The Insurance Buyer's Guide | MaxFace (Members Only)

Section 01

Why this guide exists

Most patients arrive at MaxFace after months (sometimes years) of being told their condition is "cosmetic," "experimental," or "not medical." None of that is true for the procedures we perform. What's true is that maxillofacial surgery sits in a coverage seam between medical and dental insurance, and the seam is where claims go to die.

The good news: that seam is navigable. Every major carrier (Aetna, Cigna, UnitedHealthcare, Anthem, Blue Cross plans, EmblemHealth) publishes detailed medical-necessity criteria for jaw surgery, TMJ repair, OSA surgery, and nerve repair. If your case meets the criteria and your surgeon documents it correctly, the procedure is covered. Most denials we see are not because the patient doesn't qualify, they're because the paperwork didn't speak the carrier's language.

This guide gives you that language. It's the same playbook our Patient Navigators use every day to verify benefits, write authorization letters, and overturn denials.

Section 02

Medical vs dental: the distinction that decides everything

Maxillofacial surgery is a medical specialty. The procedures we perform (orthognathic surgery, TMJ arthroplasty, trigeminal nerve repair, maxillomandibular advancement for sleep apnea, custom subperiosteal implants) are billed under medical CPT codes, reviewed under medical-necessity policies, and paid out of medical benefits. Not dental.

This matters because the first thing most front-desk staff and brokers say is "that's dental." It usually isn't. Here's the line:

Medical (covered under your health plan)

Surgical correction of skeletal deformity, joint disease, nerve injury, airway obstruction, or post-traumatic deformity. CPT codes in the 21000-21499 (maxillofacial surgery) and 64000-64999 (nerve) families. Examples: Le Fort I osteotomy, BSSO, TMJ arthroplasty, microsurgical nerve repair, MMA for OSA.

Dental (covered under a dental plan, if at all)

Routine extractions, crowns, periodontal cleanings, restorative implants without skeletal reconstruction. CDT codes (D-codes), not CPT.

The orthodontics that often accompany jaw surgery sit in their own category, usually paid out of dental or a separate orthodontic rider, even though the surgery itself is medical. We help patients sequence the two so neither benefit is wasted.

Section 03

What plans actually look at, by procedure

Every carrier publishes a "medical policy bulletin" for each procedure. These are public documents, Aetna's CPB 0095, Cigna's Coverage Policy 0209, UnitedHealthcare's MP.013.21, and Premera's 9.02.501 all govern jaw surgery, for example. The criteria they use are remarkably consistent. Here's what they look for, simplified:

Section 04

The 12 questions to ask your broker

Print this. Read it line by line. Get the answers in writing (email is fine). If a broker won't answer in writing, find a different broker.

01
Does this plan cover orthognathic / TMJ / nerve repair / OSA surgery as medical, not dental?
Why it matters: Maxillofacial surgery is medical. If they say "that's dental," they're wrong or the plan is wrong.
02
What is the out-of-network deductible and out-of-pocket maximum?
Why it matters: This is the real ceiling on your cost. In-network numbers are irrelevant if your surgeon is OON.
03
Does the plan use UCR (usual, customary, reasonable) or Medicare-based reimbursement for OON?
Why it matters: UCR-based reimbursement typically pays more than a Medicare-based reimbursement policy. Ideally, the insurance carrier will release procedure-specific allowances so you can accurately estimate your out-of-pocket costs.
04
Is prior authorization required, and what is the typical turnaround?
Why it matters: Surgical PA can take 2-8 weeks. Build it into your timeline. Our insurance coordination team helps submit prior authorizations on your behalf and handles the legwork with your carrier.
05
Are there any exclusions for cosmetic, experimental, or developmental procedures?
Why it matters: These are the loopholes insurers use to deny jaw surgery. Get the exclusion list.
06
Does the plan require a medical necessity letter, and what specific criteria must it meet?
Why it matters: Ask for the medical policy bulletin by name. Your surgeon writes the letter to those exact criteria.
07
What is the appeals process and how many levels of appeal are available?
Why it matters: Plans with 2+ levels of internal appeal plus external review are stronger.
08
Are temporomandibular joint (TMJ) services explicitly excluded?
Why it matters: Many plans carve out TMJ entirely. This is a yes/no question. Get it in writing.
09
Is there a separate dental rider, and does it cross-subsidize medical claims?
Why it matters: Some PPOs let dental and medical share toward the OOP max. Worth thousands.
10
If I add a spouse or dependent at open enrollment, when does coverage start?
Why it matters: Critical if your surgical date is January-March.
11
Is there a waiting period for major medical or surgical benefits?
Why it matters: Some employer plans impose 90-day waits. Avoid these if surgery is imminent.
12
Can I get a copy of the Summary Plan Description (SPD) and the medical policy bulletins?
Why it matters: These are the only documents that matter at appeal. Brokers who refuse are hiding something.

Section 05

Plan features that matter (and ones that don't)

Feature	Matters?	Why
OON deductible & OOP max	Yes, most	This is your real cost ceiling.
UCR-based OON reimbursement	Yes	UCR-based reimbursement typically pays more than a Medicare-based reimbursement policy.
Strong appeals process	Yes	Most maxillofacial PAs are won on appeal.
No TMJ exclusion	Yes	Non-negotiable for TMJ patients.
HDHP + HSA	Yes if planned	Pre-tax surgery dollars. Powerful with 6-12 months lead.
In-network dental discount	No	Irrelevant. This is medical.
Telehealth allowance	No	Not used for surgical care.
Wellness rebates	No	Marketing, not coverage.

