Every day is exciting when you're dealing with insurance companies, let me tell you. Right after I got home on Thursday I called the insurance company to figure out how to start my first level appeals process. The lady I got ahold of said that there was nothing to appeal, as the procedures and materials for orthognathic surgery are specifically NOT a part of my benefits package - they are specifically excluded. We talked for quite a while, and she ended up recommending me to write a personal statement about why I thought I needed the surgery despite what my insurance covered, and to label it as a "second level appeal" instead of a first level appeal, which I should be doing.
I called my school benefits people shortly after, and explained to him that I can't appeal something that hasn't been denied, and that I was worried it would take a long, long (too long) time to get another denial before I can start appealing with THEM. So he sent me the package and kind of explained what I have to do.
I have to write a personal statement and get letters from my orthodontist and surgeon about why the surgery is necessary. I have to get documentation from every person that's seen me for my headaches or jaw pain. I need to have an estimate of what the surgery will cost. Then I'll hopefully appear at a hearing with the school benefits people where I'll plead my case prior to them making a decision. I've also got a "jaw functionality" report that I need to fill out for my surgeon's office (and I'll be using it in my hearing).
I'm so scared. If any of you out there has example letters that you've written to appeal your case, can you share them with me? I'm really confused on how to write my letter/personal statement... My email is sheppard.stephanie@gmail.com or stephanierae2804@yahoo.com, if you don't want to put them online.
Our computer has been pretty wonky lately, so if I don't respond to comments quickly it's because I can't get on blogger from my school internet. I can check both emails, but that's about it.
I'll keep updating as I get more info.
2 comments:
Hi Stephanie, sorry to hear about all of the insurance complications. I will e-mail you my appeal letters, one from my OS, one from my OD (which was brilliant), and one which I wrote. The difference, however, is that I just needed to prove medical necessity. My plan did cover orthognathic surgery, but in the exclusions from my plan were cosmetic procedures. So, basically, I needed to prove it is medically necessary and not cosmetic. It sounds like not only do you need to prove medical necessity (which I believe should be no problem for you), but you also need to make a compelling case as to why they should make an exception and cover orthognathic surgery. I don't know where to start with that one, but I do remember reading some things on the yahoo site. Apparantly, it is illegal to exclude orthognathic surgery in some states, I believe CA is one of them. I am not sure about the state of WA. It might be worth a search on the Yahoo site to see if you can dig up some info. In the mean time I will e-mail you my letters and what I learned is helful when proving medical necessity. Keep us posted!
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