how do insurances companies determine if jaw surgery is medically necessary?

[kara1179]

I know some medical insurances will pay for jaw surgery if its proven to be medically necessary. What does "medically necessary" to an insurance company entail? My symptoms are recessed lower jaw (I posted pics in another post), moderate overbite, clicking aND popping of left side of jaw, very crowded/crooked middle front and lower teeth.  When I bite down on my natural bite it feels very awkward and feels like my tongue is being pushed back into the back of my throat. It also feels like I can't breath very clearly (I can still breath, but not as clearly as I can if I push my jaw forward). I have a lot of symptoms of sleep apnea as well.

I've read that sometimes insurance companies will try to say the recessed jaw probelms are a pre existing condition? What does that mean? I was born with my jaw like this, of course it's pre existing. I have never had any orthodontic treatment other than a palate expander.

I really want to set up an appt with a max face surgeon, but im nervous my insurance company won't pay for it or even some of it, and there's no way I can pay for it all anytime in the next 5 years. ALSO, In 3 months I have to come off my father's insurance because I'll be 26, and I have to find my own. Any recommendations on a good insurance company and plan that works well with jaw surgery?

[Lazlo]

I know some medical insurances will pay for jaw surgery if its proven to be medically necessary. What does "medically necessary" to an insurance company entail? My symptoms are recessed lower jaw (I posted pics in another post), moderate overbite, clicking aND popping of left side of jaw, very crowded/crooked middle front and lower teeth.  When I bite down on my natural bite it feels very awkward and feels like my tongue is being pushed back into the back of my throat. It also feels like I can't breath very clearly (I can still breath, but not as clearly as I can if I push my jaw forward). I have a lot of symptoms of sleep apnea as well.

I've read that sometimes insurance companies will try to say the recessed jaw probelms are a pre existing condition? What does that mean? I was born with my jaw like this, of course it's pre existing. I have never had any orthodontic treatment other than a palate expander.

I really want to set up an appt with a max face surgeon, but im nervous my insurance company won't pay for it or even some of it, and there's no way I can pay for it all anytime in the next 5 years. ALSO, In 3 months I have to come off my father's insurance because I'll be 26, and I have to find my own. Any recommendations on a good insurance company and plan that works well with jaw surgery?

It's really f**king easy to have it deemed medically necessary. Just have the surgeon when they do the x-ray examine your airway and if it's smaller than "normal" which it will be if you have a recessed lower jaw, then you theoretically have a danger of developing sleep apnea (or you already do). All the surgeon has to say is you have a possibility of developing sleep apnea, you may even go for a sleep apnea test where you will sleep over at the hospital and they will test everything, like your heart rate etc. etc. over the night and determine if you snore at night and your breathing is compromised at times. Other reasons could be TMJ which they can also tell from your x-ray etc. etc. jaw problems, grinding of teeth and irregular bite etc. etc. Any of these or all together could be used. Go get a consultation first!

[dantheman]

I would be careful about making generalizations about insurance coverage. Since jaw surgery is one expensive ordeal, insurance companies carry an invested interest to limit payouts. I would be surprised if all it took was a surgeon to state that you have narrowed airways to ensure full coverage for a BSSO or bimax procedure. In fact I would expect that they would request a full sleep study documenting obstructive sleep apnea and an accompanying letter from the surgeon stating the goals of surgery. You simply cannot diagnose sleep apnea based on airway parameters and quite frankly insurance companies don't give a s**t if you are "at risk" of developing sleep apnea in the future based on your anatomy.

[Alue]

I'm assuming you are in the US.  Insurance companies can no longer deny you for pre existing conditions if they are ACA compliant.  If you are about to lose your plan and can't get one through your employer you can get one now through healthcare.gov, open enrollment is still going on for 2015 ACA plans.   That being said, the guidelines for jaw surgery that insurance companies are now going by have gotten more strict.   A lot of it is going to start coming down to the bite unless you can prove there is a narrowed airway causing OSA.  Unfortunately, if you had a "compromise" orthodontic treatment with premolar extractions and growth modification, which I did, it's going to be harder to prove the necessity. 
Still there are a few things a surgeon can do to help your chances... 

I would go consult with a surgeon or two, and get their opinion, also ask the font desk which insurance carriers they have the most luck with. 

Just have the surgeon when they do the x-ray examine your airway and if it's smaller than "normal" which it will be if you have a recessed lower jaw, then you theoretically have a danger of developing sleep apnea (or you already do).

That's not always the case sadly.