Articles

Double-Check Your Preauthorization Notes
for Orthognathic Surgery
We track down the reason for an unreasonable denial

Insurance carriers don’t want to pay for orthognathic surgery — and will use every excuse they can to avoid doing so. If your preauthorization request doesn’t make the patient’s medical necessity blatantly obvious to the insurer, you’re probably headed for rejection.

Take a look at this orthognathic surgery case to learn how one office determined why a reasonable and covered surgery request kept coming up empty — and how they’ll succeed in getting their patient treatment.

The facts: An orthodontist referred a 15-year-old patient with retrognathia (mandibular hypoplasia) and bimaxillary overcrowding (maxillary verticals hyperplasia) to Eastern Carolina Oral Surgery in Goldsboro, N.C. An evaluation by one of the oral and maxillofacial surgeons determined that the patient required orthognathic surgery to correct his dentofacial anomaly — specifically, the patient needed a LeFort I osteotomy of the maxilla and bilateral sagittal split osteotomies of the mandible.

The patient’s medical carrier, State Employee Blue Cross Blue Shield (BCBS), requires preauthorization for “orthognathic surgery to correct deformities of the jaw and realign maxillofacial structures with each other.”

The practice’s insurance coordinator, Karen Jernigan, sent in the request for preauthorization, which included a detailed letter from the oral and maxillofacial surgeon along with x-rays and photographs of the patient’s condition.

The patient needs the surgery for medically necessary reasons, Jernigan says. His condition is not just cosmetic: He is unable to close his mouth correctly, and this affects his ability to chew, she says.

To Jernigan’s surprise, the carrier denied her preauthorization request. BCBS provided this explanation: “Orthognathic surgery is covered for the following indications: Treatment of malocclusion that contributes significantly to any one of the following: difficulty swallowing, ability to chew, speech, and malnutrition.”

An examination of the state employee policy shows that oral surgery benefits “are excluded for orthognathic surgery when there is an absence of documentation that the correction of the deformity is medically necessary for the maintenance of good physical health.”

If your practice is ever faced with a similar preauthorization denial, follow the quick checklist that Eastern Carolina Oral Surgery followed to find the missing link in their request.

1. Ask if Procedure Is Allowable

The procedures the oral surgeon wants to perform — a LeFort I osteotomy of the maxilla 21141 (Reconstruction midface, LeFort I; single piece, segment movement in any direction [e.g., for Long Face Syndrome], without bone graft), and bilateral sagittal split osteotomies of the mandible (BSSO), 21195-21196 (Reconstruction of mandibular rami and/or body, sagittal split ...) — are both on the BCBS list of allowable codes. Therefore, the procedure the surgeon is requesting permission to perform is not the problem.

2. Determine if Diagnosis Is Valid

According to PMIC’s 2005 Codelink for Oral and Maxillofacial Surgery, the patient’s retrognathia diagnosis (524.10, Dentofacial anomalies, including malocclusion; anomalies of relationship of jaw to cranial base; unspecified anomaly) is an appropriate diagnosis for both the LeFort and the BSSO. The practice should also consider adding codes 524.04 (Mandibular hypoplasia) and 524.01 (Maxillary hyperplasia), which indicate the patient’s skeletal anomalies.

Because the practice is using correct diagnosis codes, these are not likely the cause of the preauth denial.

3. Look to the Surgeon’s Letter

The problem, Jernigan discovered, might be in the letter and notes the oral and maxillofacial surgeon provided to obtain preauthorization. In his letter, the surgeon goes into great detail about the patient’s jaw measurements, and in his notes he mentions bimaxillary overcrowding, Jernigan says. “But that’s not a reason to do the surgery. Nowhere in his letter does he just say directly ‘The patient can’t chew his food properly.’ He’s not stating what problems are occurring [as a result of the malocclusion].

“When I read all these measurement numbers [in the letter], they don’t mean anything to me,” Jernigan says. And the BCBS employee processing the preauthorization request probably feels the same way.

4. Spell It Out for the Carrier

If the oral and maxillofacial surgeon only documented the measurements and did not say the patient is having difficulty chewing, that is certainly the cause of denial, says Mindi Rothans, CPC, CDPMA, president of CPC Unlimited in *Lake Forest, Calif.

“Overcrowding” doesn’t tell the carrier that the patient is having any trouble. The surgeon “needs to actually state somewhere that the patient is having difficulty chewing,” Rothans says. **There is no ICD-9-CM code for this condition, so the surgeon must state it in the letter.

The letter should also include the code for malocclusion (524.31, Dentofacial anomalies, including malocclusion; anomalies of tooth position of fully erupted teeth; crowding of teeth, is appropriate), she says. You should list malocclusion as the primary diagnosis and difficulty chewing as secondary, she says.

If you know your patient qualifies for a surgery and your coding is correct, check your documentation and make sure you’ve spelled out the reasons the carrier covers the surgery in the insurer’s exact terminology.

*Revision - CPC Unlimited is located in Goodyear, Arizona.

**Revision - Mrs. Rothans was mis-quoted, the ICD-9-CM code is V41.6 for difficulty chewing

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