Re: Can you all help with my insurance appeal?

[Guest guest]

Connie,

I also live in Oregon and have BCBS PPO through a State workers' contract

(PEBB). My upper and lower jaw surgery and the two surgical splints were

recently approved for medical necessity. Our benefits package states

orthognathic surgery is covered if deemed medically necessary.

My surgeon, who sent the request for approval, is out of network. Therefore,

I will have a 30% co-pay. I was excited at first until I found out how

little BCBS' " usual and customary " allowances were for this surgery. Their

70% coverage is not off the surgeon's fee, but rather their UC allowance. I

am responsible for the remainder. Because my surgeon is not participating,

he will not adjust his fees. BCBS said this is common with highly skilled

specialists. I toyed with the idea of finding a closer surgeon (my OS is in

Seattle) who is also in network, but my OD said this surgery is very

complicated and that I need the best OS working on me. He sold me there.

My OS had me fill out a questionnaire (about six pages), as to the symptoms

I was having, etc. The questionnaire and a letter from the surgeon as to

medical necessity were sent to BCBS. After receiving the letter, BCBS

requested additional x-rays and molds. It took about two months to receive

my approval (this included the OS, OD and BCBS having a little breakdown in

communication). If you'd like, I would be happy to email you the

questionnaire and letter.

My pre-ortho pictures are listed under the Diane folder. I'm scheduled for

upper/lower surgery late this fall, with a possible bone graft (here's

hoping that doesn't happen!).

Good luck. Please keep us posted.

Diane, Oregon

>

>Reply-To: orthognathicsurgerysupport

>To: orthognathicsurgerysupport

>Subject: [Orthognathic Surgery Support ] Can you all help with my

>insurance appeal?

>Date: Thu, 04 Aug 2005 01:19:52 -0000

>

[Guest guest]

I have BC/BS Federal:

Mandibular Leforte I: Approved

Genioplasty: Disapproved (Cosmetic)

Septoplasty: Pending

My OS is out of network so I have to pay 25% of the

Lefort, all of the Genio, and either 25% or all of the

septoplasty depending on what they decide.

Austria

--- connieberrymama wrote:

> I live in Oregon and have BlueCross BlueShield.

> They denied helping

> to pay for my surgey, even though it is listed as

> being covered. They

> have admitted my problems in several areas, but

> still denied me. I had

> assymetry and a crossbite, but are acting like they

> never approve for

> this type of surgery. I know even the same company

> is different from

> state to state but I was wondering if those people

> who were approved

> from BlueCross Blue Shield, whatever the state could

> let me know their

> problem, their procedure done, their state, and

> percentage paid. I

> would like to submit this to them and say, hay look,

> your peers in

> other states understand the necessity of this

> surgery, why not you?

> Thanks for your help.

>

> Connie

>

>

>

____________________________________________________

Start your day with Yahoo! - make it your home page

http://www.yahoo.com/r/hs

[Guest guest]

Diane,

Which of the pictures are you? The blonde or the redhead? Just

curious.

Connie

> Connie,

>

> I also live in Oregon and have BCBS PPO through a State workers'

contract

> (PEBB). My upper and lower jaw surgery and the two surgical

splints were

> recently approved for medical necessity. Our benefits package

states

> orthognathic surgery is covered if deemed medically necessary.

>

> My surgeon, who sent the request for approval, is out of network.

Therefore,

> I will have a 30% co-pay. I was excited at first until I found out

how

> little BCBS' " usual and customary " allowances were for this

surgery. Their

> 70% coverage is not off the surgeon's fee, but rather their UC

allowance. I

> am responsible for the remainder. Because my surgeon is not

participating,

> he will not adjust his fees. BCBS said this is common with highly

skilled

> specialists. I toyed with the idea of finding a closer surgeon (my

OS is in

> Seattle) who is also in network, but my OD said this surgery is

very

> complicated and that I need the best OS working on me. He sold me

there.

>

> My OS had me fill out a questionnaire (about six pages), as to the

symptoms

> I was having, etc. The questionnaire and a letter from the surgeon

as to

> medical necessity were sent to BCBS. After receiving the letter,

BCBS

> requested additional x-rays and molds. It took about two months to

receive

> my approval (this included the OS, OD and BCBS having a little

breakdown in

> communication). If you'd like, I would be happy to email you the

> questionnaire and letter.

