REVIEW REQUEST FOR
Mandibular/Maxillary (Orthognathic) Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00049
Policy Last Review Date: 08/08/2013
Policy Effective Date: 10/08/2013
Provider Tool Effective Date: 10/08/2013
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 Code(s) (if known):
Please check all that apply to the individual:
Request is for: (check all that apply)
Reconstructive mandibular/maxillary orthognathic surgery to address a significant variation from the normal
related to accidental injury, disease, trauma, or treatment of congenital defect
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:
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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: 08/08/2013
Policy Effective Date: 10/08/2013
Provider Tool Effective Date: 10/08/2013
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
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 defined as either of the following:
Maxillary/Mandibular incisor relationship (established norm = 2 mm) defined as one of the following:
Horizontal overjet of 5mm or more
Horizontal overjet of zero to a negative value
(Note: Overjet up to 5 mm may be treatable with routine orthodontic therapy)
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 the health plan or its
designees 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.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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