Finding out that your child has been born with a cleft lip or cleft palate can be devastating. Finding out that your insurance doesn’t cover the necessary surgery to correct the issue can make it even more traumatic. That’s why it’s so important to know everything that your policy covers in the event you’re facing a difficult medical procedure such as cleft lip or cleft palate repair.
You’ll know what you are up against should your insurance company deny a claim for any of the varied and vital forms of orofacial cleft treatment. In some cases, surgery will be required, but this isn’t always the recommended plan.
Know Your Policy
Before any type of treatment is necessary or decided upon, you’ll want to do a thorough accounting of your insurance policy. Not every policy is the same. Some provide more coverage than others and the standards for care and treatment were likely discussed with you at the time you purchased your plan. This goes for private insurance as well as employer-sponsored plans, while some government plans may have various stipulations for coverage dependent upon the type and the state in which you live.
In most every policy, you will find a clause of Exclusions. This is one of the most important sections of the policy because it will lay out what is not covered. It will typically delineate those dental or cosmetic procedures that are not included under your plan. Another thing to be cognizant of are any clauses or passages that refer to genetic birth defects as these are almost always covered under most policies.
If you are facing some form of treatment for cleft lip or palate and your insurance company denies the claim, you should request the denial in writing. Once you receive that, read it carefully to determine the reasons they have given for issuing the denial.
Many cases that are denied come as a result of individuals who have insufficient medical knowledge and they’re just simply uninformed as to the extent of the problem, misidentifying the procedure as a mere cosmetic procedure. If the denial is issued due to cosmetic reasons, adults may have a tougher time of getting this reversed than infants and children.
Some denials also fall under dental procedures that your policy may not cover. You’ll have to state a very different case in trying to convince your provider that the repair is indeed necessary and that it is not a dental issue.
You may have the opportunity to appeal the company’s decision to deny treatment or surgery and there are a variety of ways to go about it. In preparing your case, you’ll want to emphasize the functional aspects of having a cleft lip or palate repaired and list all of the medical benefits that come with any such procedure. Nothing about these treatments should be viewed as something that is elective, but very necessary to leading a normal life.
Orofacial Cleft Coverage Mandates
At this time, there are currently 14 states that have laws on the books with mandates that obligate insurance companies to provide coverage for orofacial cleft repair and similar services that may not be otherwise covered by a standard insurance policy. The following are those states and summaries of their particular laws and statutes:
Legislation from 2009 mandates that healthcare policies issued in California cover necessary surgery that supports proper basic function of the individual as well as normalizing their appearance as much as possible through reconstructive procedures.
In consideration of the term “cosmetic” under healthcare insurance definitions, the law updated the definition of “reconstructive surgery” to incorporate medically vital dental and orthodontic devices that work to repair any cleft palate, cleft lip, and similar abnormalities. This statute has been in effect since 2010.
There are laws in place in Connecticut that mandate a number of insurance policy types that must offer coverage for any orthodontic procedures and devices which are medically necessary to treat craniofacial disorders for anyone 18 years of age and under. The policies that fall under these requirements are any basic hospital or medical-surgical expense and major medical expense coverage plans, hospital or medical service plan, and any coverage offered to subscribers of healthcare centers. The legislation does not cover insurance expenses for procedures that are considered cosmetic surgery.
The state of Florida has passed legislation that policies must cover cleft lip and cleft palate treatments for children 18 and under. These plans are mandated to cover all costs associated with medical, dental, speech therapy, audiology, and nutrition services and treatment.
State laws mandate that insurers must provide infants with the same benefits offered to adults when dealing with treatments and services for medically diagnosed congenital defects and birth abnormalities. These plans must cover costs for inpatient and outpatient procedures as a result of medical and dental treatments. This includes any orthodontic and oral surgery and other devices designed for treating cleft lip and palate birth defects.
Louisiana’s healthcare laws require insurance companies to provide benefits for a list of treatments, services, and medically necessary surgeries and appliances. These include oral and facial procedures, care management, prosthetic treatments, orthodontic treatments, preventive and restorative dentistry, and various other speech-language, audiological, and otolaryngology therapies.
Maryland’s insurance laws hold provisions that include benefits for inpatient and outpatient expenses for orthodontic treatments, oral surgery, and restorative otologic, audiological, and speech therapies to treat birth defects related to cleft lip and palate issues.
Laws on the books have similar mandates as many of the other states pertaining to coverage for infants that provides protection and benefits in case of illness, injury, congenital malformation, or premature birth. The costs associated with inpatient and outpatient expenses as a result of medical and dental treatments, orthodontic and oral surgery and management of cleft lip and palate defects shall be provided for dependents up to the limiting age.
New laws were added to New York’s requirements for insurers for the purposes of amending the current laws with respect to providing coverage for cleft lip and palate along with any illnesses and related treatments that were caused as a result of these abnormalities. Unlike some other states, these laws provide for coverage to be offered for procedures that are deemed cosmetic.
The North Carolina laws are rather standard in that every health plan must extend similar coverage to newborns for treating congenital defects and abnormalities and related illnesses as children who are already covered under existing policies. These benefits are required to cover cleft lip and palate along with similar other anomalies.
Texas laws are aimed at helping children under 18 years of age with surgery to repair craniofacial and orofacial issues. These are to be performed in order to repair and restore the normal function and appearance of facial structure as a result of cleft lip and palate and similar anomalies.
State laws of Vermont address coverage for medically necessary surgical and nonsurgical procedures due to accident, congenital or developmental defect, trauma and other causes. However, the mandates do not require dental services to treat disorders or dental pathology relating to gums, teeth, or other regions of the mouth.
Virginia state laws mandate that insurers must cover children who are born to insured customers and these benefits should include basis inpatient and outpatient medical costs for dental and oral surgeries along with medically necessary orthodontics for treating cleft lip or palate.
Laws on the books in Wisconsin require insurance companies providing medical, hospital, or various forms healthcare coverage to extend the same benefits to infants of insured customers, effective at the time they are born. This coverage emphasizes cleft lip and palate defects along with various other additional abnormalities and illnesses or injuries but only for functional restoration. Cosmetic procedures with the sole purpose of improving appearance are not required for coverage under the law.