REVIEW REQUEST FOR
Mandibular/Maxillary (Orthognathic) Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00049
Policy Last Review Date: 08/18/2011
Policy Effective Date: 10/12/2011
Provider Tool Effective Date: 03/22/2012
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
Request is for: (check all that apply)
Request is for reconstructive orthognathic surgery
Genioplasty (or anterior mandibular osteotomy) not associated with masticatory malocclusion
Mandibular/maxillary orthognathic surgery
Genioplasty/anterior mandibular osteotomy with masticatory malocclusion or other anatomic abnormality
Request is for treatment of a significant physical functional impairment
Procedure can be reasonably expected to improve the physical functional impairment
Other: (please describe):
Requested procedure is intended to address which of the following symptoms or other evidence of physical functional
impairment: (check all that apply)
The individual has dysphagia.
There are symptoms related to difficulty chewing such as: choking due to incomplete mastication, or
difficulty swallowing chewed solid food, or ability to chew only soft food or reliance on liquid food
The symptoms are documented in the medical record, are significant and have persisted for at least 4
months
Other causes of swallowing or choking problems have been ruled out by history, physical exam and
appropriate diagnostic studies.
The individual has speech abnormalities determined by a speech pathologist or therapist to be due to a
malocclusion and not helped by orthodontia or at least six months of speech therapy.
The individual develops intra-oral trauma while chewing related to malocclusion (e.g., loss of food through the
lips during mastication, causing recurrent damage to the soft tissues of the mouth during mastication).
The individual has masticatory dysfunction or malocclusion as documented by below:
There is documentation of completion of skeletal growth with long bone x-ray or serial cephalometrics
showing no change in facial bone relationships over the last three to six month period
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REVIEW REQUEST FOR
Mandibular/Maxillary (Orthognathic) Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00049
Policy Last Review Date: 08/18/2011
Policy Effective Date: 10/12/2011
Provider Tool Effective Date: 03/22/2012
The individual has Class II malocclusions or is 18 years of age or older
There is documentation of malocclusion with either intra-oral casts (if applicable) bilateral, lateral x-rays,
cephalometric radiograph with measurements, panoramic radiograph or tomograms.
Other: (please describe):
Anatomic Condition
Individual has Anteroposterior discrepancies of greater than 2 standard deviations from published norms
Maxillary/Mandibular incisor relationship with overjet of 5mm or more or a value less than or equal to zero
Maxillary/Mandibular anteroposterior molar relationship discrepancy is 4mm or more
Individual has Vertical discrepancies which include: (check all that apply)
Vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted
skeletal landmarks
Individual has open bite with either no vertical overlap of anterior teeth or unilateral or bilateral posterior open bite
greater than 2mm
Individual has deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch
Individual has supra-eruption of a dentoalveolar segment due to lack of occlusion
Individual has Transverse discrepancies which include: (check all that apply)
Transverse skeletal discrepancy is two or more standard deviations from published norms
Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, given normal axial
inclination of the posterior teeth
Unilateral discrepancy is 3mm or greater, given normal axial inclination of the posterior teeth
Individual has anteroposterior, transverse, or lateral asymmetry greater than 3mm with concomitant occlusal asymmetry
Individual has significant variation from normal anatomy of maxilla and mandible not described above
Other: (please describe):
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a
routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
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