Thursday, August 28, 2008

"extreme cases"

Here's the lowdown on extreme cases. I don't qualify, by the way.

"Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury. (1)

Note: This policy does not address surgical treatment of temporomandibular joint dysfunction or the surgical management of sleep apnea; discussion of these conditions may be found in Medical Policies, Surgery Nos. 49, 122 and 142.

Policy/Criteria
Orthognathic surgery for the treatment of obstructive sleep apnea may be considered medically necessary when the criteria in Surgery, Policy No. 49 are met.

Orthognathic surgery may be considered medically necessary to correct jaw and craniofacial deformities in the absence of obstructive sleep apnea when all of the following criteria (1-3) are met: Significant functional impairment is documented as a result of illness, injury, congenital anomaly, or developmental anomaly.

Significant functional impairment must be directly attributable to jaw and craniofacial deformities and must include one or more of the following:

  • Chewing-induced trauma secondary to malocclusion
  • Significantly impaired swallowing and/or choking due to inadequate mastication secondary to malocclusion
  • Significant speech abnormalities (e.g., sibilant distortions or velopharyngeal distortion) which have not responded to speech therapy and are secondary to malocclusion
  • Loss of masticatory or incisive function due to malocclusion or skeletal abnormality
  • Airway restriction

Significant over- or underjet as documented by one of the following:

  • In mandibular excess or maxillary deficiency, a reverse overjet of 3mm or greater
  • In mandibular deficiency, an overjet of 5mm or greater
  • Open bite of 4mm or greater
  • Deep bite of 7mm or greater
  • Less than six posterior teeth in functional opposition to other teeth secondary to a developmental or congenital growth abnormality (as opposed to a consequence of the loss of teeth)
  • The functional impairment and over- or underjet are not correctable with non-surgical treatment modalities.

Orthognathic surgery in the absence of significant physical functional impairment is considered cosmetic, including but not limited to when used for altering or improving bite or for improvement of appearance.

The following documentation is required to determine medical necessity for orthognathic surgery:

  • Current study models with the appropriate bite registration and/or the back of the models trimmed such that they represent the patient's current pre-surgical centric occlusion and/or centric relation bite
  • Intra-oral and extra-oral photographs
  • Cephalometric x-rays
  • Diagnostic report
  • Panorex x-ray

7 comments:

holski said...

I am so mad for you right now. I can't even think of what to say. It's not fair. Is there anything you can do?

ps-Brennan has offered to marry you, so you can come to Canada and have the surgery for free. =)

Thinking about ya.

Stephanie said...

Steph, I can't imagine how frustrating this is for you right now. Don't give up. My surgery was denied the first time around, and I appealed, winning the appeal. Talk to your OS and OD, tell them exactly what your new policy says. They should be able to walk you through an appeal. Make sure they address the same vocabulary used in your policy. How much is your overjet right now? Yours looks similar to mine, and I am at 7 mm, so you may meet that criteria. Also, as they get you ready for surgery, it may get worse, so that actually works in your favor. If you have TMJ dysfunction, that could be considered "Chewing-induced trauma secondary to malocclusion ". I can forward you my appeal letters from my OS, OD, and myself. The letter from my OD was brilliant, I think it was what sealed the deal. Don't give up without a fight. Be ready to fight. The insurance companies count on you giving up. I will help you in any way that I can.

Katherine said...

I am so glad Stephanie chimed in on this, I was coming on here to suggest you run this by her!!!

This is a huge battle and I dson't envy you the amount of leg work it could take to get this(and from anything I've read, not an uncommon one, unfortunately). It comes down to channelling that disgust and throwing it right back at them.

Can I ask what makes you carte blanche it as not being relevant to you? Yes they use all the big words and make you feel like you have to be a circus freak to qualify, however I swear they make it sound all flowery...you just need to play the game and be a royal pain in the a$$.

You still Breathing? :)

laura said...

This really sucks! But wait ... how do you know you don't qualify as extreme? It's only been a couple of days. Did the insurance company reject you that quickly? Mine takes weeks to do anything.

You're only chewing with a few teeth, right? That's functional impairment.

And your overjet looks like mine, which is around 5mm. If it's less, perhaps that will change as you get closer to surgery time.

When I first talked to my surgeon he said that the ins company wouldn't approve me until after the orthodontist had moved my teeth into their pre-surgery position. Only then would they fit the criteria.

laura said...

btw what are you and holly using to show update times on your buddy list?

chinderella said...

This is so.. maddening!! 'Considered cosmetic', my ass. I hope Stephanie can help you jump through the loops.

mylene

Katherine said...

Just stopping by to let you know I've been thinking about you this week: hoping the first week back at school went well & all that jazz.

Keep the faith *hug*
:)