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