Guest guest Posted January 3, 2005 Report Share Posted January 3, 2005 Well - I heard back from the insurance company (Anthem) and they are denying surgery saying that it is not medically necessary. The bastards ;-) They say there is no medically documented issues of chewing, swallowing or sleeping problems? Apparently the fact that my teeth are wearing away and I constantly bite my tongue and cheeks is irrelevant... Does anyone have any suggestions on how to appeal a denial? Any suggestions would be much appreciated. -Thanks! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 3, 2005 Report Share Posted January 3, 2005 Well - I heard back from the insurance company (Anthem) and they are denying surgery saying that it is not medically necessary. The bastards ;-) They say there is no medically documented issues of chewing, swallowing or sleeping problems? Apparently the fact that my teeth are wearing away and I constantly bite my tongue and cheeks is irrelevant... Does anyone have any suggestions on how to appeal a denial? Any suggestions would be much appreciated. -Thanks! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 3, 2005 Report Share Posted January 3, 2005 First, enlist your surgeon in the fight. There may well be insurance experts who work in his office, or he himself may be knowledgeable. There are sample letters, too, on the Geocities site. My surgeon handled the whole thing, and I was approved by BC/BS on the first request. (Interestingly, they have been paying for gastric bypass surgery, but have suddenly added some restrictions -- I suspect they were looking at the sums they've been paying out, and are trying to cut costs, although I do believe that procedure can be medically necessary, and a lifesaver, for some folks.) He sent photos, x-rays, models, drawings (probably copies of all this, as some insurance companies play a nasty game of claiming to have " lost " all the documentation, some of them more than once) plus his own letter. You will want to appeal, and more than once. Some companies also seem to deny one time routinely, just to see if they can discourage people. (My company was excellent; I am fortunate to have an employer who provides complete coverage under a policy that covers many things.) Good wishes to you. There have been people who appealed more than once and won. Oh, and if your policy permits, or even if it doesn't, request a review by a panel of oral and maxillofacial surgeons. Best, Cammie ..com, " pilsner_porterstout " <pilsner_porterstout@y...> wrote: > > Well - I heard back from the insurance company (Anthem) and they are > denying surgery saying that it is not medically necessary. The > bastards ;-) > > They say there is no medically documented issues of chewing, > swallowing or sleeping problems? Apparently the fact that my teeth are > wearing away and I constantly bite my tongue and cheeks is irrelevant... > > Does anyone have any suggestions on how to appeal a denial? Any > suggestions would be much appreciated. > > -Thanks! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 3, 2005 Report Share Posted January 3, 2005 First, enlist your surgeon in the fight. There may well be insurance experts who work in his office, or he himself may be knowledgeable. There are sample letters, too, on the Geocities site. My surgeon handled the whole thing, and I was approved by BC/BS on the first request. (Interestingly, they have been paying for gastric bypass surgery, but have suddenly added some restrictions -- I suspect they were looking at the sums they've been paying out, and are trying to cut costs, although I do believe that procedure can be medically necessary, and a lifesaver, for some folks.) He sent photos, x-rays, models, drawings (probably copies of all this, as some insurance companies play a nasty game of claiming to have " lost " all the documentation, some of them more than once) plus his own letter. You will want to appeal, and more than once. Some companies also seem to deny one time routinely, just to see if they can discourage people. (My company was excellent; I am fortunate to have an employer who provides complete coverage under a policy that covers many things.) Good wishes to you. There have been people who appealed more than once and won. Oh, and if your policy permits, or even if it doesn't, request a review by a panel of oral and maxillofacial surgeons. Best, Cammie ..com, " pilsner_porterstout " <pilsner_porterstout@y...> wrote: > > Well - I heard back from the insurance company (Anthem) and they are > denying surgery saying that it is not medically necessary. The > bastards ;-) > > They say there is no medically documented issues of chewing, > swallowing or sleeping problems? Apparently the fact that my teeth are > wearing away and I constantly bite my tongue and cheeks is irrelevant... > > Does anyone have any suggestions on how to appeal a denial? Any > suggestions would be much appreciated. > > -Thanks! