What to expect out of the first consultation.

[candle1112]

I had my first consultation with the oral surgeon who was recommended to me by one of my doctors and he also takes my insurance. I drove 2 hours and met with him. They took a panoramic and ceth xray and the I spoke to the doctor for about 20 minutes where he said I would be a good candidate for double jaw surgery and that he could do it for me and that I would breath better and look better after the surgery.
He said he didn't want to do anything until I found a good orthodontist in my area (board certified), in fact, he said that he didn't want to call the insurance company until much closer to the surgery to get approval because the approval would be expired by the time I had the surgery.
My question is what should have happened at the initial consultation. (I'm new to this whole jaw surgery thing and don't' know what is usual)?
Shouldn't I have been shown a simulation of how and which way he would move my upper and lower jaws and what type of procedures he would use and by how many mm so I could see what I would look like (even it these simulations are only a rough estimate)?
Should he not have contacted my insurance company to get a preapproval or estimation of benefits or something to see how much would be covered.
Shouldn't I know his treatment plan before I start any orthodontics since the orthodontics will vary depending on what type of surgery he will perform?
He was very nice and seemed competent (has done about 200 orthognathic surgeries), but he didn't talk about any specifics at all.
Guess I need to know if I am jumping the gun and whether what I experienced at the first appointment was the usual thing and that a 2nd appointment is necessary to get surgical details and simulations.

[Optimistic]

I don't know too much about the American system, though I can say it'd be wise to do your own research. Thankfully you've found a very good forum to get you started.

As you can probably tell by now many here place huge emphasis on just who the surgeon is, let alone the type of surgery. So it's safe to say this is something that isn't for the feint hearted. In the case of your doctor pushing you into this so suddenly I'd recommend taking a step back, finding out what actual problems he has identified, talking with other maxillofacial surgeons, getting more opinions, browsing the internet to find out about different procedures and their aesthetic and functional outcomes, reading surgeons' books if you have to.

Just take your time as this isn't something you want to regret.

[candle1112]

So once I find the best surgeon for me, when do they run the simulations to show what the new profile will look like? Since my mandible has a very step plane and I have a 10mm open bite, I can't picture what I will look like when the move both the lower and upper jaws.

[Optimistic]

As far as I know there are two kinds of simulations that can be done. one involves just the x-rays to show you where the new bone would be moved to. This one I'm told involves a very high degree of accuracy.

The other is more or less photoshopping of the face to give you a rough idea of how you'd look, albeit not a terribly accurate one as soft tissue can be less predictable. That said it can still be very helpful to actually see what the surgeon believes you could look like post-op. This way you can get a feel for his idea of aesthetics and further discuss the outcome with that in mind.

[candle1112]

This doctor is 2 hours away so I needed an orthodontist up near where I live so I can go to adjustments and such. He didn't work with anyone up this way, but he said to find someone who is board certified. Interestingly enough most orthodontists aren't board certified by the American Board of Orthodontics because it is a difficult and expensive process for them to go to. I found 2 in the area who are board certified and had a consultation with 1 and she seems very good. She is the one who had me read the entire Arnette and Gunson web site so I would understand the type of surgery I needed. She is not going to do any extractions, just straighten my top and bottom arches for the surgeon to connect together (I have a severe 10mm open bite do to my jaw dropping down because of arthritis in my jaw joints that stabilized about 16 years ago).
I'm going for another orthodontist consult this week to see what his approach would be. He is the "fancy" orthodontist who works with a lot of the local celebs.
I have to go through my insurance since I can't afford a doctor's full cost. Do you guys know anyone who will take insurance (I have Cigna PPO, but if they take any insurance, they usually will take Cigna) even if I have to travel who has a stellar rep. I'm in Florida, but it looks like I'm going to have to travel to find a doctor.

[sanddunes]

Your initial consult sounds pretty standard to me.  Most surgeons will not give you a detailed plan with dolphin imaging etc. until later on.  In private practice, most actually will charge you out of pocket to do a full work up.  With one surgeon I was quoted $850 to do a full work-up with dolphin imaging, and another doctor wanted to charge me $575 for the full workup/x-rays and treatment plan.  I was told it can take up to 4 hours to plan a surgery on dolphin in order to fully consider all possibilities.  Usually the first consult is to give you a general idea of what they think should be done and whether jaw surgery would benefit you.

Unfortunately most "elite" oral surgeons are out of network with insurance.  What that means is you pay their fee up front, and whatever insurance ends up reimbursing is refunded to you later.  I would say the average surgeon fee for a private practice top surgeon is $23,000 and up.  The alternative is to go to an in-network public hospital where they will not charge you anything out of pocket (which you already know about).

As for insurance, it sounds like you will probably be approved based on the severity of your open bite.  Aetna will cover surgery for anterior open bites greater than 2mm and you have 10mm open bite.  My surgery was covered as a skeletal deformity greater than 2 standard deviatons from the norm.  I think they diagnosed it as maxillary hypoplasia.  I would see if you can find the Cigna clinical policy bulletin for orthognathic surgery which should outline under what circumstances they will cover the surgery. 

Also, you need to find out if your plan specifically excludes orthognathic surgery.  Some group policies will specifically exclude the surgery and so even if it is deemed medically necessary they still will not pay.  The pre-authorization process is something that takes a while to do and the insurance company generally wants a ton of information.  For me Aetna wanted X-rays with analysis, dental molds, orthodontic treatment plan, letter of medical necessity, Cephalometric tracings, photos, etc.  I think pre-authorizations are good for 6 months to a year, so I think it would be possible to get that figured out before you put braces on.   Once you get a pre-authorization and it expires I think you can just request an extension.

The next step for you would probably be to decide on an orthodontist and then they will meet with your surgeon to determine how to begin treatment.  At this point I would submit all the stuff to the insurance to get the ball rolling on pre-authorization.  Aetna actually requires that you get pre-authorization BEFORE you get your braces put on.  But every insurance company is different.  It is actually nice to know that your surgery will be approved before spending 6k on braces.