Question
What is the name of your state? Virginia
I have health insurance through BlueCross Blueshield of North Carolina and they have denied my preauthorization claim twice (first submit, second appeal). I have one more appeal left. The situation is I need Orthognathic surgery to correct a severe imbalance in my jaw that is causing me pain. I've undergone braces treatment for a year and a half in preparation. The first denial they claimed it wasn't medically necessary. The second denial they agree it's medically necessary... well I'll let you guys take a look. What can I do to refute this claim?
""A Board Certified DMD specializing in Oral and Maxillofacial Surgery
reviewed your case his assessment is that "this patient has a
significant developmental anterior open bite malocclusion that can
only be corrected by a combined orthodontic/orthognathic surgical
treatment plan. He has a significant tranverse discrepancy, which
again can only be corrected by orthognathic surgery. Although he has
adequate signs and symptoms there is no documentation of the use of
anti-inflammatory medications, diet alteration, or elimination of
aggravating factors in an attempt to eliminate the painful symptoms.
Although conservative therapy may not be successful in this patient,
in order for the medical necessity criteria to be met, it must be
attempted for at least 4 months."
BCBSNC's Plan Medical Director also reveiewed your case and agrees
with the Board Certified Oral Surgeon, that conservatitve therapy must
be attempted and according to this review there is no documentation of
that being done. Therefore your request for approval cannot be made."
Answer
Attempt more conservative treatment for at least 4 months.
Answer
I shouldn't have to do that. Here's more on the situation. I've been in braces since December 2005 after being diagnosed by my dentist, orthodontist, and oral surgeon that the Orthognathic surgery was the ONLY way to correct my condition. I was supposed to have the surgery done December 2006. Through December 2006, I had BlueCross Blueshield of South Carolina (Different company, my current is North carolina) and they were going to APPROVE they surgery, but due to scheduling conflicts, I couldn't have it done in December and it was prolonged to 2007. Well in 2007 my company switched providers to BCBS North Carolina, and now a company bearing the same name is denying it.
In the appeal rejection above, their own oral surgeon is admitting that the surgery is the only means to correct my condition. The four month policy is bogus - we just switched to them, how am I supposed to know to have four months of documented treatment? Not only that, my oral surgeon and orthodontist said such conservative therapy would do absolutley nothing to help my condition and it was even admitted above by their own oral surgeon. They claim the only reason their sticking the four month treatment in my face is because they are looking for any possible reason to deny my claim and make the situation suck even worse for me.
I am looking for ways to refute it. I don't feel I should have to spend any more time than I have to. According to my oral surgeon, their proposed conservative therapy is a common sense measure. Me, being in pain, of course is not going to eat any rough substances or do anything to experience pain or worsen my condition. The only thing is that hasn't been documented. But I shouldn't have to - they are stalling because they simply do not want to pay.
Answer
When you decide to stop whinning like a two year-old you might get an answer. I'm not going to bother since you don't have anything resembling a legal issue.
Answer
Maybe I'm on the wrong forum then. I was just looking for advice. I didn't realize negative trolls even existed on forums such as these. BelizeBreeze you can go to hell. And if you want to ban me for saying that then go ahead. I have no desire to be on a forum where the members talk to other members like that.
Answer
Peace out!
Answer
Maybe I'm on the wrong forum then. I was just looking for advice. I didn't realize negative trolls even existed on forums such as these. BelizeBreeze you can go to hell. And if you want to ban me for saying that then go ahead. I have no desire to be on a forum where the members talk to other members like that.
Whether you like it our not, you received accurate information...
You need to follow more conservative treatment for 4 months. Then you can get your surgery.
Answer
What is the name of your state? Virginia
I have health insurance through BlueCross Blueshield of North Carolina and they have denied my preauthorization claim twice (first submit, second appeal). I have one more appeal left. The situation is I need Orthognathic surgery to correct a severe imbalance in my jaw that is causing me pain. I've undergone braces treatment for a year and a half in preparation. The first denial they claimed it wasn't medically necessary. The second denial they agree it's medically necessary... well I'll let you guys take a look. What can I do to refute this claim?
""A Board Certified DMD specializing in Oral and Maxillofacial Surgery
reviewed your case his assessment is that "this patient has a
significant developmental anterior open bite malocclusion that can
only be corrected by a combined orthodontic/orthognathic surgical
treatment plan. He has a significant tranverse discrepancy, which
again can only be corrected by orthognathic surgery. Although he has
adequate signs and symptoms there is no documentation of the use of
anti-inflammatory medications, diet alteration, or elimination of
aggravating factors in an attempt to eliminate the painful symptoms.Although conservative therapy may not be successful in this patient,
in order for the medical necessity criteria to be met, it must be
attempted for at least 4 months."
BCBSNC's Plan Medical Director also reveiewed your case and agrees
with the Board Certified Oral Surgeon, that conservatitve therapy must
be attempted and according to this review there is no documentation of
that being done. Therefore your request for approval cannot be made."
The above posters are right. Like it or not, fair or not, BC requires documentation of "conservative treatment". Make sure there is a notation in your record each time you are seen that meets these requirements (ex: taking anti-inflammatory....not chewing gum or eating jaw breakers ...taking meditation classes to relieve your "stress" ). The sooner you start, the sooner your 4 months will be up.
After all of that, you need to be aware that there still is a good chance it will be denied. Sorry 'bout that. It's just the way it is. Good luck!
Answer
These are the guidelines written into your policy and you need to follow them if you want the treatment covered. Even if you and your doctor both know it's going to be pointless, the conservative treatment MUST be attempted and MUST be documented in your doctor's records before it can be considered by the insurance company. Sorry, but there's not going to be any way around it. That's the way it is.
Answer
Your have a contract with your insurance company. Your insurance company and you agreed that coverage for Orthognathic surgery would be approved if you met the insurance company's guidelines. Whether you and/or your doctor feels that the conservative treatment is unnecessary is not the point. I know you feel that it should be, but it's not. IF you want your insurance company to pay for your surgery, you need to obtain you insurance company's guidelines and have them followed. Otherwise you will lose your next appeal , your external appeal and even a law suit.
Although he has adequate signs and symptoms there is no documentation of the use of anti-inflammatory medications, diet alteration, or elimination of aggravating factors in an attempt to eliminate the painful symptoms. Although conservative therapy may not be successful in this patient, in order for the medical necessity criteria to be met, it must be attempted for at least 4 months
Have you had any of the above treatment? If so get the documentation. I understand how frustrating the process is. I just went through it myself. Call your doctor tomorrow and get your anti-inflammatory prescription and fill it. If you want to take the meds or flush them down the toilet, no one will know. Find out from your insurance company how you document diet alteration and elimination of aggravating factors, get it in writing and follow it. Then file a NEW pre-cert with all of the documentation. It will take you at least 2+ months to get your appeals through anyway.
In the future, you can avoid your current problem by pulling the guidelines when you first think you will need the procedure and not waiting until you are scheduling the surgery.
Good luck.
Answer
An appeal wouldn't be appropriate anyway. You appeal on the grounds that you MET the criteria, or that going through the required conservative treatment would pose a significant threat to life or limb. Neither of which are the case here.