"To whom it may concern:
Stephanie has been seen to determine the feasibility of surgically correcting the unsatisfactory functional relationship which exists between her upper and lower jaw. Clinical examination and review of records demonstrates the patient to have maxillary
hyperplasia and mandibular
hypoplasia. I have outlined to the patient a plan of treatment, which will involve surgical realignment of the maxilla and mandible. This will entail a 2-piece
Lefort I Maxillary
Osteotomy and Bilateral
Saggital Osteotomy, with Impressions and Custom
Preperation of TWO surgical splints PRIOR to the date of surgery. This form of major surgery is performed in an outpatient 23-hour observation facility using
nasoendotracheal anesthesia. It should
aslo be stressed that the proposed surgical procedure is a functional correction; it is not cosmetic or dental in nature, nor is it
TMJ-related surgery.
The above procedure is medically necessary. The American Association of Oral and
Maxillofacial Surgeons defines "medical necessity" as (1) appropriate for the symptoms and diagnosis, care and treatment of the
patient's condition, disease or injury; (2) provided for the diagnosis, care and treatment of the
patient's condition, disease or injury; and (3) in accordance with standards of good oral and
maxiollfacial surgery practice. Stephanie has a facial skeletal deformity. The
orthognathic surgery which is recommended would be done to establish normal functional relationships between
osseous, muscular and contiguous structures. I feel that medical necessity is established by the diagnosis of a musculoskeletal deformity, which is by itself,
pathologic, and constitutes a medical condition which
requires surgical correction. I would cite corrective
surgeries that are routinely allowable, such as scoliosis of the spine, cleft palate, and club foot, and would request that Stephanie's
orthognathic surgery be considered in the same context of medical necessity.
In outlining the details of surgery,
hospitalization, and anesthesia to the
Sheppards, they raised the question regarding insurance coverage that might be expected. I have mentioned the importance of obtaining a predetermination so that she might better understand her financial obligations. Two points should be stressed. First, the diagnosis mentioned above refers to a skeletal deformity. Second, the singular objective of treatment is to establish and maintain an acceptable functional relationship between the upper and lower jaw. Pending your review and response, we will advise the
Sheppards accordingly.
Sincerely,
JL"
Ahhhh!! :)
