CurrentAnthemPolicy N/A

Orthognathic Surgery Procedure Review Form

Authorization/procedure review form to be completed and submitted to Anthem Medical Management for requests concerning orthognathic (jaw/facial) surgical procedures. Collects patient, provider, procedure codes, clinical indications, history, and supporting materials (photos, x-rays, dental molds) for review/decision.

Policy Summary

PayerAnthem

PolicyOrthognathic Surgery Procedure Review Form

Policy CodePolicy N/A

Change TypeRevised (footer shows revision date)

Effective Date

Next Review Date

Key ActionProviders must send the completed Orthognathic Surgery Procedure Review Form plus photos, x-rays and dental molds to Anthem Medical Management (Mail Drop VA4004-A000, P.O. Box 85638, Richmond, VA 23285-5638) for all orthognathic surgery requests.

SourceLink

POLICY UPDATE CHANGES

Form footer shows revision date Revised 6/3/06.

10Procedure codes listed

MultipleClinical indication categories to document

Document summary & scope

This is an Anthem administrative authorization and documentation checklist titled Orthognathic Surgery Procedure Review Form, used to collect the clinical and supporting materials needed to evaluate medical necessity for orthognathic (jaw/facial) surgical procedures. The form lists requestable procedure codes, detailed indications and patient history elements, and requests photos, x-rays and dental molds be submitted with the completed form for review. Complete patient and provider identifiers, the proposed setting and surgery date, the procedure(s) requested, relevant clinical indications and history, and supporting diagnostic materials, then send the packet to Anthem Medical Management for review and decision.

Procedure codes referenced on form

Procedures listed on form (requestable)CPT

21110	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21141-21147	Reconstruction midface, LeFort I (range listed on form)
21150-21151	Reconstruction midface, LeFort II (range listed on form)
21154-21155	Reconstruction midface, LeFort III (range listed on form)
21193-21196	Reconstruction of mandibular rami (range listed on form)
21198	Osteotomy, mandible, segmental
21206	Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21208	Osteoplasty, facial bones, augmentation (autograft, allograft, or prosthetic implant)
21209	Osteoplasty, facial bones, reduction
21210	Graft, bone; nasal, maxillary or malar areas (include obtaining graft)

What providers must do

Prior Authorization

Submit completed procedure review form with supporting materials

Providers must send the completed Orthognathic Surgery Procedure Review Form plus photos, x-rays and dental molds to Anthem Medical Management at Mail Drop VA4004-A000, P.O. Box 85638, Richmond, VA 23285-5638 for all orthognathic surgery requests.

21110
21141-21147
21150-21151
21154-21155
21193-21196
21198
21206
21208
21209
21210

Documentation Required

Clinical documentation of indications and history

Provide detailed clinical documentation including diagnosis, specific anatomic and occlusal discrepancies, symptom history, diagnostic studies, speech pathology findings, nutritional status (weight loss amount/time, serum albumin) and obstructive sleep apnea status as applicable.

Diagnosis and description of anatomic/occlusal discrepancies (incisor/molar relationships, vertical/transverse discrepancies, asymmetry)
Symptom history: onset, intensity, difficulty swallowing/chewing, inability to chew solids
Diagnostic studies to rule out other causes (allergies, neurologic/metabolic disease, hypothyroidism)
Speech pathologist assessment documenting abnormalities due to malocclusion and not improved by therapy/orthodontia
Nutritional status: documented significant weight loss (amount and time) and serum albumin level
Obstructive sleep apnea documented yes/no

Billing Rule

Anthem internal decision recording

The form contains internal Anthem-only fields where Anthem will record a Certification # and the Decision (Approved with dates or Denied with reason) that providers should expect to be completed by Anthem.

Certification # (Anthem use only)
Decision: Approved (with approval dates) or Denied (with reason) — for Anthem recording only