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)
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Request for the treatment of facial skeletal deformities that result in significant malocclusion |
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Does the individual have any anterior discrepancies of maxillary/mandibular incisor overjet of 5mm or more? If yes, provide number of millimeters_____________________ |
YES |
NO |
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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 |
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Does the individual have a maxillary/mandibular anteroposterior molar relationship discrepancy of 4mm or more? If yes, provide number of millimeters_________________ |
YES |
NO |
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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 |
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Does the individual have an open bite with no vertical overlap of anterior teeth? |
YES |
NO |
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Does the individual have a unilateral or bilateral posterior open bite greater than 2mm? If yes, provide number of millimeters_____________________________ |
YES |
NO |
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Does the individual have a deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch? |
YES |
NO |
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Does the individual have a supra-eruption of a dentoalveolar segment due to lack of occlusion? |
YES |
NO |
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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 |
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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 |
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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 |
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The documentation below must be submitted prior to authorization of the service for facial skeletal deformities that result in significant malocclusion:
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Request for the treatment of obstructive sleep apnea (OSA) |
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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 |
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Has the individual failed to respond to or tolerate nasal continuous positive airway pressure (nCPAP)? |
YES |
NO |
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Did the presurgical physical evaluation support the need for orthognathic surgery? |
YES |
NO |
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Is the site of obstruction (oropharynx [palate] and/or hypopharynx [base of tongue]) confirmed by fiberoptic pharyngoscopy and cephalometric radiographs with tracing? |
YES |
NO |
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Has the obstruction been treated unsuccessfully by uvulopalatopharyngoplasty (UPPP), if OSA is due to type I obstruction (oropharynx)? |
YES |
NO |
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The documentation below must be submitted prior to authorization of the service for OSA:
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Request for the treatment of other conditions |
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Is the request for orthognathic surgery to improve the individual's facial structure in the absence of significant malocclusion? |
YES |
NO |
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Is the request for orthognathic surgery for the treatment of temporomandibular joint (TMJ) disorder? |
YES |
NO |
This document has been classified as public information.