Jaw Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthognathic surgery consisting of: midface reconstruction, LeFort 1 maxillary osteotomy, three segments, with autogenous local graft-advancement with clockwise occlusal plane rotation ; mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid internal fixation-setback with counter clockwise occlusal plane rotation; and interocclusal surgical guide.At issue in this case is whether the requested orthognathic surgical services are medically necessary to treat the patient’s medical condition. In addition, does the patient’s severe malocclusion constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease?

Findings: The physician reviewer found that The patient has requested authorization and coverage for a left high condylar shave as a component of the approved corrective jaw surgery. Disturbances in the growth pattern of the mandibular condyle during the normal growth period may result in condylar hyperplasia and is diagnosed by bone scan. Abu Arqub and colleagues report that condylar hyperplasia is one of the causes of asymmetric facial growth resulting from overgrowth or hyperactivity in the mandibular condyles and that treatment of malocclusion secondary to condylar hyperplasia may involve orthognathic surgery and condylar surgery if the condyle shows hyperactivity.

Where the denial was upheld

Findings: The physician reviewer found that the parent of a patient has requested authorization and coverage for immediate scheduling of orthognathic surgery. The patient’s provider agrees that the patient requires the requested surgery. However, the surgeon should determine the timing of the surgery based on scientific factors and specific criteria. This criteria includes whether or not the patient has stopped growing, as change in skeletal growth after orthognathic surgery may result in relapse. In this case, the patient’s provider has noted that it is recommended to obtain a computed tomography (CT) scan in one year to determine if the patient has ceased growing. At that point, the provider could compare previous radiographs and CT scans to determine if the patient is appropriate for the surgery, which is a reasonable and appropriate course of treatment.

The patient is a 52-year-old man with a well-documented history of obstructive sleep apnea. His previous treatment with tonsillectomy and uvulopalatopharyngoplasty has not solved the problems. The patient is intolerant of CPAP. There is no record of treatment with dental occlusal splints. There is a history of significant obesity. A request has been made for orthognathic surgery.Review of the submitted documents indicates there is no history of maxillomandibular deformity requiring correction with orthognathic surgery. The proposed orthognathic surgery (Lefort I maxillary osteotomy and bilateral mandibular ramus sagittal split osteotomies with bimaxillary advancement) is not medically indicated because more conservative surgical treatment involving repositioning the tongue and floor of mouth musculature including the suprahyoid musculature has not yet been carried out.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Jaw Surgery, then check the rights and deadlines that apply to your plan.