PART or repair an injury that occurs while the person is covered

under the plan. "

Based on how the above reads, I would assume that I should be

ok...but was just wondering if anyone's manual read the same and what

their experience was with UHC? Please advise?

Thanks,

> > Hi Everyone,

> >

> > Just a quick question. Has anyone ever gotten approval for this

> > surgery even though it is specifically listed under general

> > exclusions in your policy? I have just under 3 weeks to go

before

> a

> > surgery date of 1/27, which my husband's COBRA coverage was

> supposed

> > to cover. The insurance company is still giving me the

runaround,

> > and then of course, January started, and now our out of pocket

max

> > for the year is $6000 instead of $3000, so I have to pay an

> > additional $3000 for my surgery if it is even approved. (Out of

> > network surgeon (there are no in-network surgeons in my area),

> he's

> > only covered at 65%, and the hospital is at 85%) So....(are you

> all

> > following me here:-)?) my insurance plan through my employer

> starts

> > on Feb. 1st. It specifically excludes " Orthognathic

> reconstructive

> > surgery " . I spoke to the insurance agent, and he told me that

> > sometimes even excluded things get covered. He has offered to

> help

> > in any way possible. I just don't know whether to go through

with

> > the surgery in January (if it even gets approved), or to save the

> > $6000 and wait until February to try.

> >

> > Anyone have any suggestions, or experience with this?

> >

> >

[Guest guest]

My policy read almost the same way except reconstructive surgery to

improve function was covered - that is what I used - you have a

place to start with and work from. Make sure you watch what you

write and nothing that you write or your surgeon can be taken as one

of the items that they don't cover - make sure it is all about " the

function " . They might deny you the first time and you may have to

appeal, but if you start from the beginning with a good case for

function reasons only you may have a good chance to get it approved

the first time around.

> > I did - orthognathic surgery was specifically not covered under

my

> > policy. I found a way around it and used reconstructive surgery

as

> > my angle instead (which was a covered surgery) and gave

supportive

> > evidence why I needed to have this done and why what I was doing

> was

> > reconstructive. My insurance company also said that even though

a

> > plan specifically excludes something doesn't always mean that

they

> > won't cover it under every circumstance - each case is

individual

> > and if you have a good case - very likely that you can get it

> > covered - I had to go through the appeals process, write a few

> > letters, make a million phone calls and send in x-rays and

molds.

> > Use your agent - get a copy of the plan and find out what they

do

> > cover and see if something fits what you are planning on having

> done.

> >

> >

> >