Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea
Treatment: Jaw surgery 
The health plan denied: Jaw surgery 
The determination is: Overturned 

The patient is a male with obstructive sleep apnea. He has a history of a prior septoplasty, tonsillectomy and adenoidectomy, a Pillar implant placement in the pallet, and a Lefort I osteotomy. His sleep study showed an apnea hypopnea index (AHI) of 6.3 and a respiratory disturbance index (RDI) of 21.3. The patient has a maxillary hypoplasia and mandibular hyperplasia. The provider is planning to perform maxillomandibular advancement surgery to include a genioplasty.
At issue is the medical necessity of the jaw surgery.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of jaw surgery is medically necessary for this patient.
According to the American Association of Oral & Maxillofacial Surgeons, procedures for the correction of maxillofacial skeletal deformities are often indicated for the treatment of obstructive sleep apnea (OSA). Untreated sleep apnea can increase the chance of having high blood pressure, heart attack, stroke, diabetes, work related and driving accidents. Maxillomandibular advancement surgery demonstrates well documented success in the treatment of OSA.
Maxillomandibular advancement surgery should be considered as a first-line treatment for obstructive sleep apnea in both the skeletal deformity patient and those presenting with normal cephalometric values, aesthetics, and a class 1 occlusion. Maxillomandibular advancement surgery is considered to be the most successful surgical alternative to a tracheostomy. This surgery improves the dimensions and stability of the pharyngeal airway. Fiberoptic nasopharyngoscopy after maxillomandibular advancement surgery revealed a significant enlargement of lateral and anteroposterior airway dimensions for all patients.
The computed tomography (CT) scan and interpretation are necessary. Using this computer-aided surgical simulation protocol, the computerized plan can be transferred accurately and consistently to the patient to position the maxilla and mandible at the time of surgery. Preoperative evaluations and measurements of these types provide the oral and maxillofacial surgeon with 3 dimensional information that will translate into shortening surgical procedures and minimizing potential surgical risks and complications. Postoperatively, CT scans allow the surgeon to assess the positions of the osteotomy segments, bone plates and screws, bone grafts, and the mandibular condyles within the glenoid fossae. The removal of the hardware is necessary to allow the Le Fort I procedure to be performed.
Genioplasties are medically necessary and non-cosmetic when performed to treat sleep apnea or lip incompetence. An increased vertical dimension in the chin area causes lip strain. Reducing the height and advancing the chin reduces the height of the chin and improves lip incompetence. Genioplasties are often performed to treat sleep apnea or as an adjunct to maxillomandibular advancement surgery. This has been shown to open the airway space. The genioplasty involves an osteotomy in the anterior mandible, creating a segment that incorporates the genial tubercles and associated muscle attachments. The chin segment is then repositioned anteriorly to advance and suspend the hyoid bone and this has been proven to result in a further increase in posterior airway space.
The oral surgical splint is medically necessary to accurately position the jaws into their preplanned surgical positions prior to the application of rigid fixation. These are fabricated preoperatively in the laboratory based on the model surgery. The interdental wiring is necessary to place the teeth in the proper occlusion prior to the application of rigid fixation.