Orthognathic Surgery denials in California external review

What the reviewers wrote

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for orthognathic surgery (reconstruction of midface, LeFort, bilateral sagittal split osteotomy, segmental osteotomy, with genioglossus advancement, septoplasty, excision inferior turbinate, oral surgical splint, virtual surgical planning, and maxillomandibular fixation). As noted by the Researchers“The surgical correction of maxillofacial skeletal deformities includes the reconstructive procedures that correct deformities of the maxilla, mandible, facial skeleton, and associated soft tissue structures.” Further, the AAOMS noted that “The principal goal for surgical correction of the maxillofacial skeletal deformity is to create or restore normal form, function, and health, while minimizing potential negative short-term and long-term sequelae.” On review of the r…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for periodontal care, gum recession surgery, extractions, and orthognathic surgery nature for treatment of the enrollee who is status post repair of a cleft palate. Findings: The physician reviewer found that there is a lack of support for the medical necessity of the requested services in this clinical setting. The patient does have periodontitis that will require dental treatment but that is not related to the patient’s cleft palate. The risk factors for periodontitis include amongst others poor oral hygiene. Treatment with scaling and root planning would be appropriate for the patient. Grafting the patient’s gingiva to augment her gingiva is also appropriate given the patient’s periodontal findings.

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.

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 Orthognathic Surgery, then check the rights and deadlines that apply to your plan.