Navigating Insurance Issues
Navigating health insurance for cleft and craniofacial treatment can be challenging. This page offers a state-by-state list of mandated benefits, steps to take before treatment, and resources to help you understand your rights, respond to denials, and secure the care you or your child needs.
States with Mandated Health Benefits for Cleft Lip & Palate
Arkansas - California - Colorado - Connecticut - Florida - Illinois - Indiana - Louisiana - Maryland - Massachusetts - Minnesota - Oregon - New York - North Carolina - South Carolina - Vermont - Virginia
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Outline of Things To Do Before Treatment
Note: The term insurance refers to both health insurance providers and managed care organizations (HMOs), unless otherwise specified.
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Understand Your Coverage
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Obtain a copy of your Evidence of Coverage for both health and dental plans.
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Do not assume that a treatment or procedure will be approved simply because it is listed.
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Managing Denials
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Request all denials in writing, including references to the applicable sections of your Evidence of Coverage.
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Written documentation establishes a clear timeline for appeals—be sure to review your policy for specific deadlines and procedures.
Common Problems in Interpreting Coverage
1. Exclusions for Dental Conditions
Your Rebuttal
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Emphasize that surgical procedures for cleft and craniofacial conditions are medically necessary, not dental.
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In correspondence, consistently stress the medical necessity of the treatment.
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Request that providers re-submit claims using medical necessity letters and medical claim forms, rather than dental claim forms.
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Note that routine dental care (e.g., cleanings, fillings) may be excluded. For these services, refer to your dental policy.
2. Exclusions for Cosmetic Procedures
Your Rebuttal
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Reinforce the medical necessity of the procedure and avoid terminology such as cosmetic, self-esteem, or dental.
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Reconstructive Surgery: Corrects abnormal structures caused by congenital defects, trauma, or disease, primarily to restore function.
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Cosmetic Surgery: Reshapes normal structures to enhance appearance or self-esteem.
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For Example: Orthognathic (Jaw) Surgery:
Highlight the procedure’s role in restoring essential functions, including:
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Biting
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Chewing
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Swallowing
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Breathing
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Make Sure You
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Request assignment of a complex care case worker as early as the first denial.
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Additional Resources
Parameters for Evaluation and Treatment of Patients
with Cleft Lip/Palate or Other Craniofacial Anomalies
American Cleft Palate-Craniofacial Association
May 1993, Rev. 2009
Standards for Cleft Palate and Craniofacial Teams
Developed by the American Cleft Palate-Craniofacial Association and Cleft Palate Foundation
Administered by the Commission on Approval of Teams
Your Guide To The Appeal Process
From the Patient Advocate Foundation
What To Expect At A Grievance Hearing
Sample Presentation To Grievance Committee
More Sample Letters From Cleft Advocate Families
Position Papers from the American Society of Plastic Surgeons (ASPS)
Insurance Coverage: A Patient's Guide
From the ASPS
A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, 2005 Update
Guidelines for the Preauthorization of Therapy Services for
Children with Special Health Care Needs (CSHCN)
Developed by the Department of Pediatrics, University of Arkansas
for Medical Sciences
Getting Your Employer to Cover Speech-Language and Hearing Services
A checklist for consumers from ASHA (American Speech-Language-Hearing Association)