Section 06

Open enrollment timing for surgical patients

Maxillofacial cases take 3-9 months from consult to surgery. That means open enrollment is a planning tool, not a paperwork chore.

Surgery in Q1 (Jan-Mar)

Switch plans at this fall's open enrollment. Submit prior auth in November so it clears before January 1st coverage starts.

Surgery in Q2 (Apr-Jun)

Time to switch plans, satisfy any waiting periods, and run a full appeal cycle if the first PA is denied.

Surgery in Q3-Q4 (Jul-Dec)

Decide whether to wait for next year's plan or schedule against a deductible you've already met. Sometimes November is the financially smart month.

Section 07

Documentation that wins authorizations

Supply these items directly to your insurance coordinator to help prepare your authorization request. Our coordinator works remotely, so please send insurance documents to them rather than handing them to your surgeon at your consult:

Insurance card (front and back)
Most recent SPD or benefits booklet (PDF)
Any prior denials, appeal letters, and medical policy bulletins
All prior imaging: CBCT, MRI, panoramic, sleep study, EMG
Referral letters from your dentist, ENT, neurologist, or sleep physician
Photos documenting symptom progression (jaw position, swelling, asymmetry)
A symptom diary if you have TMJ, nerve, or sleep symptoms

Section 08

When you get denied: the appeals playbook

First denials are common. They are not the end. Most large carriers report appeal-overturn rates between 40% and 60% on first internal appeal, and external reviews favor patients more often than not when the documentation is complete. Here is the sequence we use:

Read the denial letter. Really read it

The letter cites a specific reason and a specific policy section. The two most common denial codes for maxillofacial cases: "not medically necessary" (you didn't meet stated criteria) and "considered cosmetic/dental" (wrong category). The fix for each is different.

Request the full medical policy bulletin and the case file

Under federal law (ERISA for employer plans, ACA for individual plans), you are entitled to the criteria the reviewer used and the records they reviewed. Get them in writing. This usually takes 30 days.

Build the appeal letter to the criteria, point by point

Don't write a narrative. Write a checklist. For every criterion in the bulletin, cite the corresponding finding in your record. If criterion #3 says "AP discrepancy ≥4 mm," your letter cites "Patient cephalometric analysis dated 03/14/26: AP discrepancy 6.2 mm (Exhibit B)."

Add a peer-to-peer review

Your surgeon calls the carrier's medical director directly. Most appeals turn here. Carriers schedule these within 1-2 weeks if requested.

If denied again, escalate to external review

You have the right to an Independent Review Organization (IRO) outside the insurer. IRO decisions are binding on the plan. State insurance commissioners also accept complaints.

Section 09

Red-flag phrases that mean a denied claim

If a broker, HR rep, or insurer rep says any of the following, push back and document it:

"That's dental, not medical."
Your move: Maxillofacial surgery is medical. Ask for the policy that says otherwise.
"It's considered cosmetic."
Your move: Functional jaw surgery is not cosmetic. Demand the medical policy bulletin.
"You'll need to use an in-network surgeon."
Your move: Only true on HMO. PPOs have OON benefits, use them.
"There's no prior authorization required."
Your move: Sometimes true, but get it in writing. Verbal "no PA" promises don't survive a claim review.
"We don't cover TMJ."
Your move: If true, this is a deal-breaker. Switch plans at open enrollment.
"Nerve allografts are experimental."
Your move: Outdated. Cite peer-reviewed outcomes data on processed nerve allograft and request a peer-to-peer.

Section 10

Glossary

CPT code: Current Procedural Terminology. The 5-digit code that identifies a medical procedure for billing. Maxillofacial surgery codes live in the 21000-21499 range.
CDT code: Current Dental Terminology. The dental equivalent of CPT. If your procedure is being billed under a CDT code, it's being treated as dental. Push back.
Medical policy bulletin: The document the insurer publishes that defines medical necessity for a procedure. You can usually find these on the carrier's provider portal.
Prior authorization (PA): Pre-approval from the insurer before surgery. Required for most maxillofacial procedures. Submitted by your surgeon's office.
UCR (usual, customary, reasonable): A benchmark insurers use to set out-of-network reimbursement. UCR-based plans pay closer to fair-market fees than Medicare-based plans.
Out-of-network (OON): A provider who hasn't signed a contract with your insurer. PPO plans cover OON care at a lower percentage; HMO plans typically don't cover OON at all.
Out-of-pocket maximum (OOP max): The most you'll pay in a plan year before the insurer covers 100%. Tracked separately for in-network and out-of-network care on most plans.
SPD (Summary Plan Description): The legal document describing exactly what your employer plan covers and excludes. The only document that matters at appeal.
Peer-to-peer review: A direct conversation between your surgeon and the insurer's medical director. Often the fastest path to overturning a denial.
IRO (Independent Review Organization): An external reviewer that hears appeals after internal appeals are exhausted. Their decisions are binding on the insurer.