Re: insurance denial - help!

[Guest guest]

Amelia,

I had the same trouble and denial with my ins. co. My doctor told

me about a leagl statute that makes it illegal to deny based on

descriminating against a joint or bone (ie: Jaw), if they cover

other joints or bones - which they of course do! It depends what

state you live in , as not all states have these types of statutes.

Search the web for yours, I live in Florida - I copied the statute

below for your reference.

I found mine in about 5 minutes.

Good luck, read below.....

" The 2003 Florida Statutes

Title XXXVII

INSURANCE Chapter 641

HEALTH CARE SERVICE PROGRAMS View Entire Chapter

641.31094 Nondiscrimination of coverage for certain surgical

procedures involving bones or joints.--No health maintenance

contract or policy which provides coverage for any diagnostic or

surgical procedure involving bones or joints of the skeleton shall

discriminate against coverage for any similar diagnostic or surgical

procedure involving bones or joints of the jaw and facial region,

if, under accepted medical standards, such procedure or surgery is

medically necessary to treat conditions caused by congenital or

developmental deformity, disease, or injury. This section shall not

be construed to affect any other coverage under this part or to

restrict the scope of coverage under any policy, plan, or contract.

Nothing in this section shall be construed to discourage appropriate

nonsurgical procedures or to prohibit the continued coverage of

nonsurgical procedures in the treatment of a bone or joint of the

jaw and facial region. Furthermore, nothing in this subsection

requires coverage for care or treatment of the teeth or gums, for

intraoral prosthetic devices, or for surgical procedures for

cosmetic purposes. "

> Cigna has denied my upper and lower jaw surgery (anterior open

bite)

> NOT on grounds that it isn't a significant skeletal deformity. They

> concede that point. But they say I haven't demonstrated that it is

a

> " significant functional impairment. " Of course, I'll appeal. My

> question to any of you is, what advice would you give for

> demonstrating significant functional impairment to Cigna?

>

> The following is true: I developed severe jaw fatigue over the past

> couple of years, which has limited and changed my eating habits. It

> makes it harder to get through meals, and it definitely limits the

> food that I will even attempt to eat. I'm not choking on every

bite,

> but I do think I -- at times -- swallow pieces of food that are not

> chewed as well as they should be. And my braces have made my bite

even

> worse.

>

> And I know my molars have worn excessively. I've had to get filling

> after filling, crowns, etc., and I floss and brush compulsively,

keep

> my teeth immaculately clean, so I know my teeth aren't decaying on

> their own.

>

> I also have had problems with not being able to open my mouth wide,

> popping jaws, headaches and all the rest, but I'm not going there

with

> Cigna because they exclude TMJ.

>

> It makes me very angry, because the symptoms/effects of my open

bite

> are definitely getting worse the older I get (37), and just imagine

> when I'm in my sixties or seventies, when arthritis and all the

rest

> really kicks in. What am I supposed to do, resign myself to a diet

of

> oatmeal and bananas? Why not get the problem fixed now? The older I

> get, the harder the recovery period from surgery will be, as well.

> I can't imagine that having eating difficulties and worn-down,

> banged-up teeth isn't significantly impairing.

>

> As far as cosmetic concerns go, I won't even get much of that with

> this surgery, unless I have a genio, which insurance won't cover,

and

> I'll have to pay for myself. So it's not for cosmetic reasons.

>

> Any advice on proving my case would be greatly appreciated.

>

>

> Thanks,

> Amelia