Re: Can you all help with my insurance app...

[Guest guest]

I have Aetna and it is an insurance nightmare. They are refusing to pay for

anything. They say it's cosmetic. I'm sure I will need a lawyer....

[Guest guest]

Hi Kathy,

I have been researching Orthognathic surgery this weekend and coincidentally

found a link from Aetna. I am attaching it below. I hope it helps you!

Elana

Document Utilities

Home > Clinical Policy Bulletins > Medical > Orthognathic Surgery

Clinical Policy Bulletins

Number: 0095

Subject: Orthognathic Surgery

Reviewed: March 11, 2005

Important Note

This Clinical Policy Bulletin expresses Aetna's determination of whether

certain services or supplies are medically necessary, experimental and

investigational, or cosmetic. Aetna has reached these conclusions based upon a

review of

currently available clinical information (including clinical outcome studies

in the peer-reviewed published medical literature, regulatory status of the

technology, evidence-based guidelines of public health and health research

agencies, evidence-based guidelines and positions of leading national health

professional organizations, views of physicians practicing in relevant clinical

areas, and other relevant factors). Aetna makes no representations and accepts

no

liability with respect to the content of any external information cited or

relied upon in this Bulletin. The discussion, analysis, conclusions and

positions

reflected in this Bulletin, including any reference to a specific provider,

product, process or service by name, trademark, manufacturer, constitute Aetna's

opinion and are made without any intent to defame. Aetna expressly reserves

the right to revise these conclusions as clinical information changes, and

welcomes further relevant information including correction of any factual error.

Each benefit plan defines which services are covered, which are excluded, and

which are subject to dollar caps or other limits. Members and their providers

will need to consult the member's benefit plan to determine if there are any

exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does

not constitute a representation or warranty that this service or supply is

covered (i.e., will be paid for by Aetna) for a particular member. The member's

benefit plan determines coverage. Some plans exclude coverage for services or

supplies that Aetna considers medically necessary. If there is a discrepancy

between this policy and a member's plan of benefits, the benefits plan will

govern. In addition, coverage may be mandated by applicable legal requirements

of a

State, the Federal government or CMS for Medicare and Medicaid members. CMS's

Coverage Issues Manual can be found on the following website:

http://cms.hhs.gov/manuals/pub06pdf/pub06pdf.asp.

Policy

Certain jaw and cranio-facial deformities may cause significant functional

impairment. These deformities include apertognathia (either lateral or anterior

not correctable by orthodontics alone), significant asymmetry of the lower

jaw, significant class 2 and class 3 occlusal discrepancies, and cleft palate.

Aetna considers orthognathic surgery medically necessary for correction of the

following skeletal deformities of the maxilla or mandible when it is documented

that these skeletal deformities are contributing to significant dysfunction,

and where the severity of the deformities precludes adequate treatment through

dental therapeutics and orthodontics alone:

Maxillary and/or Mandibular Facial Skeletal Deformities Associated with

Masticatory Malocclusion

Aetna considers orthognathic surgery medically necessary for correction of

skeletal deformities of the maxilla or mandible when it is documented that these

skeletal deformities are contributing to significant masticatory dysfunction,

and where the severity of the deformities precludes adequate treatment

through dental therapeutics and orthodontics:

Anteroposterior discrepancies

Maxillary/mandibular incisor relationship: overjet of 5 millimeter (mm) or

more, or a 0 to a negative value (norm 2 mm),

Maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm

or more (norm 0 to 1 mm). Note: These values represent two or more standard

deviations from published norms.

Note: These values represent two or more standard deviations from published

norms.

Vertical discrepancies

Presence of a vertical facial skeletal deformity which is two or more

standard deviations from published norms for accepted skeletal landmarks

Open Bite

No vertical overlap of anterior teeth greater than 2 mm

Unilateral or bilateral posterior open bite greater than 2 mm

Deep overbite with impingement or irritation of buccal or lingual soft

tissues of the opposing arch

Supraeruption of a dentoalveolar segment due to lack of opposing occlusion

creating dysfunction not amenable to conventional prosthetics.

Transverse discrepancies

Presence of a transverse skeletal discrepancy which is two or more standard

deviations from published norms.

Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4

mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal

axial inclination of the posterior teeth.

Asymmetries

Anteroposterior, transverse or lateral asymmetries greater than 3 mm with

concomitant occlusal asymmetry.

Facial Skeletal Discrepancies Associated with Documented Sleep Apnea, Airway

Defects, and Soft Tissue Discrepancies.

Aetna considers orthognathic surgery medically necessary in cases where it is

documented that mandibular and maxillary deformities are contributing to

airway dysfunction, where such dysfunction is not amenable to non-surgical

treatments, and where it is shown that orthognathic surgery will decrease airway

resistance and improve breathing.

For example, studies demonstrate that persons with vertical hyperplasia of

the maxilla have an associated increase in nasal resistance, as do persons with

maxillary hypoplasia with or without clefts. Following orthognathic surgery,

such individuals routinely demonstrate decreases in nasal airway resistance and

improved respiration.

