Validity of Medical Insurance Guidelines for Orthognathic Surgery – PMC
materials and methods
this retrospective study was conducted at houston methodist hospital in houston, texas, after receiving institutional review board approval (pro00025630). The study evaluated the validity of orthognathic surgery guidelines used by major US health insurance companies: Aetna, Anthem Blue Cross Blue Shield (BCBS), Cigna, Humana, and UnitedHealthcare (UHC). To assess validity, we calculated the approval and denial rates for the 5 insurance guidelines when used to assess medical necessity for a carefully selected control group of patients.
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all rejected cases (sentinel events) were analyzed to determine the root cause of the denials. the validity of the guidelines was also assessed by checking their completeness and correctness. these characteristics were determined by comparing each insurance guideline to a benchmark guideline we developed for a prudent provider. a prudent provider is the average prudent provider who practices the standard of care for his or her community.10
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Prior to patient selection, researchers met to discover criteria for prudent providers. The investigator group included an orthodontic graduate student (ss), an oral and maxillofacial surgery fellow (kc), a senior academic orthodontist (je), and a senior academic oral and maxillofacial surgeon (jg).
The group adopted the American Medical Association definition of medical necessity: health care services or items that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms of One way is to say: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the financial benefit of health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.11
After reviewing all pertinent literature12-83 at several consensus meetings, the group agreed on the following criteria for orthognathic surgery: (1) one or both jaws are deformed; that is, the configuration of the jaw prevents the normal articulation of the teeth, narrows the airways, or disfigures the face. (2) the deformity affects health by impairing function, promoting injury, or causing or aggravating disease. (3) there is no equally effective and less complicated treatment. (4) the surgery is appropriate for the patient. these criteria became the inclusion criteria for the study.
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The patient search of our medical records was limited to patients seen after June 2018, by a single provider (jg). In June 2018, we had developed, for our clinical practice, a single data collection form that amalgamated all the information required by the different insurance guidelines. this document was added to our orthognathic consultation template, part of our electronic medical record system. We only selected single provider orthognathic surgery consultations because they were meticulous in measuring and recording all data fields on the form. In addition to collecting data from clinical notes, we also collect cephalometric analyses. patients were added to the study group if their medical records were complete and they met our criteria for orthognathic surgery. we studied 110 patients who met the research criteria.
To determine approval or denial based on different insurance guidelines, we developed scorecards for each insurance company. because orthognathic surgery may be considered medically necessary under the guidelines for orthognathic surgery, obstructive sleep apnea, or temporomandibular joint disorders, the grids combined the 3 separate guidelines.6-9, 84-94 a single investigator calibrated (ss), not familiar with the patient, reviewed anonymized medical records and scored each patient according to the 5-payer guidelines. the evaluation of the clinical histories was objective. subjective assessments were not allowed. only those anatomical and functional disorders that were unambiguously documented in medical records were scored.
all data was collected and analyzed in microsoft excel. descriptive statistics were used to present the findings.