Thursday, April 5, 2012

Jaw Surgery & Insurance Coverage: When is Jaw Surgery "Medically Necessary"?

    The short answer is ~ Jaw Surgery is medically necessary when the deformity, malformation, hypoplasia, hyperplasia, occlusion or alignment, etc. creates a situation in which your general ability to FUNCTION is severely impeded.  Insurance companies generally won't pay for jaw surgery if the chief complaint is a cosmetic one -- meaning, if you just aren't happy with your jawline or profile, or you're not happy with some asymmetry in your face, or you're unhappy with SOMETHING involving your jaw and want jaw surgery to fix it, unless there is a medical necessity, expect to pay for surgery out of your own pocket.

This video is basically all of the same information as this blog post, I just felt like giving the info in two formats... well, no, I made the video first then thought a blog post would be a good idea and decided to combine the two since they're basically providing the same info...

How Did You Get Your Insurance to Cover Jaw Surgery?
     I didn't. My health insurance is through the military because I'm married to a U.S. Army officer. My dental insurance is through a separate organization (separate, as in - not the same as my health insurance but still through the Army). My dental insurance would NOT cover braces, which are necessary for jaw surgery. Their reasoning is: Military dependents, including spouses and children, over the age of 23-years, are not covered for orthodontics treatment.  I was 29 when I started braces, this time, so I had to pay for them out of pocket.

    The orthodontist gave me a referral for a jaw surgery consultation. To get my insurance (health, not dental) to cover the consult, I had to submit it to their system. To do this, I took the referral to a medical doctor who entered it into their computer as a regular referral. When the referral was processed, it was flagged by the hospital at Bethesda, MD and I was told I had to go there for my consult. Since I knew that arguing would likely result in a battle for coverage, I simply agreed and was seen at the military hospital - now it's called Walter Reed National Military Medical Center.

   By agreeing to have my surgery performed in a military facility, I never once saw a bill. I will never see a bill. I  had complete, total, 100% coverage for the procedures and no trouble other than having to wait until my jaw was "ready"... since it's a training facility, the teeth/jaws MUST be in the best possible positions to give them the best chance at a safe surgery experience. They won't approve the procedure and authorize/schedule your surgery until then, so I was sent back to my orthodontist 3 times before I finally got a surgery date.

My Insurance Company Said They Don't Think Jaw Surgery is Medically Necessary!!!
    This is VERY COMMON. Jaw surgery is a sort of "gray area" between medical and dental coverage. Dental coverage almost never handles jaw surgery -- so if you're submitting paperwork to your dental insurance company, you're likely barking up the wrong tree.

    Medical/health insurance will cover jaw surgery in many cases BUT the surgery must be seen as a "medical necessity" and NEVER as a cosmetic or elective procedure.

   A friend of mine contacted me recently, frustrated after receiving a letter from her insurance company. They did not view her case as medically necessary for jaw surgery. She'd already had braces on for a long time, and jaw surgery was really the only hope of improving the problems permanently. This is similar to my case - we both had/have open-bites, many of the same complaints and difficulties... she wondered what I would say in response to her insurance company's request for clarification of "difficulty eating" and "dental trauma" ~~ they were explained by the oral surgeon but not to the satisfaction of the insurance company.

   We looked at her symptoms, complaints, and difficulties and listed them out. We then looked at the letter from the insurance company and listed out all the things they specifically wanted to know, from her in her words. She was given 2 weeks to reply but I explained to her that if she took 2 weeks to reply they may view that as not really "important enough" to her. So we got to work right away!

   We also reviewed the insurance company's website, and several other insurance companies' websites, for information regarding what they do cover, what they do NOT cover, and why.

   In the end, we drafted a letter that was a little longer than a page, with spacing between paragraphs to make it easier to read. We kept it short and sweet... to the point... and we avoided using ANY TERMINOLOGY that could possible sound "cosmetic surgery-related".... we NEVER discussed her appearance, self-consciousness that comes from having jaw and teeth problems, asymmetry, jawline, profile... none of it every came up. What we did discuss, however, are the psychological, professional and physical difficulties that arise from having this type of problem.

   A week after sending out her letter, she received the approval from her insurance company! They FINALLY saw why she was saying it was medically necessary.... they finally understood!!  This was so big, and I feel so honored to have been able to help her. Honored that she trusted me and that she felt comfortable relying on me for help. And I was so pleased to hear the good news!

  I will eventually put all of the best suggestions and advice for dealing with stubborn insurance companies up on my Jaw Recovery Playbook site. But since that's such a slow project with all that I've been dealing with, I wanted to put some information up SOMEWHERE to help people now, in the meantime. These tips should help:
  1. For jaw surgery to be "medically necessary" you should avoid mentioning ANYTHING that relates to the cosmetic aspects of the procedures. Those are a side-effect, not a reason for needing surgery.
  2. Review what your insurance company does and does NOT cover by going to their website and checking out the coverage information, and compare that information to correspondence with the company so far. This will help you better understand why they're giving you trouble, if they are. 
  3. Write out a list of everything the insurance company is asking for, specifically, from you.
  4. Write another list of all of your complaints, symptoms, etc. and everything they affect (e.g. work, sleep, health, psychology, ability to care for self, ability to care for children, etc.)
  5. Organize this information in a coherent outline BEFORE writing the letter. This will help you keep it organized and to the point.
  6. When writing the letter, avoid "fluff"... you want things short and sweet, but with sufficient information to present a compelling argument for needing jaw surgery. 
  7. After you've written the letter, read it aloud several times. Anything that's unnecessary or "fluff" remove or change. Your letter should be less than 2 pages.

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