Code review and potential prior authorization

Review the procedure codes listed in the policy to determine whether each code is being billed as cosmetic or reconstructive; codes provided in the Applicable Codes section are for reference and may require prior review/authorization per contract and state requirements.

• Codes listed in the policy do not by themselves indicate coverage; determine reconstructive vs cosmetic designation before billing.
• Prior review/authorization may be required based on member contract and state requirements.

Prior authorization guided by InterQual and member benefits

Follow InterQual clinical criteria where applicable (e.g., Tissue Transfer/Flap and Orthognathic Surgery) and verify federal, state, or contractual benefit requirements in the member's file when requesting prior authorization or making coverage determinations.

• Use InterQual CP: Procedures, Tissue Transfer (Flap) for flap repairs (see policy statement).
• InterQual CP: Procedures, Orthognathic Surgery is referenced for jaw reconstruction per the policy revision.
• Confirm the member's federal, state, or contractual benefit requirements; these govern in the event of conflict with the policy.

Provide complete, legible supporting documentation

Ensure all required supporting documentation is available and legible in the patient's medical record; documentation may be requested to assess whether clinical criteria for coverage are met and does not guarantee coverage.

• Make documentation available upon request to support any coverage review.
• Documentation may be required even when InterQual criteria are used and coverage is not guaranteed by submission of records.

Step therapy not specified

No step therapy requirements are specified in this policy segment; do not apply step therapy conditions unless separately required by the member's benefit plan or another applicable guideline.

• Verify plan-specific benefits for any stepwise treatment prerequisites not covered in this document.

Document history, exam, and diagnostic results

Include in the medical record the relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that together fully support the medical necessity for the requested service.

• Relevant medical history and physical exam findings.
• Pertinent diagnostic test results or procedure reports.

Maintain legible, accessible medical records supporting necessity

Ensure the patient's medical record contains legible documentation that fully supports medical necessity and make it available upon request; documentation may be required to assess clinical criteria for coverage.

• Maintain legible records in the patient's chart.
• Provide records on request for coverage review; presence of documentation does not guarantee coverage.

Insufficient documentation may cause denial

Be aware that lack of medical record documentation (relevant history, physical exam, diagnostic tests) supporting medical necessity may result in denial of the request.

• Failure to provide supporting records can lead to denial of service coverage.

Documentation gaps risk denial or non-approval

Understand that inadequate medical records that do not fully support medical necessity may result in denial or inability to approve the requested services; documentation may be required but does not guarantee approval.

• Complete, adequate documentation is necessary to satisfy clinical criteria; incomplete records risk non-approval.