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Re: Scheduled MMA

Posted by sleepy-in-seattle on December 28, 2005 at 11:54:30:

In Reply to: Scheduled MMA posted by snores-a-lot on December 28, 2005 at 06:22:59:

The method I used for convincing insurance company:

Initially, I went to the orthognathic surgeon. He instructed me to "build my case" by proceeding in a stepwise fashion.

1) I went to my Primary Care Physician to get a referral to a specific sleep center. I complained that CPAP did not seem to be working anymore (the truth) and I believed my OSA had returned after UPPP surgery in 2000. (This was therefore documented.)

2) I had the sleep study. Since CPAP was not working for me, they then referred me to a sleep disorders surgical consultant. (Again documented.)

3) The sleep disorders surgical consultant looked at my results, did a laryngoscope with video, and recommended an MMA with the *maximum* advancement. My airspace behind my tongue was 2mm sitting up, 0mm laying down. (Again, this was documented.)

4) I was referred to my original surgeon - what a coincidence! His office then spent the next four months sending the package for predetermination over and over again. When they finally admitted to receiving it, they denied coverage. We initiated an appeal and it was approved.

You still have a chance to *document* the fact that CPAP does not work for you (with your primary physician). Then get a written referral to your surgeon. Have them document their appraisal and recommendations. Then do the predetermination, making sure that

a) CPAP not working
b) significant sleep apnea
c) recommendation of MMA (and GA?) as the best course to treat your OSA *due to your specific physiology*

are all included in the predetermination package.

Also, make sure that orthognathic surgery for OSA treatment is covered by your insurance. My insurance company excluded any orthognathic surgery except for OSA. We had to keep pointing them to their own plan summary to remind them of their legal obligation.

Out of network just means they will cover less. If the hospital is in network, you might get full coverage there. I was able to get full coverage for the hospital and anesthologist.

Recipes for liquid diet - someone posted a link to a product site called zip and squeeze or something similar. I think they sell a low cost booklet full of recipes. Do a search in this forum for "zip" and I'll bet it pops up.

You might consider doing the septorhinoplasty first. MMA may cause some severe nasal congestion for awhile (the upper jaw advancement causes a lot of stress on the sinus area, especially if you are already nasally compromised).

If you haven't looked already, earlier forums this year had recovery posts from Seattlebill, myself, and Westernjoe (and many others, but these were the longest and most detailed). Westernjoe even created a website/blog. There is a ton of nuts and bolts information there for the actual recovery. I'd recommend reading ALL of it.

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