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Aetna Health InsuranceDenied me upper and lower jaw surgery

Aetna Health Insurance has approved me part of my surgery but denied me the upper and lower jaw surgery of my surgery. I have an underdeveloped upper and lower jaw (hypoplasia), non union of jawbone, decreased airway at 4mm (normal is 11mm), decreased ROM at 5mm (normal is 40mm), misaligned jaws, pain, headaches. It was determined by a world renowned surgeon that I needed joint surgery combined with jaw surgeries to completely correct my problems. They denied me on the grounds they feel the jaw surgeries are cosmetic despite the fact that six different doctors have written letters to Aetna stating the medical necessity of my surgery. My surgeon even stated my airway is not increased could be life threatening and my non-union of bone could cause infection or eventually loss of bone. Despite this Aetna continues to deny the jaw surgeries. My surgeon even wrote a letter to Aetna stating I have a 4mm transverse deficiency which falls under their guidelines to cover Orthographic surgery.


  • Th
    thesporksofdoom Feb 03, 2011

    I have the same problem with my insurance just not as severe. I have an underdeveloped lower jaw and worsening tmj problems. I meet every factor to make this surgery medically necessary according to my insurance yet despite my efforts they still choose to claim that is is a purely cosmetic surgery. The fact is that it is clearly worsening as I get older and developing new ways to affect my quality of life and ability to live properly. My doctor had warned me that all insurance companies have their heads up their [censor] around this particular issue, and I must say it seems to be very true. I got here by scouring the internet for clues and help trying to convince my insurance company. I wish you the best of luck!

    I get what your saying ticked about people expecting everything to be taken care of for them. I however do not see how you relate the need of this surgery to obesity. There is now choice that you make that ends up putting you in the position of needing this surgery. It is something that you develop from your time of conception, there is no life choice here. Also why would you buy insurance if its only going to cover the little things that you could probably handle on your own? I believe most people buy insurance to cover their [censor] when something happens that they cannot afford. Like for example a ~$15, 000 surgery on the low end to fix your jaw. You might not see jaw issues as a severe life affecting problem but thats because its quite clear that you have not experienced them. Come back to say how whiny needed this surgery makes you when you can't eat because your jaw hurts after a few bites (think about that your jaw hurts so bad that even after being ravenous a couple bites in you loose your appetite), after talking for a couple minutes, not being able to eat many foods, having your jaw lock and become immobilized so you cant talk..ect. If you want to reexamine your argument and actually make it relevant to this issue please feel free.

    Good point oldster! You get insurance to cover your [censor] despite your life choices thats why high risk people have to pay more!

    0 Votes
  • Ol
    oldster Mar 09, 2009

    Dear ticked - -Wow - where did you get that anger? Maybe you should ask your insurance company to pay for some counseling? I am sick of insurance companies asking their CUSTOMERS to make lifestyle changes, healthy choices - -like not smoking for example - --and then denying coverage for things like obesity surgery. You can quit cigarettes - - you cannot quit food. Sorry - -it's not as simplistic as you make it out to be. Obesity is caused by many factors - -and it's a shame that insurance companies are willing to replace kidneys, hearts and lungs of people who have abused themselves all their lives - -with cigarettes. YET - -they won't cover a surgery that will help someone change their life. My husband is trying to get the obesity surgery to help himself live a better life - -to help himself get off some of the medications he is on - -diabetic and blood pressure - -to help him live longer, to help him exercise better WITHOUT so much expense for health care - --
    You can't say that about cigarette smokers or alcoholics who have ruined their organs and need transplants and other costly interventions. Most of them (at least from my experience)if they don't need or are qualified for transplants suffer eventually from emphysema, COPD, heart disease/congestive heart failure, cirrhosis, etc. I do expect our insurance company to cover his surgery - -just as they would cover any other necessary surgery.

    1 Votes
  • Ti
    ticked123 Feb 20, 2009

    I am so tired of hearing people moan and groan about insurance companies denying them services. What people fail to realize is that the bottom line with services that are not covered or denied for whatever reasons is that 9 times out of ten if a procedure or service is not covered it is the fault of the employer that group insurance policies are obtained through. A perfect case in point is Bariatric surgery I cant even tell you how many times I have talked to someone that is totally outraged over the fact that Aetna or another insurance carrier is denying a medically necessary procedure. I have never heard such a whiney society! First of all, the customer service rep that you call and yell and scream at because you need this surgery because you are morbidly obese cant do a thing to change the fact that this is not covered; Have a conversation with your employer if you are ticked that you cant have this surgery. I am the first to admit that Bariatric surgery is a necessity for some people but for all of you people out there that want to eat whatever you please and gain tons of weight and then have an invasive surgical procedure to fix it don’t expect your insurance to cover this. The deductible and co insurance rates as well as co-pays are no exception to this rule, the employer works with the health insurance carrier to put together a plan that the employer can AFFORD. In reality if they pick the lower co-pay or deductible they are going to pass that expense along to you in your premiums, then everyone will complain about their premiums, which again the health carrier has NOTHING TO DO WITH. We as a society expect that everything be free in life, especially health benefits. NEWSFLASH nothing in life is free and anything pertaining to the health care field is going to be expensive. Don’t expect to get insurance or health care for free because its not going to happen. It is very frustrating to take calls from members who are screaming and yelling at you about things that you cant change and have nothing to do with. So the next time that you get on the phone and are screaming profanities at the customer service rep think twice about where your anger should be directed. Your plan is mostly based on what your employer is willing to pay for and what they want YOUR premiums to be. Think about this, you don’t buy a car without first doing research on the vehicle luxuries and gas mileage you want to get the most for your money. When its time to renew your benefits do some research LIKE YOU WOULD ON ANYTHING ELSE YOU ARE SPENDING MONEY ON!

    -3 Votes

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