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 3, 2005 Report Share Posted January 3, 2005 Hi. Sorry for the following long-winded reply, but this is an issue near and dear to my heart. I had surgery back in March, and my insurance company (CIGNA) denied my claim twice as not medically necessary before finally approving it 2 days before the surgery was scheduled. I don't know what all your surgeon has done to get it covered, but my surgeon, who I adored professionally, did not seem to be trying very hard to get my surgery covered. I don't know if this was because he would make more money if I paid for the surgery myself in the absence of insurance coverage (I hope that wasn't the reason) or because his office staff was horrible, but the letters that he sent the insurance company were way too boilerplate and did not provide any details of my condition. I finally took matters into my own hands when I started realizing how much this was going to cost if I didn't get it approved. Once my claim was denied for the second time, I asked my ortho to write a letter to CIGNA (in which he said that there was absolutely nothing he could do to fix my problems without surgery), and I wrote a letter for my surgeon to sign. In the surgeon letter, I detailed my history of orthodontic and (more importantly) medical problems (including daily headaches and jaw/ear pain). I also stated that I had been through 6 years of braces and oral surgery as a teenager to attempt to remedy the same problem, and that I still had these issues 20 years later. My surgeon made a few minor changes, but signed the letter. I then sent his letter, the ortho's letter, photos of my molds, x-rays, and cephalometric analysis by Fed Ex directly to CIGNA. It was a huge pain, but I think receiving all of the information at once made a difference, because they finally approved it. Writing the letter for your surgeon is probably not necessary in most cases, but my surgeon's office just couldn't seem to send CIGNA anything useful. Since I knew a lot more about my orthodontic and dental history than my surgeon, I could provide a great level of detail. You might ask to see what your surgeon provided the insurance company to see if maybe that's part of the problem--it may be that they see no " medically documented " problem because your doctor hasn't told them enough yet. Don't give up--there are a lot of people in this group that have been through the same process and were ultimately successful. Insurance companies (spawn of Satan that they are) count on people just giving up, and often (as in my case) don't even let a doctor, much less an orthognathic surgeon) see your case until the second appeal (a general nurse denied my first two claims). Hang in there! > > Well - I heard back from the insurance company (Anthem) and they are > denying surgery saying that it is not medically necessary. The > bastards ;-) > > They say there is no medically documented issues of chewing, > swallowing or sleeping problems? Apparently the fact that my teeth are > wearing away and I constantly bite my tongue and cheeks is irrelevant... > > Does anyone have any suggestions on how to appeal a denial? Any > suggestions would be much appreciated. > > -Thanks! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 3, 2005 Report Share Posted January 3, 2005 Hi. Sorry for the following long-winded reply, but this is an issue near and dear to my heart. I had surgery back in March, and my insurance company (CIGNA) denied my claim twice as not medically necessary before finally approving it 2 days before the surgery was scheduled. I don't know what all your surgeon has done to get it covered, but my surgeon, who I adored professionally, did not seem to be trying very hard to get my surgery covered. I don't know if this was because he would make more money if I paid for the surgery myself in the absence of insurance coverage (I hope that wasn't the reason) or because his office staff was horrible, but the letters that he sent the insurance company were way too boilerplate and did not provide any details of my condition. I finally took matters into my own hands when I started realizing how much this was going to cost if I didn't get it approved. Once my claim was denied for the second time, I asked my ortho to write a letter to CIGNA (in which he said that there was absolutely nothing he could do to fix my problems without surgery), and I wrote a letter for my surgeon to sign. In the surgeon letter, I detailed my history of orthodontic and (more importantly) medical problems (including daily headaches and jaw/ear pain). I also stated that I had been through 6 years of braces and oral surgery as a teenager to attempt to remedy the same problem, and that I still had these issues 20 years later. My surgeon made a few minor changes, but signed the letter. I then sent his letter, the ortho's letter, photos of my molds, x-rays, and cephalometric analysis by Fed Ex directly to CIGNA. It was a huge pain, but I think receiving all of the information at once made a difference, because they finally approved it. Writing the letter for your surgeon is probably not necessary in most cases, but my surgeon's office just couldn't seem to send CIGNA anything useful. Since I knew a lot more about my orthodontic and dental history than my surgeon, I could provide a great level of detail. You might ask to see what your surgeon provided the insurance company to see if maybe that's part of the problem--it may be that they see no " medically documented " problem because your doctor hasn't told them enough yet. Don't give up--there are a lot of people in this group that have been through the same process and were ultimately successful. Insurance companies (spawn of Satan that they are) count on people just giving up, and often (as in my case) don't even let a doctor, much less an orthognathic surgeon) see your case until the second appeal (a general nurse denied my first two claims). Hang in there! > > Well - I heard back from the insurance company (Anthem) and they are > denying surgery saying that it is not medically necessary. The > bastards ;-) > > They say there is no medically documented issues of chewing, > swallowing or sleeping problems? Apparently the fact that my teeth are > wearing away and I constantly bite my tongue and cheeks is irrelevant... > > Does anyone have any suggestions on how to appeal a denial? Any > suggestions would be much appreciated. > > -Thanks! 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.