MMA insurance info + victory dance
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MMA insurance info + victory dance

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Posted by dirtywater on December 20, 2007 at 23:52:49:

Hi all,

I thought I would share some information about the insurance claim for my MMA (double-jaw surgery). I hope someone finds this useful.

I originally introduced myself in non-CPAP forum 19 (January 23, 2006). Two years later I'm 15 lbs heavier, still very tired, and finally ready for surgery! It's scheduled for January 15th, 2008 with Dr. T in Boston. (It took the braces a while to do their thing, plus the surgeon books out 3 months in advance.) What a journey this has been! I will try to compose another post about the upcoming surgery. But suffice it to say that the preparation for this surgery has been like a part-time job for me!

I am in Massachusetts and I have Tufts HMO. The following documents from their website are informative. Just search for them on their website:

1) Document ID #1035186. "Orthognathic Surgery for Temporomandibular Joint (TMJ) or Severe Oral/Maxillofacial Functional Disorders"

2) No document ID. "Hospital Outpatient Surgical Fee Schedule Codes"

They require preauthorization for jaw surgery. I was a bit apprehensive because the surgeon's billing manager said that Tufts can be difficult about approving it. My surgeon wrote a preauthorization letter to them in which she diagnosed me with the following:

Maxillary hypoplasia (ICD-9: 524.03)
Mandibular hypoplasia (ICD-9: 524.04)
Obstructive sleep apnea (I think the ICD-9 was 327.23?)

She requested preauthorization for the following procedures:

LeFort I Osteotomy (i.e. upper jaw)
Saggital Split Osteotomy (i.e. lower jaw)
Geniotubercle advancement (i.e. genioglossus)
Surgical splint
Model surgery


Tufts approved all except the model surgery, which was deemed not to be medically necessary. This was not surprising because the model surgery is part of the orthognathic work-up, and my Tufts policy states that they do not cover work-ups. I was pleasantly surprised, however, that they covered the surgical splint. "List price" for the splint is $1500.

These are the procedures that Tufts approved (descriptions are taken from the above two documents on their web site):

Oral surgical splint; CPT 21085

Reconst lwr jaw w/ fixation (Reconstruction of mandibular rami and/or body, saggital split; with internal rigid fixation); CPT 21196

Reconstruction midface, lefort (Reconstruction midface, LeFort I; single piece, segment movement in any direction [eg, for Long Face Syndrome], without bone graft); CPT 21141

Lwr jaw w/advance (Osteotomy, mandible, segmental; with genioglossus advancement); CPT 21199

It was difficult getting the status of the preauthorization claim over the phone. Their front-line customer service reps don't have full access to the preauthorization information. One of them told me that the information was there on his computer, but that it ran off the right side of his screen and he couldn't scroll far enough to read it :-)

Later, they mailed me written confirmation that I had been approved. The four confirmation letters were mailed separately, all postmarked on the same day. However, in a comical (or cruel?) twist, two of the letters were delayed by a week (perhaps due to a recent major snowstorm). So for a week, all I knew was that they had approved me for lower jaw surgery and a surgical splint. A week later, the second two letters arrived and I breathed a sign of relief :-)

Jeremy

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