Aetna considers orthognathic surgery medically necessary for members with

underlying craniofacial skeletal deformities that are contributing to

obstructive

sleep apnea. See CPB 004 - Obstructive Sleep Apnea. Before surgery, such

individuals should be properly evaluated to determine the cause and site of

their

disorder and appropriate non-surgical treatments attempted when indicated.

Temporomandibular Joint Pathology

Aetna considers orthognathic surgery for correction of temporomandibular

joint disease or myofascial pain dysfunction experimental and investigational.

See

CPB 028 - Temporomandibular Joint Syndrome (TMJ) and Temporomandibular

Disorders (TMD).

Speech Impairments

Aetna considers orthognathic surgery medically necessary for treatment of

speech impairments accompanying severe cleft deformity. Orthognathic surgery may

help to reduce the flattening of the face that is characteristic of severe

cleft deformity. By using osteotomy techniques along with bone and cartilage

grafts, the upper and lower jaws and facial skeletal framework are moved and

appropriately reconstructed. Pre-surgical orthodontic treatment is usually

recommended.

Aetna considers other orthognathic surgeries experimental and investigational

for correction of articulation disorders and other impairments in the

production of speech because there is inadequate evidence from prospective

clinical

studies in the peer-reviewed published medical literature of the effectiveness

of orthognathic surgery for this indication.

Aetna considers orthognathic surgery for correction of distortions within the

sibilant sound class or for other distortions of speech quality (e.g.,

hypernasal or hyponasal speech) not medically necessary as these distortions do

not

cause functional impairment.

Unaesthetic Facial Features and Psychological Impairments

Orthognathic surgery is considered cosmetic for correction of unaesthetic

facial features, regardless of whether these are associated with psychological

disorders.

Mentoplasty or genial osteotomies/ostectomies (chin surgeries) are always

considered cosmetic when performed as an isolated procedure to address genial

hypoplasia, hypertrophy, or asymmetry, and may be considered cosmetic when

performed with other surgical procedures.

No benefits are available for orthognathic surgery performed primarily for

cosmetic purposes. See Aetna CPB 031 - Cosmetic Surgery.

Note: Precertification requests or claims for orthognathic surgery are

subject to review by Aetna's Oral and Maxillofacial Surgery Unit.

Orthodontic Treatment Prior to Orthognathic Surgery

Note: Expenses associated with the orthodontic phase of care (both pre- and

post-surgical) are considered dental in nature and are not covered under

Aetna's medical plans. See CPB 082 - Dental Services and Oral and Maxillofacial

Surgery: Coverage Under Medical Plans.

Orthodontic treatment may be needed prior to orthognathic surgery to position

the teeth in a manner that will provide for an adequate occlusion following

surgical repositioning of the jaws. For plans that require precertification,

orthognathic surgery must be precertified prior to pre-surgical orthodontic

treatment. The interim occlusion that is achieved by orthodontic treatment may

be

dysfunctional prior to the completion of the orthognathic surgical phase of

the treatment plan. Therefore, all requests for orthognathic surgery must be

reviewed/precertified by an the Aetna Oral and Maxillofacial Surgery Unit prior

to the initiation of pre-surgical orthodontic care. Failure to precertify the

orthognathic surgical request prior to orthodontic care may result in the

denial of benefits.

Documentation Requirements

Note: Orthognathic surgery may be subject to precertification review in plans

that include precertification requirements. The following documentation

should be forwarded to Aetna's Oral and Maxillofacial Surgery Unit for review: a

written explanation of the member's clinical course, including dates and nature

of any previous treatment; physical evidence of a skeletal, facial or

craniofacial deformity defined by study models and pre-orthodontic imaging; and

a

detailed description of the functional impairment considered to be the direct

result of the skeletal abnormality.

See also CPB 082 - Dental Services and Oral and Maxillofacial Surgery:

Coverage Under Medical Plans.

Background

Orthognathic surgery is the revision by ostectomy, osteotomy or osteoplasty

of the upper jaw (maxilla) and/or the lower jaw (mandible) intended to alter

the relationship of the jaws and teeth. These surgical procedures are intended

(i) to correct skeletal jaw and cranio-facial deformities that may be

associated with significant functional impairment, and (ii) to reposition the

jaws when

conventional orthodontic therapy alone is unable to provide a satisfactory,

functional dental occlusion within the limits of the available alveolar bone.

Congenital or developmental defects can interfere with the normal development

of the face and jaws. These birth defects may interfere with the ability to

chew properly, and may also affect speech and swallowing. In addition, trauma to

the face and jaws may create skeletal deformities that cause significant

functional impairment. Functional deficits addressed by this type of surgery are

those that affect the skeletal masticatory apparatus such that chewing, speaking

and/or swallowing are impaired.

The above policy is based on the following references:

McCarthy JG, Stelnicki EJ, Grayson BH. Distraction osteogenesis of the

mandible: A ten-year experience. Semin Orthod. 1999;5(1):3-8.

Baker NJ, S, Barnard DW, et al. Occlusal outcome in patients undergoing

orthognathic surgery with internal fixation. Br J Oral Maxillofac Surg.

