Title: Guidelines for Determining Necessity for Orthognathic Surgery

Content:
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IMPORTANT NOTE:

This guideline has been developed to outline basic principles applicable to the treatment of certain disorders, or to provide clarification for the determination of whether or not a treatment analysis is more appropriate from a medical or a dental perspective. This guideline is not considered a Medical Policy. Decisions not to approve services are made only by the Horizon Medical Director or physician reviewer in accordance with Horizon’s policies and procedures and include an analysis focusing on medical necessity. However, this guideline may be used as guidance in considering the various elements of medical necessity. If a member’s contract benefits differ from the principles outlined in this guideline, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This guideline is not intended to direct the course of clinical care a physician provides to a member, and does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

This guideline does not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Diagnostics - All of the following are mandatory to properly evaluate necessity for requested maxillo-facial surgery procedures:

• List of symptoms (if any), the patient's medical and dental history, and medical, dental, and orthodontic records.
• Cephalometric films and tracings including prediction tracings and cephalometric analysis.
• List of procedures to be performed (along with the appropriate CPT Code #’s) with fees.
• Photographs (optional but recommended)

Evaluation of the above and any treatment recommendations is made in conjunction with dental consultants and appropriate specialists where necessary.

Parameters for Consideration

• Occlusion

Occlusion refers to the functional relationship of the mandibular and maxillary teeth when the jaws are in a closed position. Ideally: (1) all of the mandibular teeth are in optimal contact with all of the maxillary teeth, (2) the mandibular posterior teeth interdigitate with the maxillary posterior teeth and the facial cusps of the maxillary teeth overlap the facial cusps of the mandibular teeth, and (3) the incisal surfaces of the maxillary anterior teeth overlap the incisal surfaces of the mandibular teeth and are in passive contact with them.

There is a wide spectrum of occlusions which run the gamut from "functional" to "functional with minor"abnormalities to "major" occlusal abnormalities. To the extent that symptoms and functional capacity, now and in the future, do not relate to functional occlusions and or "minor" occlusal abnormalities, only "major" occlusal defects will be considered for medical necessity review.

The absence of a functional occlusion with documentation of a significant clinical funtional impairment directly related to the existing occlusion is the most important consideration in evaluating the medical necessity for orthognathic surgery and can only be determined by examining cephalometric tracings along with the medical and dental histories. Is the patient occluding on only a few teeth? Is there a cusp to fossa relationship or merely cusp to cusp? Can the patient chew properly? Is there cuspal interference that precludes the patient closing properly or does a crossbite exist that may or may not need correcting, etc. Is there a significant dysfunction related to the occlusion, eg. speech problem, masticatory impairment, swallowing difficulty, respiratory difficulty?

The ultimate guide is whether the patient has a symptomatic "major occlusal abnormality". Non-symptomatic, functional occlusions or occlusions without significant clinical impairment are not considered to be medically necessary.

• Cephalometrics

Cephalometric tracings and films allow the formal diagnosis and classification of a particular skeletal or developmental anomaly and help determine the course of treatment.

At its most basic level three points are involved 1) Nasion, 2) Point A, and 3) Point B. Lines are drawn from N to A and from N to B. If Point B is anterior to Line NA, the patient is a true skeletal Class III (prognathic). If Point A is anterior to Line NB, the patient exhibits a Class II jaw relationship.

Other factors visible on films which should be taken into account in determining the type of skeletal relationship are the angle of the lower anterior teeth to the angle of the mandibular ramus, the lower angle of the mandible, and relative sizes of the mandible and maxilla.

Please note that the diagnosis of a skeletal abnormality does not indicate necessity for treatment. If there is not a significant clinical functional impairment there is no medical necessity to correct the abnormality.

• Age

Age is an important factor in determining the necessity, type of treatment, and, ultimately, whether the benefits will be paid as medical or dental.

Patients under the age of 12-14 may exhibit malocclusions that are based on the existence of a mixed occlusion consisting of both deciduous and permanent teeth. Minimal, if any, orthodontic tooth guidance may result in a functional occlusion when the permanent dentition has fully erupted and the patient's growth is completed.

Any surgery requested for a patient below the age of skeletal maturity should be accompanied by a narrative with justification for the surgery at that particular age.

Patients (teens or adults) exhibiting malocclusions and/or skeletal anomalies can often be improved with non-surgical orthodontics. Requests for surgery in such individuals are not considered medically necessary as they may be improved by dental means.

