Tips for fighting a non-covered procedure?

May 3, 2006 5:22 AM

Health insurance question: My daughter needs a "non-covered procedure". Can I successfully fight that? Can anyone provide any tips for successfully challenging the denial of coverage for a given procedure?

I work at a university, which (as I understand it) is basically self-insured using Blue Cross & Blue Shield to administer the plan. It is a pretty decent plan, but Murphy's Law seems to have hit and a procedure needed by my daughter is not covered. (Her orthodontist discovered that her bite only touches on 4 teeth. The oral surgeon calls it a "correctable deformity" and says when she takes a bite out of a ham sandwich, she leaves the ham.

The surgery is that fun one where they cut the jaw bones and realign the jaw. While some people may have this procedure for purely reasons of appearance/cosmetics, in my daughter's case, it is to correct a genetic deformity.

As you might imagine, this is an expensive procedure and we will have a difficult time paying for it out-of-pocket. Can anyone provide any tips for successfully challenging the denial of coverage for a given procedure? My daughter and I thank you in advance.

posted by spock to work & money (14 comments total)

I think the key to winning insurance disputes is to win the medically necessary battle. That might cause you problems. No doubt the surgery will make your daughters life better - but can you make an argument that it is medically necessary?

What did the ortho say? Can he write a letter explaining why he feels the surgery is medically necessary? My wife had a dispute with our insurance company back with insulin pumps were brand new. Insurance company didn't want to pay for it - doctor wrote a letter explaining all the bad and expensive things that might happen if my wife didn't have a pump, insurance company relented. So it does happen.

Good luck - but start thinking about how you might raise the money as plan B.
posted by COD at 5:51 AM on May 3, 2006

COD seems to have the right idea. If you can make the case that it's worse for the insurance company to let this slide they are much more likely to give in.

I'm willing to bet most of the people who get the surgery for cosmetic reasons clam that they really need it in order to get the procedure paid for. But they can't make the case that not correcting their bite will lead to greater problems down the road. You can. Unless the insurance company is managed by morons they should be willing to cooperate just to save themselves money.
posted by oddman at 6:00 AM on May 3, 2006

First, speak with the doctor's office to see what they can do to provide documentation to the insurance company showing why they feel she needs the surgery and that it is not for cosmetic reasons. They may need to do x-rays or take a cast of her bite.

Second, speak with the person at the doctor's office who handles their insurance billing and ask for advice from that person. Since they work with insurance companies on a daily basis, they have great insight as to how to go about this.

Third, if the company says "No", try again and again. Insurance companies will frequently deny a claim but will pay if yoiu contest it. In this case, you're trying to prove that you're correcting an issue which directly impacts how your daughter chews.

Finally, this is the hard part. Be patient. Always speak nicely to the insurance folks. Getting testy with them will make them less likely to help you.

Oh, one last thought... see if getting this classified as a medical necessity and not dental will make the difference. If you can get your daughter's physician involved and get him to refer you to an oral surgeon, you may get this covered.

Good luck.
posted by onhazier at 6:00 AM on May 3, 2006

Ask the insurance copmany for a hearing or in person case review. I had a problem with my septum that made breathing through my nose difficult. The surgery to correct it was a rhinoplasty, which is generally cosmetic. I got a sit down with the insurance company, we reviewed documentation from the doctor, and they covered the procedure.
posted by jimfl at 6:06 AM on May 3, 2006

You might also want to get a second opinion from a different doctor (dental vs. medical) - like a Craniofacial or Maxilla Facial office. It might be viewed less like cosmetic correction and more like a medically necessary procedure. Also, she may have sleep apnea or other more general airway problems due to the misalignment, seeing an Otolaryngologist might help the case.
posted by blackkar at 6:32 AM on May 3, 2006

Have you talked to a second oral surgeon or orthodontist? I was reading up on jaw joint/TMJ conditions a few months ago and there's some level of skepticism about the number of surgeries done that may not be necessary. There are a lot of mouthpieces that are aimed at slowly moving the jaw into place that your insurance company might cover. Is there a claims representative you can ask to determine what they do cover and who a good doctor may be for a second opinion?
posted by mikeh at 8:04 AM on May 3, 2006

My university's health plan self-insured and administered by BCBS, one thing ive wondered, is if you can appeal to your benefits office instead of BCBS, or try going up the chain from there into the school's higher administration.
posted by yeahyeahyeahwhoo at 8:09 AM on May 3, 2006

If the plan is self-insured, then the ultimate decision on whether the claim will be paid lies with the employer. If you talk to HR and explain the situation, they may be willing to make the case to management that this is a good instance to grant an exception and pay the claim in order to keep an employee happy. The other scenario is that your employer will hide behind the administrator's adjudication, either because they're wary of granting exceptions or because they're cheap.