1999;37(2):90-93.

ME, CL. Assessment of health-related quality of life for

patients with severe skeletal disharmony: A review of the issues. Int J Adult

Orthodon Orthognath Surg. 1999;14(1):65-75.

Cope JB, Samchukov ML, Cherkashin AM. Mandibular distraction osteogenesis: A

historic perspective and future directions. Am J Orthod Dentofacial Orthop.

1999;115(4):448-460.

Drew SJ, Schwartz MH, Sachs SA. Distraction osteogenesis. N Y State Dent J.

1999;65(1):26-29.

Buttke TM, Proffit WR. Referring adult patients for orthodontic treatment. J

Am Dent Assoc. 1999;130(1):73-79.

Davies J, S, Sandy JR. Distraction osteogenesis--a review. Br Dent J.

1998;185(9):462-467.

American Society of Plastic and Reconstructive Surgeons (ASPRS). Orthognathic

Surgery: Recommended Criteria for Third-Party Payer Coverage. Arlington

Heights, IL: ASPRS; September 1997.

Barkate HE. Orthognathic surgery by distraction osteogenesis: A literature

review. Dentistry. 1997;17(3):14, 16-18.

Lupori JP, Van Sickels JE, Holmgreen WC. Outpatient orthognathic surgery:

Review of 205 cases. J Oral Maxillofac Surg. 1997;55(6):558-563.

Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in

orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 1995;10(2):97-107.

Ruhl CM, Bellian KT, Van Meter BH, et al. Diagnosis, complications, and

treatment of dentoskeletal malocclusion. Am J Emerg Med. 1994;12(1):98-104.

Sinn DP, Ghali GE. Advances in orthognathic surgery. Curr Opin Dent.

1992;2:38-41.

Hunt OT, ston CD, Hepper PG, et al. The psychosocial impact of

orthognathic surgery: A systematic review. Am J Orthod Dentofacial Orthop.

2001;120(5):490-497.

Koh H, PG. Occlusal adjustment for treating and preventing

temporomandibular joint disorders (Cochrane Review). In: The Cochrane Library,

Issue 1,

2003. Oxford: Update Software.

American Academy of Oral and Maxillofacial Surgeons (AAOMS). Criteria for

orthognathic surgery. Reimbursement and Appeal Resources. Health Policy and

Third

Party Payor Relations Resources. Rosemont, IL: AAOMS; 2002. Available at:

http://www.aaoms.org/allied/allied_template.asp?content_type_id=126 & entity_id=12\

2.

Accessed April 15, 2003.

Tulloch JF, Proffit WR, C. Outcomes in a 2-phase randomized clinical

trial of early Class II treatment. Am J Orthod Dentofacial Orthop.

2004;125(6):657-667.

Property of Aetna Inc. All rights reserved. Clinical Policy Bulletins are

developed by Aetna to assist in administering plan benefits and constitute

neither offers of coverage nor medical advice. This Clinical Policy Bulletin

contains only a partial, general description of plan or program benefits and

does not

constitute a contract. Aetna does not provide health care services and,

therefore, cannot guarantee any results or outcomes. Participating providers are

independent contractors in private practice and are neither employees nor agents

of Aetna or its affiliates. Treating providers are solely responsible for

medical advice and treatment of members. This Clinical Policy Bulletin may be

updated and therefore is subject to change.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

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[Guest guest]

Don't jump to a lawyer right away. You have a little

ways to go before that. I had a little bit of trouble

with my insurance. They initially said mine was not

medically necessary, which is essentially saying it's

cosmetic. The first thing you need to do is get the

most recent copy of your insurance policy. Verify

what you coverage states about the type of surgery you

are having. Many times, insurance will try and put

orthognathic surgery in a dental category, but it is a

medical procedure. You will want to verify how they

are trying to classifying it. You will want to

break down their definition of cosmetic and medically

necessary and explain how they are wrong. You always

have the right to appeal the decision and at this

point you want all the ammunition you can get. Often

times they contradict their own policy so keep an eye

out and attach pertinent parts of the policy for their

reference.

Have any physicians (including dentist, general

physician, orthodontist, oral surgeon) that have

played a part in the process draft a letter advising

that the procedure is necessary and is NOT cosmetic.

Make sure to include problems you are having such as

eating properly, jaw pain, etc. DO NOT address the

aesthetic issue at all. Then basically draft a time

line chronicling from diagnoses to where you are now

what you have done.

Make sure they know that since your physician's deem

this medically necessary the insurer is showing bad

faith in declining the claim.

Be aware there are usually deadlines for your appeal.

If you have any other questions let me know. I have

been through this, but many states are different. I

am in Texas and I have a third party self insured

policy so that ERISA is the controlling legal avenue,

but often it is a state insurance board.

--- kathyb53@... wrote:

> I have Aetna and it is an insurance nightmare. They

> are refusing to pay for

> anything. They say it's cosmetic. I'm sure I will

> need a lawyer....

>

>

> [Non-text portions of this message have been

> removed]

>

>

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