Tuesday, January 27, 2009

letter number 1!

"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.



Ahhhh!! :)


funkyrhodes said...

I don't think you can get a better request letter!!! I'm sold! When do you find out their response?

Katherine (Kate) said...

"Code Jaw! Code Jaw! This girl needs help, STAT!" Sounds good!

And now, we wait........

changes911 said...

Wow! I love how that letter was worded. It was perfect. If they say no to that, they are idiots. I can't wait till this surgery is considered a medical nessecity (sp)rather then cosmetic. I think they consider it cosmetic because its surgery on the face and the end result is a new/different looking face.

mcgee33 said...

Oh, that was a good letter, thanks for printing it. I'm sure it seems weird to hear things like "facial skeletal deformity"... but that will really help when the insurance company reads the letter. It was very convincing of medical necessity. I hope you get the approval letter very soon! I know you're ready!

~Elaine (2 weeks out from MMA/GA)