I would do this before trying to wrangle your way through the administrator's appeal process as you're unlikely to be able to make a convincing case if it's something that's explicitly excluded in the contract.
posted by MarkAnd at 8:11 AM on May 3, 2006

Not to be a wet blanket here, but your question doesn't actually make a lot of sense.

"Correcting a genetic deformity" and "cosmetic reasons" aren't mutually exclusive, for one. Something can be a genetic deformity and have only cosmetic effects, and I'm not an expert, but are dental problems like that EVER not caused by genetics?

Also, you claim the dentist says she can't eat a ham sandwich. You're her parent, you should know that better than he does. Does it ACTUALLY cause problems with her eating?

My experience with dentists is they tend to act as if everything is really deadly important (and they have big words to prove it, like "malocclusion" when most of the time, it IS cosmetic.
posted by dagnyscott at 8:57 AM on May 3, 2006

I have this problem, and we convinced our insurance to cover it. You have to talk to your oral surgeon about the down the line effects this will have on your daughter. In my case, the mis-alignment led to bone degeneration and arthritis in the jaw joints. I have pretty severe pain in both jaw joints as well as constant headaches from tensing my muscles to keep the jaw placed in a better position for eating and speaking. For me, this is something that will only get worse. If the surgeon thinks this is something that will degenerate, the insurance company should be more willing to cover the procedure.
HOWEVER, not everyone with the problem will end up this way. It's also possible that the deformity will remain exactly as it is and cause no more than minor annoyance. One of my good friends has a nearly identical problem and she has no pain from it whatsoever. Her biggest complaint is that she can't eat onion rings. She won't, and shouldn't, get corrective surgery.
A good oral surgeon will both be able to tell you how necessary the surgery really is and go to bat for you if you decide you have to have the procedure.
posted by ohio at 9:31 AM on May 3, 2006

The trick is that the explanation should be by the oral surgeon, not by the orthodontist. Provide an evaluation, not a recommendation. Including health risks resulting from dental problems that she will incurr while still a minor and therefore covered under this health insurance.
posted by desuetude at 9:35 AM on May 3, 2006

I had exactly this same problem, but thankfully my parent's insurance didn't give us a hassle covering the surgery. I'll just reiterate a few points made above:

- if you don't already, you need an oral surgeon to make the official call that your daughter needs this procedure; ideally, the surgeon should have a good billing staff that's used to dealing with the hassles of justifying this kind of work.

- one of the things that will help make your case is the medical necessity of the procedure. Even if your daughter isn't having issues yet, the potential for more serious complications later is not a trivial matter. Personally I had no issues with jaw pain yet, but because of the bite only contacting at my back molars, I had a tremendous amount of wear on those teeth, my dentist said at 15 I had the wear of a 30 year old.

- it may help to have your surgeon, orthodontist and dentist sketch out a treatment plan for your daughter, so the insurance can estimate the cost. My experience was that the surgeon and orthodontist worked pretty closely figuring out how to correct my issues (I had orthodonic work 2yrs prior and 6mo after the surgery), and those estimates did help getting a relatively quick approval from insurance.

-one last note - not to discourage you, but even if you get the surgery covered, chances are you'll still be on the hook for some substantial orthodonic bills (unless you have orthodonic coverage)... you may want to keep that in mind as you plan/budget.

p.s. if you have any more questions about the procedure/etc itself, feel free to contact me (email's in the profile), and I'd be happy to share my experience.
posted by dicaxpuella at 11:57 AM on May 3, 2006

first, i hate to say, but get used to this, everybody...the insurance industry is rapidly heading to a 'deny first, ask questions later' system...

- first, don't be discouraged at this point, because insurance preauthorization these days is all about roadblocks...they spend tons of money to put a whole bunch of bodies in between you and their bank vault--arguably, more than they would spend if they just authorized the stuff in the first place...

- the oral surgeon should submit a letter of medical necessity, as others have mentioned here, and should clearly state the proposed treatment as the 'standard of care' (important words in insurance oversight) for this condition, as well as indicating the possible medical complications resulting from non-treatment...

- for any appeals, the oral surgeon should insist on a peer-to-peer review with another oral surgeon (as opposed to one with a guy who got his medical degree in a one-year crash course in el salvador and happens to do a good david spade impression)...
posted by troybob at 1:00 PM on May 3, 2006

Just so you know, my teeth only meet at about four places, none of them at the front. The worst effect for me is that I can't bite sticky tape except with a canine, and I have trouble eating chinese dumplings with chopsticks. Ham sandwiches are no problem; you can tear ham.

Then again, I am British, which means that 'genetically deformed' teeth are part of my national identity. As is free orthodontistry.
posted by cogat at 3:16 PM on May 3, 2006