REVIEW REQUEST FOR
Mandibular/Maxillary (Orthognathic) Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00049
Policy Last Review Date: 08/06/2015
Policy Effective Date:
10/06/2015
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
10/06/2015
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):
This medical policy based, data collection tool is for medically necessary* review requests for reconstructive and cosmetic
procedures involving the mandible, maxilla or both, with the exception of orthognathic surgery for the treatment of
temporomandibular disorders or obstructive sleep apnea. This document is not for medical necessity review requests for
orthodontia (braces) services.
Relevant Definitions for this form:

Medically Necessary*: In this document, procedures are considered medically necessary if there is a significant
physical functional impairment AND the procedure can be reasonably expected to improve the physical functional
impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant
variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.
Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document.
Benefit language supersedes this document.
 Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that
would be considered within normal human anatomic variation. Cosmetic services are often described as those which
are primarily intended to preserve or improve appearance.
Please check all of the following that apply to the individual.
Page 1 of 3
REVIEW REQUEST FOR
Mandibular/Maxillary (Orthognathic) Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00049
Policy Last Review Date: 08/06/2015
Policy Effective Date:
10/06/2015
Provider Tool Effective Date:
10/06/2015
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 6 months of speech therapy
The individual develops intra-oral trauma while chewing related to malocclusion (for example, 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 3 to 6 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 4 mm 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
Page 2 of 3
REVIEW REQUEST FOR
Mandibular/Maxillary (Orthognathic) Surgery
Provider Data Collection Tool Based on Medical Policy SURG.00049
Policy Last Review Date: 08/06/2015
Policy Effective Date:
10/06/2015
Provider Tool Effective Date:
10/06/2015
Other indication not specified above: (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 Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance
Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. For some plans utilization review services are
provided by Anthem UM Services, Inc., a separate company.
Page 3 of 3