P K Patel MD
6. Insurance Approval and Financial Coverage for Jaw Surgery
Jaw (orthognathic) Surgery is NOT covered by EVERY insurance plan. In many it is a specific exclusion. In some it is restricted to the underlying condition. For example children/patients who are born with a birth defect such as facial clefts, jaw deformities that result from trauma (car accidents) or from cancer or surgical resection may be covered a benefit. In many insurance policies,jaw problem that develop during adolescence, the developmenral dentofacial deformities, are not covered.
Insurance companies require photographs, x-rays and dental models. In addition they will ask for what problems are you having because your jaws. Evaluation by a speech/language pathologist, psychologists, and sleep medicine (sleep study) can greatly support the functional need for jaw surgery. Additionally a letter from your primary care doctor is important and a letter from the orthodontist stating how long you have been in treatment and this can not be corrected by braces alone will be essential.
It is important that you know the what is covered and what is not covered by your insurance policy. Please contact your insurance provider or through their website to check if your specific policy covers jaw surgery and under what conditions. We will need copy of your insurance card information to submit either a predetermination or preauthorization letter.
An complete packet for an insurance provider to review would include:
Surgeon's Letter (severity of the problem and a summary of the functional problems)
Orthodontist Letter (months of treatment, unable to correct the deformity by braces alone)
X-Rays (cephalometric x-ray and an analysis that compares it to the population sevity)
Patient Letter (what are the problems that you are experiencing)
Primary Care Physician (need for a surgical evaluation because of the functional problems)
Speech Pathologist (will jaw surgery benefit speech articulation)
Sleep Medicine (when it applies, will jaw surgery help with airway)
We will submit the above, once we have all the information. If we submit an approval for insurance request without
all the required supporting documents you are likely to get a denial and an appeal is extremely difficult. They may approve all of the procedures, some of the procedures or none of the procedures.
If jaw surgery is not a covered benefit, then we will make other financial arrangements. Our experience is that in the majority of our patients who have had to pay for the surgery, we have been able to come to an acceptable arrangement.