Orthognathic surgery, also known as corrective jaw surgery, is a procedure that involves altering the position of the upper and/or lower jaws to correct functional or aesthetic issues. While the benefits of orthognathic surgery are widely recognized, one major concern for many patients is the cost of the procedure and whether it is covered by insurance. In this article, we will explore the various aspects of orthognathic surgery and delve into the topic of insurance coverage.
1. Medical Necessity
Orthognathic surgery is generally considered a medically necessary procedure when the patient experiences severe functional problems that cannot be resolved through other treatments. These functional issues may include difficulties with chewing, breathing, speaking, or temporomandibular joint (TMJ) disorders. Insurance companies often cover orthognathic surgery when it is deemed medically necessary, as it addresses underlying health concerns.
It is essential to consult with an oral and maxillofacial surgeon who can evaluate your case, determine the medical necessity, and provide documentation to support your insurance claim.
For example, Sarah, a 28-year-old woman, has been struggling with severe sleep apnea due to her jaw misalignment. Her insurance company approves coverage for orthognathic surgery since it is deemed medically necessary to improve her breathing and overall health.
2. Orthodontic Treatment Inclusion
Orthodontic treatment is an integral part of the orthognathic surgery process. Orthodontics aims to align the teeth before the surgical procedure to achieve optimal results. While orthognathic surgery itself may be covered by insurance, it is essential to consider that some insurance plans may not cover orthodontic treatment as part of the overall treatment plan.
In cases where orthodontic treatment is excluded from coverage, patients may need to bear the cost of braces or other orthodontic appliances separately.
For instance, Michael has insurance coverage for orthognathic surgery due to his severe jaw misalignment. However, his insurance plan does not cover orthodontic treatment. As a result, Michael is responsible for the costs associated with braces, retainers, and regular orthodontic appointments.
3. Preauthorization and Documentation
Insurance companies usually require preauthorization for orthognathic surgery to evaluate the medical necessity of the procedure. As part of the preauthorization process, your healthcare provider will need to submit a detailed treatment plan, including diagnostic imaging, examination records, and documentation of failed alternative treatments, if applicable.
It is crucial to work closely with your oral and maxillofacial surgeon and orthodontist to ensure that all required documentation is provided to your insurance company for a higher chance of getting approval and coverage for the procedure.
For example, John's surgeon provides the insurance company with comprehensive documentation, including his medical history, diagnostic images, and a detailed treatment plan. This thorough approach increases the likelihood of receiving insurance coverage for John's orthognathic surgery.
4. Coverage Limitations and Conditions
While many insurance plans cover orthognathic surgery, it is essential to note that they may have certain limitations and conditions. These limitations may include age restrictions, specific functional criteria, waiting periods, or exclusions for certain types of jaw discrepancies.
It is crucial to review your insurance policy and discuss the details with your insurance provider to fully understand the coverage limitations and conditions applicable to your situation.
For instance, Megan, a college student, discovers that her insurance plan covers orthognathic surgery. However, due to age restrictions, she needs to wait until she turns 21 before pursuing the procedure.
5. Out-of-Pocket Expenses
Even with insurance coverage, orthognathic surgery often involves out-of-pocket expenses for the patient. These expenses may include deductibles, co-pays, or costs related to non-covered procedures or services.
Understanding the potential out-of-pocket expenses is crucial for patients considering orthognathic surgery, as it helps them plan and budget accordingly.
For example, David's insurance covers 80% of the orthognathic surgery costs, leaving him responsible for the remaining 20% as his co-pay. Additionally, since David opted for Invisalign treatment during his orthodontic phase, he is responsible for the cost of the aligners.
FAQs (Frequently Asked Questions)
1. Is orthognathic surgery covered by all insurance plans?
No, each insurance plan may have different coverage policies. It is important to review your specific insurance policy or consult with your insurance provider to understand the coverage and any associated conditions.
2. What can I do if my insurance denies coverage for orthognathic surgery?
If your insurance denies coverage initially, you may have the option to appeal the decision. Work with your healthcare provider to gather additional supporting documentation and letters of medical necessity to strengthen your case.
3. How long does the insurance preauthorization process typically take?
The preauthorization process can vary depending on the insurance company and complexity of the case. It may take several weeks to a few months to receive a decision. It is important to start the process early and maintain open communication with your healthcare provider and insurance company.
References:
1. Aihara, Y., Enomoto, S., & Takada, K. (2019). Decision‐making process when orthognathic surgery is covered by medical insurance in Japan – Analysis in consideration of functional severity. The Angle Orthodontist, 89(1), 91-101.
2. White, M. L., & Edwards, S. P. (2020). Evolution of Orthognathic Surgical Coverage by Insurance Providers. Journal of Oral and Maxillofacial Surgery, 78(10), e12.
3. Shahdad, S. (2017). Orthognathic Surgery: Principles, Planning and Practice. JP Medical Ltd.
