Guest guest Posted February 3, 2004 Report Share Posted February 3, 2004 Many, many people have been denied and appealed successfully. Some have appealed, appealed and had no luck. First step: Ask your surgeon for help. If he/she won't: Ask for a review by a panel of oral and maxillofacial surgeons. Le Forte (or Le Fort) is upper. Lower is advancement or movement backwards. The costs can be staggering. I have heard figures as great at $40,000 -- and even more, with some of the majorly expensive surgeons and hospitals. My one-day hospital stay, in a relatively inexpensive part of the country, was upward of $10,000. There are ways to help minimize such things (dental schools, outpatient surgery, etc. etc.) But first, ask your surgeon for advice and help. You may find better results that way. best of wishes to you.. C. > Hello all, just found the site and wanted to introduce myself and ask > a few questions. > > My name is , and I've know for a while that I'd have to have jaw > surgery to correct an underbite (someday.. done growing, etc.). I > put it off while in college mostly because I'd adapted and it wasn't > causing me many problems. I've been having more problems with my jaw > recently (age - 25) so it set me in action. So I saw the > Orthodontist and Oral Surgeon, finding that I needed Lefort I (lower > and maybe upper) at a cost of ~12.5k. I got the braces put on a few > weeks ago and had the oral surgeon pre-certify the surgery. > > Here's the catch: pre-certification was denied. Even though my > health plan covers oral surgery relating to " congenital abnormalities > of the jaw " and " charges in connection with TMJ problems " . This > completely caught me off guard. They denied it because it was found > to be " developmental " by the reviewing doctor. I'm looking into the > best way to appeal it now. > > So here's my question: Anyone else have a claim denied in this or a > similiar way? Also, how much more can I espect to pay for the 1-2 > day hospital stay? Just trying to set up some kind of plan for worst > case, even though I cannot really afford to pay the full cost > myself. Thanks for reading. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2004 Report Share Posted February 4, 2004 Thanks for your info, sounds like this may not be possible without the help of my insurance. Found out today that they are questioning the medical necessity of the surgery and wondering why I did not have this done as a child. I'll be talking with the insurance person at my OS tommorrow and hopefully will get this worked out for appeal. This whole thing is really stressing me out, I'm kind of angry that my insurance co is giving me trouble. This is going to be hard enough without having to deal with them. Here's hoping I guess. > > Hello all, just found the site and wanted to introduce myself and > ask > > a few questions. > > > > My name is , and I've know for a while that I'd have to have > jaw > > surgery to correct an underbite (someday.. done growing, etc.). I > > put it off while in college mostly because I'd adapted and it > wasn't > > causing me many problems. I've been having more problems with my > jaw > > recently (age - 25) so it set me in action. So I saw the > > Orthodontist and Oral Surgeon, finding that I needed Lefort I > (lower > > and maybe upper) at a cost of ~12.5k. I got the braces put on a > few > > weeks ago and had the oral surgeon pre-certify the surgery. > > > > Here's the catch: pre-certification was denied. Even though my > > health plan covers oral surgery relating to " congenital > abnormalities > > of the jaw " and " charges in connection with TMJ problems " . This > > completely caught me off guard. They denied it because it was > found > > to be " developmental " by the reviewing doctor. I'm looking into > the > > best way to appeal it now. > > > > So here's my question: Anyone else have a claim denied in this or > a > > similiar way? Also, how much more can I espect to pay for the 1- 2 > > day hospital stay? Just trying to set up some kind of plan for > worst > > case, even though I cannot really afford to pay the full cost > > myself. Thanks for reading. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2004 Report Share Posted February 4, 2004 Thanks for your info, sounds like this may not be possible without the help of my insurance. Found out today that they are questioning the medical necessity of the surgery and wondering why I did not have this done as a child. I'll be talking with the insurance person at my OS tommorrow and hopefully will get this worked out for appeal. This whole thing is really stressing me out, I'm kind of angry that my insurance co is giving me trouble. This is going to be hard enough without having to deal with them. Here's hoping I guess. > > Hello all, just found the site and wanted to introduce myself and > ask > > a few questions. > > > > My name is , and I've know for a while that I'd have to have > jaw > > surgery to correct an underbite (someday.. done growing, etc.). I > > put it off while in college mostly because I'd adapted and it > wasn't > > causing me many problems. I've been having more problems with my > jaw > > recently (age - 25) so it set me in action. So I saw the > > Orthodontist and Oral Surgeon, finding that I needed Lefort I > (lower > > and maybe upper) at a cost of ~12.5k. I got the braces put on a > few > > weeks ago and had the oral surgeon pre-certify the surgery. > > > > Here's the catch: pre-certification was denied. Even though my > > health plan covers oral surgery relating to " congenital > abnormalities > > of the jaw " and " charges in connection with TMJ problems " . This > > completely caught me off guard. They denied it because it was > found > > to be " developmental " by the reviewing doctor. I'm looking into > the > > best way to appeal it now. > > > > So here's my question: Anyone else have a claim denied in this or > a > > similiar way? Also, how much more can I espect to pay for the 1- 2 > > day hospital stay? Just trying to set up some kind of plan for > worst > > case, even though I cannot really afford to pay the full cost > > myself. Thanks for reading. