Arnett-Gunson Insurance Coverage?

[OHjawz]

I had a little different experience with the insurance lady.  It's still a conversation-in-progress, but whereas I don't think I fit medical necessity, she is saying she can get me in on OSA and, secondarily, bite/overjet issues.  Neither of which fit BCBS's medical criteria in their explicitly stated policy, and my bite is only really misaligned when you tuck my jaw back into the condyles about  ~2mm, which is unnatural for me.  The kicker is they won't file an insurance predetermination until you commit to paying them the full cost of surgery, regardless of if you get insurance coverage. I'm sure that's common with out of network doctors, but this isn't just a 15k rhinoplasty. If insurance deems it cosmetic and you suffer collateral damage post op, insurance won't cover extra doctor repair bills either on the premise that it is a complication from a cosmetic procedure.

So I got my repsonse from Arnett-Gunson's insurance lady.  Here's what she said:
"No that is not true.  Pre-authorizations are submitted 4 to 6 months prior to surgery after a patient has had a consultation, is in braces and has a tentative surgery date we are working towards.   We do collect the full surgeons fees 60 days prior to surgery.  Claims will be submitted to insurance after the surgery (for approved procedures)."

[ditterbo]

So I got my repsonse from Arnett-Gunson's insurance lady.  Here's what she said:
"No that is not true.  Pre-authorizations are submitted 4 to 6 months prior to surgery after a patient has had a consultation, is in braces and has a tentative surgery date we are working towards.   We do collect the full surgeons fees 60 days prior to surgery.  Claims will be submitted to insurance after the surgery (for approved procedures)."

Ok so this varies depending on your situation.  In my case, where my bite is currently very well camouflaged/compensated, I will have to first set my teeth into a craptastic bite relationship ('decompensated') before a preauthorization is submitted to insurance.  Makes sense to show your insurance a terrible bite, and not the one you currently have.

The potential pitfalls with that approach is if insurance decides, after significantly messing up your bite with decomp ortho work first, that there still isn't medical necessity for bimax. OR you somehow decide the costs are still too great for bimax, then you are left with braces on until they cause damage and are removed, or you remove them and live with a terrible bite that you just spent about 8-10 grand for.  I think a good question, for every case, is how bad your bite and smile aesthetic will be 6-8 months into decomp orthodontics. 

[ditterbo]

My biggest problem is that the first guy over-rotated my upper jaw too far to the left.  I get a cramped feeling like everything does not have enough room back there on that side.  As well, instead of double jaw surgery (lower jaw is crooked), he tilted the upper jaw to match the cant of the lower jaw.  Dumb idea.  So what you end up with is and over-rotation, several mm cant in both jaws, and a misplacement of the midline by 3mm or 3 & a fraction of a mm more.  I hope it would be deemed medically necessary.  I'm not planning that way, but I hope so.  The insurance lady at Arnett-Gunson seemed to help put my mind at ease a little bit by reassuring me that the have a good relationship with Anthem and have been applying to insurances for over 30 yrs.  I hope I can get a better idea once I go in for a consult and they actually see my mouth in person.

Your plan won't be exactly this, but in my plan your situation would probably be accepted by insurance.

Transverse discrepancies:

Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms; or

Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth; OR

Asymmetries:

Anteroposterior, transverse or lateral asymmetries greater than 3 mm, with concomitant occlusal asymmetry.