Adults may exhibit malocclusions and/or skeletal abnormalities that may need correction by orthodontics, surgery, or that do not require treatment at all. An important consideration with an even significant malocclusion in the adult, is the person’s apparent ability to function adequately over prolonged periods of time. As a result questions arise regarding the necessity for correction from the perspective of functional necessity. (Even in individuals with occlusions that might have required treatment at younger ages, the medical necessity for treatment needs to be questioned when persons have functioned well, often without symptoms, over a period of many years.) It is imperative that the history of impairments be documented in adult patients.

• Patient Symptoms

Patients may present with symptoms that may or may not be significant, documented in the record, measurable, related to a medically necessary problem, or problem for which reimbursement is allowed. We should have information in all these areas and understand the extent to which there is a TMD problem, pain on chewing and biting, inability to masticate properly, muscular sensitivity, eating and digestive disorders, weight loss, etc. Symptoms should be significant, documented in the medical/dental record, and be related to the occlusal abnormality.

• Appearance

Skeletal anomalies and poor occlusion may be reflected in the patient's outward appearance. This is often the driving force that causes them to seek treatment, especially as adults. The occlusion/abnormality may or not need treatment. To the extent that the major driving force for surgery is appearance -the surgery is not a reimbursable service.

• Temperomandibular Disorders (TMD)

TMD is a condition that represents a spectrum of disorders with a myriad of causes and presenting symptoms. Similarly, treatments vary and run a spectrum from virtually no intervention (condition self-limited) to invasive surgical procedures. According to experts TMD affects only 2% of the general population. Of these, only 3.6 - 7% need treatment and only 2% of this small patient subset require surgery. Surgical procedures are not limited to orthognathic correction of the bite but more often involve actual invasion of the TM joint. The correlation of the occlusion to the TMD symptoms must be established and fully explain how the orthognathic surgery will resolve the TMD symptoms.

AAOMS guidelines recommend that in the case of a diagnosed condition of TMD, all conservative non-surgical treatment options be attempted and fail before considering surgical intervention. Orthognathic surgery and/or occlusal changes are not first line therapies nor do they represent the first choice in surgical interventions.

Horizon BCBSNJ has written and adapted guidelines for determining medical necessity for TMD which describes in detail accepted modalities of treatment. This guideline should be consulted when TMD is present.

Decision Process
1. It is necessary to establish the medical necessity of any orthognathic surgery procedure to determine whether services are eligible for payment under the patients medical insurance.

When all diagnostics have been received they are examined, evaluated with regard to the parameters listed above including symptoms(if any), age of patient, history of symptoms and impairment, presence and severity, if any, of a skeletal anomaly, and the status of the patient's occlusion.

There is a wide spectrum of occlusion which run the gamut from "functional" to "functional" with minor occlusal abnormalities to "major" occlusal abnormalities. To the extent that symptoms and functional capacity, now and in the future, do not relate to functional occlusions and/or "minor occlusal abnormailites," only "major" occlusal defects will be considered as medically necessary conditions.

Therefore if:
• a functional (or minor occlusal abnormality) is present or:
• the patient has existed with a partially functional occlusion for a reasonable amount of time:
No treatment will be approved.

If:
• there is a "major" functional occlusal abnormality, and
• the patient exhibits significant documented symptoms;
Then treatment is medically necessary and eligible for reimbursement under medical insurance.

2. When treatment is indicated, the type of treatment must be determined.

If restoration of a "major" non-functional occlusion can be accomplished by orthodontic tooth movement only (tooth extractions and prosthetic appliances may or may not be necessary), no matter what the patient's age, the case will be considered purely dental and no medical benefits will be allowed.

If restoration of a "major" non-functional, symptomatic occlusion cannot be obtained solely by orthodontic tooth movement or prosthetics and requires orthognathic surgery (with or without an orthodontic component), the patient will be eligible for medical benefits (see #4 below).

3. Cosmetic components of necessary surgeries (ex. genioplasty) will not be covered by medical benefits.

4. Medical Benefits will not be paid for any of the dental components of medically necessary surgeries. These include, but are not limited to, any orthodontia or tooth movement including pre and post surgical banding, removal of third molars or wisdom teeth (removal of bony and partial bony impacted wisdom teeth may be a contractual benefit), prosthetics (crowns, full or partial dentures), implant placement or procedures that involve the gingiva, alveolar bone, or teeth and their supporting structures.


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Guidelines can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to a Horizon BCBSNJ Guideline should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

This guideline is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this guideline are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this guideline may be updated or changed without notice, unless otherwise required by law and/or regulation.
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