Overbite Underbite: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the following components (osteotomy, mandible, segmental; face bone graft; nasal, maxillary or malar areas (includes obtaining graft); and/or lower jawbone graft; mandible, includes obtaining graft), for the requested orthognathic surgical procedure.Findings: The physician reviewer found that etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional and/or degenerative problems. The records provided for review document that this patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone.

Nature of Statutory Criteria/Case Summary: The patient is a 14-year-old female who has been diagnosed with a maxillofacial skeletal deformity, specifically maxillary and mandibular hypoplasia. Findings: The physician reviewer found that s a result of this deformity, the patient has experienced difficulty with mastication. Her orthodontist and surgeon have recommended orthognathic surgery to correct her deformity. She is planning to undergo presurgical orthodontics and the surgical plan at this time is for a multi-piece LeFort osteotomy, BSSO of her mandible and possible anterior mandibular osteotomy (genioplasty). Per the Health Plan, the request for a LeFort 1 surgery CPT code 21147 has been approved.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for genioplasty surgery. Genioplasty is the gold standard technique to modify the natural chin anatomy based on a mandible inferior border osteotomy enabling three-dimensional repositioning of the chin. In this case, the patient has a history of maxillofacial deformity with malocclusion and temporomandibular joint (TMJ) pain. The records submitted for review indicate that the patient was experiencing malocclusion due to congenital hypoplasia of the maxilla with retrognathia and hypoplasia of the mandible with retrognathia, which caused difficulty in masticating and TMJ pain. The patient underwent orthognathic surgery for malocclusion and TMJ dysfunction, specifically, LeFort 1 osteotomy with advancement and bilateral sagittal split with mandibular advancement.

An enrollee has requested reimbursement for dental braces. The submitted documentation does not support the medical necessity of the services at issue. Colleagues have studied the relationship between malocclusion and quality of life in adolescents. Their study concluded that malocclusion and orthodontic treatment do not appear to affect general or oral health quality of life to a measurable degree. This is despite subjective and objective evidence for improved appearance, oral function and health and social well-being. To assess the need for orthodontic treatment, there are many objective tools to quantify the degree of handicap caused by the malocclusion. Orthodontic treatment need indices are used to rank the malocclusion.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for overbite underbite was denied, the published record says the denial is worth fighting.