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2004 Report Share Posted February 4, 2004 Thanks for your info, sounds like this may not be possible without the help of my insurance. Found out today that they are questioning the medical necessity of the surgery and wondering why I did not have this done as a child. I'll be talking with the insurance person at my OS tommorrow and hopefully will get this worked out for appeal. This whole thing is really stressing me out, I'm kind of angry that my insurance co is giving me trouble. This is going to be hard enough without having to deal with them. Here's hoping I guess. > > Hello all, just found the site and wanted to introduce myself and > ask > > a few questions. > > > > My name is , and I've know for a while that I'd have to have > jaw > > surgery to correct an underbite (someday.. done growing, etc.). I > > put it off while in college mostly because I'd adapted and it > wasn't > > causing me many problems. I've been having more problems with my > jaw > > recently (age - 25) so it set me in action. So I saw the > > Orthodontist and Oral Surgeon, finding that I needed Lefort I > (lower > > and maybe upper) at a cost of ~12.5k. I got the braces put on a > few > > weeks ago and had the oral surgeon pre-certify the surgery. > > > > Here's the catch: pre-certification was denied. Even though my > > health plan covers oral surgery relating to " congenital > abnormalities > > of the jaw " and " charges in connection with TMJ problems " . This > > completely caught me off guard. They denied it because it was > found > > to be " developmental " by the reviewing doctor. I'm looking into > the > > best way to appeal it now. > > > > So here's my question: Anyone else have a claim denied in this or > a > > similiar way? Also, how much more can I espect to pay for the 1- 2 > > day hospital stay? Just trying to set up some kind of plan for > worst > > case, even though I cannot really afford to pay the full cost > > myself. Thanks for reading. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2004 Report Share Posted February 4, 2004 You have my sympathies, but keep trying. I went through 3 diferrent insurance plans before I got on one that would pay. One denied me because I didn't have it done earlier - I didn't know I needed the surgery until after I was out of college! Anyway, I didn't win any appeals, I just got a different insurance through my husband's job. I had upper and lower. Surgeon and assistant surgeon were about $23,000. Hospital for two nights was about the same. (But after the negotiated insurance discounts the insurance company only paid about 35% of that! And I paid $4000. ) In appealing, discuss with your doc if their are other reasons for appeal. I did a sleep study (insurance paid for most of it) and got diagnosed with sleep apnea, which I think helped my case with the insurance company. If you just can't get insurance to pay, definitely talk to the docs and hospitals about if they will give cash discounts. Talk to your doc about dental/medical schools if available, and what is the minimum hospital time you can do. Best of luck to you! christine > > > Hello all, just found the site and wanted to introduce myself and > > ask > > > a few questions. > > > > > > My name is , and I've know for a while that I'd have to have > > jaw > > > surgery to correct an underbite (someday.. done growing, etc.). > I > > > put it off while in college mostly because I'd adapted and it > > wasn't > > > causing me many problems. I've been having more problems with my > > jaw > > > recently (age - 25) so it set me in action. So I saw the > > > Orthodontist and Oral Surgeon, finding that I needed Lefort I > > (lower > > > and maybe upper) at a cost of ~12.5k. I got the braces put on a > > few > > > weeks ago and had the oral surgeon pre-certify the surgery. > > > > > > Here's the catch: pre-certification was denied. Even though my > > > health plan covers oral surgery relating to " congenital > > abnormalities > > > of the jaw " and " charges in connection with TMJ problems " . This > > > completely caught me off guard. They denied it because it was > > found > > > to be " developmental " by the reviewing doctor. I'm looking into > > the > > > best way to appeal it now. > > > > > > So here's my question: Anyone else have a claim denied in this > or > > a > > > similiar way? Also, how much more can I espect to pay for the 1- > 2 > > > day hospital stay? Just trying to set up some kind of plan for > > worst > > > case, even though I cannot really afford to pay the full cost > > > myself. Thanks for reading. