Friday, April 10, 2009

update part deux

I completely misunderstood what was happening with my school district vs. insurance company. Since there IS a specific exclusion, it's up to my school district to pay for my surgery or not to pay for my surgery. End of story. I don't know where THAT misconception came from, but it sure was a big one - I had my poor insurance company (ha) on a wild goose chase. Oops.

I feel like I'm completely annoying the school district people. I don't mean to inundate them with information about my situation - but it seems like the more they know, the easier making an informed decision will be for them. And since this doesn't seem to be the most common problem in the world, I want them to understand what my daily life is really like. And I want them to understand that this is a last resort - not just a flyby could-possibly-help surgery - it will change my quality of life considerably. CONSIDERABLY. I've tried so many things to make this better and have had migraines my whole life - to think that I could go for weeks without a migraine? To think that I could eat a steak or chew a piece of gum and not be sick for a week? To chew breakfast, lunch, and dinner? To not have to worry about playing my clarinet or trumpet in class or in rehearsals too much. To be able to play my saxophone. The list goes on and on and on.

Well, all I can do is wish and hope and pray. And leave the insurance and school district benefits people alone.

Oh! I wanted to put out MY appeal letter in case someone is writing their own - it took me FOREVER to write and had it not been for help from Stephanie I'm not sure it would be as decent as it is.

To Whom It May Concern:

I am writing this letter to serve as an appeal to the denial of insurance coverage for the surgery recommended to me by Dr. Bruce Molen, Dr. Rick Molen, and Dr. Jessica Lee. This surgery is medically necessary, and Regence Blue Shield turned me down because the plan specifically excludes orthognathic surgery – not because of medical necessity. I would like to appeal that exclusion.

I have been exploring non-surgical methods to deal with my migraines and chronic jaw discomfort since college with limited success. While I had gotten migraines prior to college, they were solely hormonal in nature and very seldom. In college when they began to occur frequently, I began to seek treatment at the medical center in Ellensburg. My doctor tried topomax to prevent migraines, which had no success. I responded to Imitrex taken early on in a migraine, but after 4 years of taking Imitrex I began having “rebound migraines” every time I took it. I am now on Zomig, which is only minimally successful in treating my current migraines. I also suffer severe side-effects from Zomig.

When I had my first consult with my orthodontist back in November of 2007, I was only interested in straightening my teeth, as they were becoming too crooked to play my clarinet well. After showing me the misalignment in my jaw, he asked me if I suffered from migraine headaches, and then explained that all of the tension in my jaw (from posturing it to a “normal” position) was likely a cause of most of my migraines. I was amazed.

Currently, to prevent migraines and to relieve jaw pain, I wear a splint at night and during the evening hours to help my jaw relax and to prevent me from clenching. I have seen chiropractors, massage therapists, and acupuncturists. I take ibuprofen 3-4 times a day and Amrix, a muscle relaxant usually only used in the short-term, every evening. I have also completely changed my diet to prevent migraines and jaw pain. I do not chew food for more than one meal a day. My diet consists almost solely of oatmeal, yogurt, soup, smoothies, and pasta.

Despite all of these precautions, I have moderate to severe jaw pain almost every day and a migraine headache 3-5 times a week or more. I have already missed 10 days of work this year from migraine headaches so severe I am unable to function. Last year I missed 9 days of school due to migraine headaches. I have also missed countless rehearsals outside of school and days of work at my part-time job. A migraine headache for me consists of blurred vision in my left eye, sensitivity to light and sound, nausea and vomiting, severe pain in the front left side of my head and temple, and dizziness, plus muscle pain in my jaw and the muscles around my jaw.

I am a middle school band and orchestra teacher. I am also a semi-professional musician who plays clarinet for organizations around the south sound area. As my jaw has continued to deteriorate this year and migraines have become more and more frequent, I have been forced to turn down performance gigs. I also find myself not playing examples for my students in class for fear of migraines and jaw pain. I can often be found in my classroom with the lights down low and wearing earplugs to try to keep my pain level manageable.

If my condition is not corrected I have a very high chance of my symptoms continuing to get worse over the years. I have already watched my symptoms get significantly worse over the last two years, and personally and professionally I cannot allow them to continue to deteriorate.

Thank you for the consideration of this appeal. Dr. Molen, Dr. Lee and I would be happy to discuss with you in further detail about this procedure if necessary.

Stephanie Sheppard


changes911 said...

steph i know all about the military and their healthcare system. All I know is military. I have never lived off base in my life. My dad was military, and now I am. If your husband is active duty you will not have to pay for your surgery. AT ALL! In fact....while your husband is in his training you should be under tricare....
Anywho, your hospital stay, anesthesia, all that is free. I am getting my surgery done through the Navy.
But like I said I am pretty sure that your hubby is acive duty now. If you want to get a head start you can all your local army bases dental clinic (sometimes Oral surgery is at the clinic/hospital) and see if they have an oral surgeon that does orthognathic surgery. if the army does not have one, then they will call you in to have an eval and send you out to another branch to get it done. either way you are covered, and you will get your surgery....and you should still get it this year. call this number:1.888.874.9378
they should be able to tell you if you are currently covered. this is the tricare west number. good luck, and if you have any questions you can email me. i'll figure out how to send you my email without making the message public.

laura said...

Holy &$%& ... what a mess! I really hope that you can get it done through the military.

Canada is still expensive if you have to pay for it yourself, and you have to live in the province for 6 months before they cover you.

Though ... my friend had to spend the night in the emergency room when we first arrived there, and they took her in and sent her a bill for something like $300 later, which I realize now is super cheap.

Thailand is meant to be great for general medical and dental. Inexpensive and high quality. Google "thailand medical tourism".

I really hope the military just takes care of it for you and that all of this is over soon. Hang in there!

Reuel said...

Although we have different insurance issues, I know how you feel. It took me 4 years and three surgeons before mine was approved. My current OS had to call the Dr. who disapproved my insurance and explained the necessity of the procedures. In spite of the approval, I had to put in $10K deposit.

I am sure you'll get it. It's just a matter of time. Good luck.