>

> My pre-ortho pictures are listed under the Diane folder. I'm

scheduled for

> upper/lower surgery late this fall, with a possible bone graft

(here's

> hoping that doesn't happen!).

>

> Good luck. Please keep us posted.

>

> Diane, Oregon

>

> >From: " connieberrymama " <attebery@f...>

> >Reply-To: orthognathicsurgerysupport

> >To: orthognathicsurgerysupport

> >Subject: [Orthognathic Surgery Support ] Can you all help with

my

> >insurance appeal?

> >Date: Thu, 04 Aug 2005 01:19:52 -0000

> >

>

>

>

>

[Guest guest]

Hi Connie -

I have BCBS of Vermont- a HMO/PPO hybrid (HMO coverage after a high deductible

is met)

They are covering 100% of a Leforte I - 2 piece and a Bilateral Sagital Split

Osteotomy (BSSO)

I am using a BCBS approved provider.

I have to say that my surgeon's office did all the work getting me approved. My

surgeon asked me a series of questions reguarding headaches, jaw issues like

chewing, sleeping etc - and I answered them " correctly " to make the case of a

medical correction. I passed a test when I didn't even know how important it

was!

Good Luck

Cyndy

--- connieberrymama wrote:

> I live in Oregon and have BlueCross BlueShield.

> They denied helping

> to pay for my surgey, even though it is listed as

> being covered. They

> have admitted my problems in several areas, but

> still denied me. I had

> assymetry and a crossbite, but are acting like they

> never approve for

> this type of surgery. I know even the same company

> is different from

> state to state but I was wondering if those people

> who were approved

> from BlueCross Blue Shield, whatever the state could

> let me know their

> problem, their procedure done, their state, and

> percentage paid. I

> would like to submit this to them and say, hay look,

> your peers in

> other states understand the necessity of this

> surgery, why not you?

> Thanks for your help.

>

> Connie

>

>

>

____________________________________________________

Start your day with Yahoo! - make it your home page

http://www.yahoo.com/r/hs

[Guest guest]

Connie,

My hair is an auburn red. Mine is the first Diane folder. Here's the link:

http://photos.groups.yahoo.com/group/orthognathicsurgerysupport/vwp?.dir=/Diane & \

..src=gr & .dnm=Pre-Orthodontics+Appt..jpg & .view=t & .done=http%3a//photos.groups.yah\

oo.com/group/orthognathicsurgerysupport/lst%3f%26.dir=/Diane%26.src=gr%26.view=t

>

>Reply-To: orthognathicsurgerysupport

>To: orthognathicsurgerysupport

>Subject: [Orthognathic Surgery Support ] Re: [Orthognathic Surgery

>Support ] Can you all help with my insurance appeal?

>Date: Thu, 04 Aug 2005 19:23:18 -0000

>

>

>

>

>

>Diane,

>

>

>

>Which of the pictures are you?  The blonde or the redhead?  Just

>

>curious.

>

>

>

>Connie

>

>

>

>

>

> > Connie,

>

> >

>

> > I also live in Oregon and have BCBS PPO through a State workers'

>

>contract

>

> > (PEBB). My upper and lower jaw surgery and the two surgical

>

>splints were

>

> > recently approved for medical necessity. Our benefits package

>

>states

>

> > orthognathic surgery is covered if deemed medically necessary.

>

> >

>

> > My surgeon, who sent the request for approval, is out of network.

>

>Therefore,

>

> > I will have a 30% co-pay. I was excited at first until I found out

>

>how

>

> > little BCBS' " usual and customary " allowances were for this

>

>surgery. Their

>

> > 70% coverage is not off the surgeon's fee, but rather their UC

>

>allowance. I

>

> > am responsible for the remainder. Because my surgeon is not

>

>participating,

>

> > he will not adjust his fees. BCBS said this is common with highly

>

>skilled

>

> > specialists. I toyed with the idea of finding a closer surgeon (my

>

>OS is in

>

> > Seattle) who is also in network, but my OD said this surgery is

>

>very

>

> > complicated and that I need the best OS working on me. He sold me

>

>there.

