Orthognathic Surgery Evaluation Tool

Orthognathic Surgery Evaluation Tool
Predetermination Request Form

BlueCross BlueShield of Tennessee

(The medical policy is located at: http://www.bcbst.com/MPManual/Orthognathic_Surgery.htm)

Patient Name: ___________________________Age: ___________Date: ____________________

Provider's name: __________________________________________________________________

Provider's address: ________________________________________________________________

Provider's phone number: ___________________________________________________________

Diagnosis code(s): ________________________________________________________________

CPT code(s): _____________________________________________________________________

Date Services are to be rendered: ____________________________________________________

Member's ID:_____________________________________________________________________

Please attach the information below to the appropriate form for your request (e.g., predetermination, precertification) and line of business (e.g., Commercial, BlueCare).

(All the information listed below is required for medical appropriateness criteria determination)

Request for the treatment of facial skeletal deformities that result in significant malocclusion

Does the individual have any anterior discrepancies of maxillary/mandibular incisor overjet of 5mm or more? If yes, provide number of millimeters_____________________	YES	NO
Does the individual have any anterior discrepancies of maxillary/mandibular incisor overjet of 0mm to a (-) negative value? If yes, provide number of millimeters____________________________	YES	NO
Does the individual have a maxillary/mandibular anteroposterior molar relationship discrepancy of 4mm or more? If yes, provide number of millimeters_________________	YES	NO
Does the individual have a vertical facial skeletal deformity, which is two or more standard deviations from published norms for accepted skeletal landmarks? If yes, provide standard deviation________________________________	YES	NO
Does the individual have an open bite with no vertical overlap of anterior teeth?	YES	NO
Does the individual have a unilateral or bilateral posterior open bite greater than 2mm? If yes, provide number of millimeters_____________________________	YES	NO
Does the individual have a deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch?	YES	NO
Does the individual have a supra-eruption of a dentoalveolar segment due to lack of occlusion?	YES	NO
Does the individual have a transverse skeletal discrepancy, which is two or more standard deviations from published norms? If yes, provide standard deviation_______________________________	YES	NO
Does the individual have a total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, or a unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth? If yes, provide number of millimeters____________________________	YES	NO
Does the individual have an anteroposterior, transverse or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry? If yes, provide number of millimeters____________________________	YES	NO
The documentation below must be submitted prior to authorization of the service for facial skeletal deformities that result in significant malocclusion: Dental films Frontal and profile photographs of the face (color photos preferred) Measurements

Request for the treatment of obstructive sleep apnea (OSA)

Does the individual have documented results of a full polysomnogram, which confirms a diagnosis of obstructive sleep apnea (OSA) due to type II obstruction (oropharynx/hypopharynx) or type III obstruction (hypopharynx)?	YES	NO
Has the individual failed to respond to or tolerate nasal continuous positive airway pressure (nCPAP)?	YES	NO
Did the presurgical physical evaluation support the need for orthognathic surgery?	YES	NO
Is the site of obstruction (oropharynx [palate] and/or hypopharynx [base of tongue]) confirmed by fiberoptic pharyngoscopy and cephalometric radiographs with tracing?	YES	NO
Has the obstruction been treated unsuccessfully by uvulopalatopharyngoplasty (UPPP), if OSA is due to type I obstruction (oropharynx)?	YES	NO
The documentation below must be submitted prior to authorization of the service for OSA: Results of a full polysomnogram. Evidence that the individual has failed to respond or tolerate nCPAP. Documentation that the presurgical physical evaluation supports the need for orthognathic surgery. Results of fiberoptic pharyngoscopy and cephalometric radiographs with tracing of obstruction (oropharynx [palate] and/or hypopharynx [base of tongue]). Evidence that the obstruction has been treated unsuccessfully by uvulopalatopharyngoplasty (UPPP), if OSA is due to type I obstruction (oropharynx).

Request for the treatment of other conditions

Is the request for orthognathic surgery to improve the individual's facial structure in the absence of significant malocclusion?	YES	NO
Is the request for orthognathic surgery for the treatment of temporomandibular joint (TMJ) disorder?	YES	NO

This document has been classified as public information.