Re: Message for Maddie

[Guest guest]

Thank you so much for sharing this!!! I have a problem that the

three orthodontists I have been to have not seen before, and even

after the consults none of them has a plan. They all say I

definately need jaw surgery, but I don't need the orthodontic work

for a bite problem. My bite is fine and my profile is fine even

with a very slight overbite. I just have a really collapsed

mouth/jaw, so collapsed that even my tongue can't move when I bite

down. I have no volume in my arches, and my jaw goes beyond the

normal lever angle to overclose. So I can't eat with food in my

mouth (it is pocketed in my cheeks and fed small bits at a time with

overly developed cheek muscles, which are perfoming the function of

my tongue for eating), and because there is no tongue movement, I

choke easily and often. I can't direct things in my mouth when my

teeth are closed (which is every time you are concentrating or

working on something) So I frequently choke even on small amounts of

saliva. It is an unusual jaw problem that each of the orthodontists

say they will have to discuss with the orthognathic surgeon to see

what can even be done, and then to develop a plan.

The problem for me is that my insurance is a self-funded program.

So special circumstances like this one are not set in stone as to

coverage. Since it will require orthodontics to move my teeth to

meet only for the post op position of my jaw adjusted for the

choking, which is a medical necessity separate from any bite issues,

the orthodontics may actually be covered for me as medically

necessary even though orthodontic treatment is not covered for

adults with our policy. It is independently reviewed when it is a

special case, for which this one apparently classifies. It is not a

dental problem.

I have called the orthognatic surgeons office about this, but they

do not accept clients without referral. But if I proceed with the

orthodontists, I will be implementing the plan with providers from

my dental plan. That sort of disqualifies me from having this

evaluated separately as a jaw/choking issue from the medical field.

I have been caught in limbo. I didn't know what next to do about

it.

From experience with insurance about other issues, I know that if

you make a mis-step at the beginning while seeking the coverage you

are entitiled by policy, it is extremely difficult to go back and

correct it and have reasonable expectations that your case will be

evaluated fairly. The entire job of the medical reviewers is to

deny you coverage - they work for the insurance companies not you -

and your initial presentation is critical.

I have actually been sitting still, doing nothing, trying to figure

out how to navigate this. But you have just pointed the way!! By

going to a Ear, Nose and Throat doctor, I can probably get a direct

referral to a maxillofacial specialist or maybe to an orthognathic

surgeon from that direction. That means it is set up in the correct

medical channels from the outset. And I avoid the dental plan which

would direct, by policy, the costs back to me. It also disallows

the insurance from passing the buck between dental plan and medical

plan coverage. It might even be the backdoor way to get the braces

covered in my case. That would be a HUGE help. I am going to make

some calls today to some ENT specialists and get this going.

So thank you, thank you, thank you!! You just pointed the way and

got me moving again!

Fran

> >

> > Hi Maddie,

> >

> > I have another question for you -- how did you get your kaiser

> > referral to Dr.O'? Did you just go to your primary care

> > physician and ask her for the referral? Years ago, an

orthodontist

> > told me I needed the surgery but my insurance wouldn't cover it

> back

> > then. Now I have Kaiser, but I'm not sure how to get the

referral

> to

> > Dr.O'. Should I go see an orthodontist again and get them to

> > write a note to my primary care physician?

> >

> > Thanks,

> > mcs