Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthognathic surgery consisting of: midface reconstruction, LeFort 1 maxillary osteotomy, three segments, with autogenous local graft-advancement with clockwise occlusal plane rotation ; mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid internal fixation-setback with counter clockwise occlusal plane rotation; and interocclusal surgical guide.At issue in this case is whether the requested orthognathic surgical services are medically necessary to treat the patients medical condition. In addition, does the patients severe malocclusion constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Cottrell and colleagues state that the surgical correction of maxillofacial skeletal deformities includes the reconstructive procedures that correct deformities of the maxilla, mandible, facial skeleton, and associated soft tissue structures. Researchers explain that the principal goal for surgical correction of the maxillofacial skeletal deformity is to create or restore normal form, function, and health, while minimizing potential negative short-term and long-term sequelae. In this case, the patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. The recommended surgical procedures will result in the patient having improved musculoskeletal and dento-osseous relationships and improvement in mastication. Under these circumstances, the requested orthognathic surgery consisting of midface reconstruction, LeFort 1 maxillary osteotomy, three segments, with autogenous local graft-advancement with clockwise occlusal plane rotation, mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid internal fixation-setback with counter clockwise occlusal plane rotation, and interocclusal surgical guide are medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patients severe malocclusion is a maxillofacial skeletal deformity and thereby constitutes an abnormal structure of the body. The etiology of maxillofacial skeletal deformities may be congenital, developmental, or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional and degenerative problems. The patients abnormal structure of the body was therefore caused by congenital defect or developmental abnormality. The requested surgical procedures will result in improved musculoskeletal and dento-osseous relationships and improvement in mastication, and they will therefore result in improved function. The requested surgical procedures will also provide more than a minimal improvement in appearance. Accordingly, the requested orthognathic surgery consisting of midface reconstruction, LeFort 1 maxillary osteotomy, three segments, with autogenous local graft-advancement with clockwise occlusal plane rotation, mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid internal fixation-setback with counter clockwise occlusal plane rotation, and interocclusal surgical guide also constitute medically necessary reconstructive surgery as defined in California law.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. The reviewer also determined that the patients severe malocclusion did constitute an abnormal structure of the body that was caused by congenital defect or developmental abnormality, that the requested surgery would be performed to improve function, that the surgery would provide more than a minimal improvement in appearance, and that the requested services were therefore medically necessary reconstructive surgery. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.