Today was a good day in my journey towards getting my underbite fixed.
Many of you know that I started this process in October of 2012 when my then new dentist encouraged me to start the journey of looking into getting my underbite fixed with
orthognathic surgery.
Here are some links to my previous posts detailing this if you're interested:
Post 1: My New Metal Mouth
Post 2: My First Surgery
We originally started to plan the surgery for December of 2014, but that didn't work our for several reasons.
Long story short...Sarah changed jobs in January. Leaving her last job in December meant our health insurance left too. We had pre-approvals for everything with the surgery with the old insurance company and we were hopeful things would be good with the new insurance company, that we got through my work.
In January, my surgeon's office called the insurance company to check if all the surgery stuff (including pre and post op) were covered billing codes. They said yes those are covered codes, but you will need to get a pre-authorization. So, we planned to have the surgery the first week of May 2015.
We were all systems go at this point, or so we thought...
In February, the surgeon's office put in the authorization request, I got FMLA and short term disability approval from work, and we had everything scheduled.
Then one March afternoon, about a month after we requested the authorization, I got the mail on my way home like I do most days. I don't remember the exact day, but on this day there was an envelope from my insurance company. I opened the envelope to find a letter from my insurance company saying the authorization for a pre-surgery CT scan and any surgery was denied due to an exclusion for dental procedures in my insurance policy.
We were in shock. It seemed very odd after being told the billing codes were covered, and having many medical professionals tell me this surgery was "medically necessary" for me, to get a denial of benefits.
The bad news: a denial; the good news: you can appeal the decision.
So we appealed. My surgeon's office put together documentation proving the medical necessity, including letters from the surgeon and my orthodontists. We felt good about this appeal and thought we had a good chance based on all the evidence we provided. The appeal paper work was faxed the first week of April 2015.
Due to some weird appeal authorization (we were told we did not need) required for the surgeon's office to appeal on my behalf, the appeal did not get looked at until May 27th.
The first level appeal panel, upheld the initial decision citing the same vague dental exclusion, which in my opinion likened my jaw surgery to getting a tooth pulled or getting x-rays.
At this point we were unsure what to do, but the paper work said we could do a 2nd Level Appeal. So that's what we did. My surgeon's office gathered more information and evidence and sent off the 2nd level appeal, the last week of June.
After a lot of waiting, considering, and praying, we started looking into options to have the surgery without using the insurance. Sarah and I looked at loans, borrowing against her 401K, starting a Go Fund Me Page, etc.
On August 14, I received an email from a Grievances and Appeals Analyst named John from my insurance company, inviting me to attend a meeting on September 2 to state my case for why I believe the surgery should be covered. I did not get such an invitation for the 1st level appeal.
This bring us to today. This morning September 2, 2015, Sarah & I attended this 2nd level appeal panel meeting. We were almost late due to the wonderful Denver traffic. Thanks Denver!
When we got to the insurance building we were met by John. He gave us an overview of what would happen in the meeting and told us that they would make a decision on the appeal today after our meeting.
The meeting lasted about 20 minutes for us. The meeting facilitator introduced the three panel members who would be voting and explained the agenda to Sarah and I. Then they had the Analyst John, give a summary of what we were asking in the appeal to the panel.
At this point the facilitator gave me the floor and allowed me to present my case for why I believed the surgery was medically necessary. Sarah added a few points as well!
Next, the facilitator asked the panel if they had any questions for us. They asked a few questions. Then our part was done.
We thanked them for allowing us to be there and for listening to our case. John walked us out, and now it was time for them to review all the info, deliberate, and most importantly, vote.
We were really unsure what to expect from this appeal meeting, but it was all rather cordial and pleasant. When we were leaving John said to me, "You did a really good job!" Sarah and I took that as a sign to be cautiously optimistic.
As we were leaving, John told us he would send out paperwork later this week with the panel's decision, but I asked if he would email me today, so I would know and not have to wait for days for an answer.
Sarah and I got back to our house in Colorado Springs from Denver and there was an email waiting from John.
The verdict was in...we checked nervously...APPROVED!
We were ecstatic! I jumped around the house like a little kid at the excitement of Christmas shouting, "Praise the LORD!"
So, now we will start the process of getting the surgery planned again, this time with insurance approval!
I am so thankful for the many family members and friends that have been praying for this. The past eights months have been hard dealing with this. Today was a huge relief and blessing!
I'll will keep this blog updated with surgery details, so be looking for that.
As always, thanks for taking the time to read my blog. May God richly bless you and your family!