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2004 Report Share Posted February 4, 2004 You have my sympathies, but keep trying. I went through 3 diferrent insurance plans before I got on one that would pay. One denied me because I didn't have it done earlier - I didn't know I needed the surgery until after I was out of college! Anyway, I didn't win any appeals, I just got a different insurance through my husband's job. I had upper and lower. Surgeon and assistant surgeon were about $23,000. Hospital for two nights was about the same. (But after the negotiated insurance discounts the insurance company only paid about 35% of that! And I paid $4000. ) In appealing, discuss with your doc if their are other reasons for appeal. I did a sleep study (insurance paid for most of it) and got diagnosed with sleep apnea, which I think helped my case with the insurance company. If you just can't get insurance to pay, definitely talk to the docs and hospitals about if they will give cash discounts. Talk to your doc about dental/medical schools if available, and what is the minimum hospital time you can do. Best of luck to you! christine > > > Hello all, just found the site and wanted to introduce myself and > > ask > > > a few questions. > > > > > > My name is , and I've know for a while that I'd have to have > > jaw > > > surgery to correct an underbite (someday.. done growing, etc.). > I > > > put it off while in college mostly because I'd adapted and it > > wasn't > > > causing me many problems. I've been having more problems with my > > jaw > > > recently (age - 25) so it set me in action. So I saw the > > > Orthodontist and Oral Surgeon, finding that I needed Lefort I > > (lower > > > and maybe upper) at a cost of ~12.5k. I got the braces put on a > > few > > > weeks ago and had the oral surgeon pre-certify the surgery. > > > > > > Here's the catch: pre-certification was denied. Even though my > > > health plan covers oral surgery relating to " congenital > > abnormalities > > > of the jaw " and " charges in connection with TMJ problems " . This > > > completely caught me off guard. They denied it because it was > > found > > > to be " developmental " by the reviewing doctor. I'm looking into > > the > > > best way to appeal it now. > > > > > > So here's my question: Anyone else have a claim denied in this > or > > a > > > similiar way? Also, how much more can I espect to pay for the 1- > 2 > > > day hospital stay? Just trying to set up some kind of plan for > > worst > > > case, even though I cannot really afford to pay the full cost > > > myself. Thanks for reading. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2004 Report Share Posted February 4, 2004 You have my sympathies, but keep trying. I went through 3 diferrent insurance plans before I got on one that would pay. One denied me because I didn't have it done earlier - I didn't know I needed the surgery until after I was out of college! Anyway, I didn't win any appeals, I just got a different insurance through my husband's job. I had upper and lower. Surgeon and assistant surgeon were about $23,000. Hospital for two nights was about the same. (But after the negotiated insurance discounts the insurance company only paid about 35% of that! And I paid $4000. ) In appealing, discuss with your doc if their are other reasons for appeal. I did a sleep study (insurance paid for most of it) and got diagnosed with sleep apnea, which I think helped my case with the insurance company. If you just can't get insurance to pay, definitely talk to the docs and hospitals about if they will give cash discounts. Talk to your doc about dental/medical schools if available, and what is the minimum hospital time you can do. Best of luck to you! christine > > > Hello all, just found the site and wanted to introduce myself and > > ask > > > a few questions. > > > > > > My name is , and I've know for a while that I'd have to have > > jaw > > > surgery to correct an underbite (someday.. done growing, etc.). > I > > > put it off while in college mostly because I'd adapted and it > > wasn't > > > causing me many problems. I've been having more problems with my > > jaw > > > recently (age - 25) so it set me in action. So I saw the > > > Orthodontist and Oral Surgeon, finding that I needed Lefort I > > (lower > > > and maybe upper) at a cost of ~12.5k. I got the braces put on a > > few > > > weeks ago and had the oral surgeon pre-certify the surgery. > > > > > > Here's the catch: pre-certification was denied. Even though my > > > health plan covers oral surgery relating to " congenital > > abnormalities > > > of the jaw " and " charges in connection with TMJ problems " . This > > > completely caught me off guard. They denied it because it was > > found > > > to be " developmental " by the reviewing doctor. I'm looking into > > the > > > best way to appeal it now. > > > > > > So here's my question: Anyone else have a claim denied in this > or > > a > > > similiar way? Also, how much more can I espect to pay for the 1- > 2 > > > day hospital stay? Just trying to set up some kind of plan for > > worst > > > case, even though I cannot really afford to pay the full cost > > > myself. Thanks for reading. