SMILES

My son was born with a unilateral cleft lip and pallete in August of 1999. His
surgeon recommended presurgical orthodontics (an appliance and process that helps
close the segments and lift nose) prior to his lip repair surgery. What the
orthodontist charged and the insurance company is willing to consider usual &
customary are two different worlds. I have had this under review and appeal a couple
of times already with no progress.


I would like to know if anyone else has had this procedure done, and what the
outcome was with the insurance company? I would not be so upset if they were
in the same ballpark. I think the bill was around $3,100 and the insurance
considers $650 usual and customary. It may be how the orthodontist coded the
procedure, but they do this on a regular basis.


Any feedback would be helpful, since it is hard to get a usual & customary fee
for a procedure that is so new.

My daughter was born in June 1994 and we also had the orthoditic appliance for preparing her palate for surgery. The appliance cost around 600.00 and this was in 1994. My insurance denied this claim because they didn't consider it medical. I fought them to no avail. I told them that if my child needed any other form of prosthesis, they would pay, but not for her mouth. We went as far as we could but finally paid the bill. She outgrew this appliance and had to have another one a year later and believe it or not - they paid no questions asked. They said it was a difference in the way the doctor coded it - so check out how they coded it and what your insurance company is looking for.


Hope this helps.

My son needed this to. When Ins. denied the precertification, I got ahold of the dr. and had him estimate the cost of surgery without the appliance. When this was explained they offered to pay for it at a special rate if I would agree to the proceedure!