>

> >

>

> > My OS had me fill out a questionnaire (about six pages), as to the

>

>symptoms

>

> > I was having, etc. The questionnaire and a letter from the surgeon

>

>as to

>

> > medical necessity were sent to BCBS. After receiving the letter,

>

>BCBS

>

> > requested additional x-rays and molds. It took about two months to

>

>receive

>

> > my approval (this included the OS, OD and BCBS having a little

>

>breakdown in

>

> > communication). If you'd like, I would be happy to email you the

>

> > questionnaire and letter.

>

> >

>

> > My pre-ortho pictures are listed under the Diane folder. I'm

>

>scheduled for

>

> > upper/lower surgery late this fall, with a possible bone graft

>

>(here's

>

> > hoping that doesn't happen!).

>

> >

>

> > Good luck. Please keep us posted.

>

> >

>

> > Diane, Oregon

>

> >

>

> > >From: " connieberrymama " <attebery@f...>

>

> > >Reply-To: orthognathicsurgerysupport

>

> > >To: orthognathicsurgerysupport

>

> > >Subject: [Orthognathic Surgery Support    ] Can you all help with

>

>my

>

> > >insurance appeal?

>

> > >Date: Thu, 04 Aug 2005 01:19:52 -0000

>

> > >

>

> >

>

> >

>

> >

>

> >

[Guest guest]

Connie - Hello there! Just so you know: I'm the Diane from Idaho &

my pre-ortho picture is in Diane folder #2. I'm the one who wrote

you a while back about your ceramic braces. Well, my ceramic

brackets were installed last Tuesday and my spacers were put in on

Tuesday. So far, so good. Spacers don't hurt at all - they're a

nuisance, as I feel there's some food constantly stuck in between my

molars (a sensation I know all to well). Thank you very much for

sharing your story about your ceramics. My OMS is fine with my

having them and has never had a problem with them in surgery. I had

another question and answer session with my Surgeon yesterday. I

brought eighteen questions with me and he answered them all. He

printed a copy of my " before & after the BSSO " pictures for me. What

a dramatic change in my appearance! (actually his color printer was

having a problem so the images of me color-wise aren't very good.)

Next Tuesday is my OD appointment to get the spacers out and the

rest of the hardware put in (bands, archwires, and ligatures/o-

rings). Looks like my Orthognathic Journey has definitely begun!! ~~

Diane

> > Connie,

> >

> > I also live in Oregon and have BCBS PPO through a State workers'

> contract

> > (PEBB). My upper and lower jaw surgery and the two surgical

> splints were

> > recently approved for medical necessity. Our benefits package

> states

> > orthognathic surgery is covered if deemed medically necessary.

> >

> > My surgeon, who sent the request for approval, is out of

network.

> Therefore,

> > I will have a 30% co-pay. I was excited at first until I found

out

> how

> > little BCBS' " usual and customary " allowances were for this

> surgery. Their

> > 70% coverage is not off the surgeon's fee, but rather their UC

> allowance. I

> > am responsible for the remainder. Because my surgeon is not

> participating,

> > he will not adjust his fees. BCBS said this is common with

highly

> skilled

> > specialists. I toyed with the idea of finding a closer surgeon

(my

> OS is in

> > Seattle) who is also in network, but my OD said this surgery is

> very

> > complicated and that I need the best OS working on me. He sold

me

> there.

> >

> > My OS had me fill out a questionnaire (about six pages), as to

the

> symptoms

> > I was having, etc. The questionnaire and a letter from the

surgeon

> as to

> > medical necessity were sent to BCBS. After receiving the letter,

> BCBS

> > requested additional x-rays and molds. It took about two months

to

> receive

> > my approval (this included the OS, OD and BCBS having a little

> breakdown in

> > communication). If you'd like, I would be happy to email you the

> > questionnaire and letter.

> >

> > My pre-ortho pictures are listed under the Diane folder. I'm

> scheduled for

> > upper/lower surgery late this fall, with a possible bone graft

> (here's

> > hoping that doesn't happen!).

> >

> > Good luck. Please keep us posted.

> >

> > Diane, Oregon

> >

> > >From: " connieberrymama " <attebery@f...>

> > >Reply-To: orthognathicsurgerysupport

> > >To: orthognathicsurgerysupport

> > >Subject: [Orthognathic Surgery Support ] Can you all help

with

> my

> > >insurance appeal?

> > >Date: Thu, 04 Aug 2005 01:19:52 -0000

> > >

> >

> >

> >

> >