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 5, 2004 Report Share Posted February 5, 2004 They can wonder all they want about why you didn't have this fixed as a child. Fact is, you were a minor, and your parents were making whatever decisions about your health care back then. So I'd say the insurance company has its nerve. When I was a child, they didn't know anything about the importance of matching up the jaws. They just straightened things out and said " We're done. " As for their questioning the medical necessity -- do they cover repair of skeletal abnormalities in general? That's exactly what this is. Of course, you can also talk with them about sleep apnea, if you have it; breathing problems, if you have them; difficulties in chewing, iyht; jaw pain, iyht; etc., etc. Your surgeon's insurance person ought to be able to help you with this part of it. Good wishes. Cammie > Thanks for your info, sounds like this may not be possible without > the help of my insurance. Found out today that they are questioning > the medical necessity of the surgery and wondering why I did not have > this done as a child. I'll be talking with the insurance person at > my OS tommorrow and hopefully will get this worked out for appeal. > This whole thing is really stressing me out, I'm kind of angry that > my insurance co is giving me trouble. This is going to be hard > enough without having to deal with them. > > Here's hoping I guess. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 5, 2004 Report Share Posted February 5, 2004 Thanks for the info, . After having my HR department talk to my insurance people, I found that they wanted to know two things: 1) why it wasn't done sooner. Surgeon said we should be able to cover this one because I had to be done growing. And before starting this I wanted to be absolutely sure. I'm 25 now, only been out of college for 1.5 yrs. Hopefully this will be enough. 2) Medical necessity. Surgeon said this should be covered dual-fold by my inability to chew correctly and the pain that's been developing in my jaw/face. I'm hoping the appeal goes well because I would have to switch jobs to get new insurance, this is the only provider we have here. > > > > Hello all, just found the site and wanted to introduce myself and > > > ask > > > > a few questions. > > > > > > > > My name is , and I've know for a while that I'd have to have > > > jaw > > > > surgery to correct an underbite (someday.. done growing, etc.). > > I > > > > put it off while in college mostly because I'd adapted and it > > > wasn't > > > > causing me many problems. I've been having more problems with my > > > jaw > > > > recently (age - 25) so it set me in action. So I saw the > > > > Orthodontist and Oral Surgeon, finding that I needed Lefort I > > > (lower > > > > and maybe upper) at a cost of ~12.5k. I got the braces put on a > > > few > > > > weeks ago and had the oral surgeon pre-certify the surgery. > > > > > > > > Here's the catch: pre-certification was denied. Even though my > > > > health plan covers oral surgery relating to " congenital > > > abnormalities > > > > of the jaw " and " charges in connection with TMJ problems " . This > > > > completely caught me off guard. They denied it because it was > > > found > > > > to be " developmental " by the reviewing doctor. I'm looking into > > > the > > > > best way to appeal it now. > > > > > > > > So here's my question: Anyone else have a claim denied in this > > or > > > a > > > > similiar way? Also, how much more can I espect to pay for the 1- > > 2 > > > > day hospital stay? Just trying to set up some kind of plan for > > > worst > > > > case, even though I cannot really afford to pay the full cost > > > > myself. Thanks for reading. > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 5, 2004 Report Share Posted February 5, 2004 See if you can get a statement from your surgeon that this is MEDICAL, not Dental. That it is for repair of a congenital skeletal defect. With the appropriate codes. That should help a lot. Mine also said it was not cosmetic, not TMJ, but was being done to correct a " skeletal dysplasia. " Sounds like he's willing to work with you. Good luck. Cammie > Thanks for the info, . > > After having my HR department talk to my insurance people, I found > that they wanted to know two things: > > 1) why it wasn't done sooner. Surgeon said we should be able to > cover this one because I had to be done growing. And before starting > this I wanted to be absolutely sure. I'm 25 now, only been out of > college for 1.5 yrs. Hopefully this will be enough. > > 2) Medical necessity. Surgeon said this should be covered dual- fold > by my inability to chew correctly and the pain that's been developing > in my jaw/face. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 5, 2004 Report Share Posted February 5, 2004 The first letter he sent listed the surgery as needed to repair a skeletel malformation. But the insurance co still wanted more info on why, so the rest is backup. I'd have thought the first submission would get through alone, guess not. I'll talk to the OS people again and see if it can be classified as congenital if you think that might help. I kind of get the feeling that the insurance co is just trying to make this a real big hassle so I drop it. Not going to happen, though Thanks, > > Thanks for the info, . > > > > After having my HR department talk to my insurance people, I found > > that they wanted to know two things: > > > > 1) why it wasn't done sooner. Surgeon said we should be able to > > cover this one because I had to be done growing. And before > starting > > this I wanted to be absolutely sure. I'm 25 now, only been out of > > college for 1.5 yrs. Hopefully this will be enough. > > > > 2) Medical necessity. Surgeon said this should be covered dual- > fold > > by my inability to chew correctly and the pain that's been > developing > > in my jaw/face. Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.