Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cleft lip and palate congenital deformity
Treatment: Jaw Surgery (genioplasty) CPT (Current Procedural Terminology) codes        21142, 21141, 21210, 21121, 21198, 21146), 
The insurer denied the Jaw Surgery (genioplasty)  ( CPT codes: 21142, 21141, 21210, 21121, 21198, 21146),
The denial is overturned.

The patient is a male. He has a prior history of a cleft lip and palate congenital deformity.  The patient has previously undergone repair of the lip, palate, as well as a bone grafting procedure to the alveolar ridge.  All the previous procedures were performed in another state.

The patient now presents complaining of malocclusion.  Specifically, the patient was documented as having class III malocclusion, which is not inconsistent with a cleft lip and palate congenital deformity.  Due to the discrepancy between the upper and lower dentition and jaw, the patient is having difficulty with mastication and complains of pain and discomfort.  The patient has already undergone orthodontic alignment in preparation for the surgery, and now, the patient has consulted with a plastic surgeon who has recommended oral maxillofacial jaw surgery to better realign the mandible and maxilla.

Orthodontic evaluation including a Panorex and cephalometric analysis revealed an 8 mm (millimeter) reverse overjet due to maxillary hypoplasia and a transverse maxillary asymmetry.  In conjunction with the maxillomandibular orthodontic surgery, the treating surgeon has recommended a genioplasty to more correctly align the maxillomandibular relationship.

Yes, the proposed jaw surgery is medically necessary for this patient, given the clinical information provided.
Based on review of the clinical information provided and clinical practice standards and peer-reviewed literature established by the relevant medical community, the requested maxillomandibular orthognathic surgery, including a genioplasty procedure, for this patient are considered to be medically necessary and appropriate for this patient.  The clinical documentation provided shows that the patient suffers from a cleft lip and palate congenital deformity and required multiple previous surgeries to repair the lip, palate and alveolar ridge.  Now that the patient has grown much older, the patient is experiencing significant midface deficiency, creating a maxillomandibular discrepancy.  Because the patient had a congenital deformity, which already makes his aesthetic appearance abnormal compared to the normal population, but does not suffer from the congenital deformity, the patient also has functional impairment with mastication manifesting with pain and discomfort.  This midface hypoplasia along with mandibular prominence is a very common facial deformity consistent with a cleft lip and palate congenital deformity.

The standard of care established by the relevant medical community, is to consider coverage for services related to correct the congenital facial deformity.  This includes both aesthetics to restore a normal appearance and surgeries to restore functional symptoms.  Although the maxillomandibular orthognathic surgery will help with the patient's functional mastication and pain symptomology, the genioplasty which includes a setback of the mandible is also intended to restore a normal appearance and that is not typically considered a purely cosmetic procedure.  Because the genioplasty is intended to correct an abnormal appearance that developed as a consequence of a congenital deformity, the procedure should be considered medically necessary.  All the requested CPT (Current Procedural Terminology) codes are typical procedures performed to correct the stigmata associated both aesthetically and functionally with a cleft lip and palate deformity.  Therefore, all the requested services should be covered for this patient given the clinical information provided, as they are medically necessary.