Sydney A Schneider1, Jaime Gateno2, Kevin B Coppelson3, Jeryl D English4, James J Xia5. 1. Resident and Graduate Student, Department of Orthodontics, University of Texas Houston Health Science Center School of Dentistry, Houston, TX. 2. Chairman, Oral and Maxillofacial Surgery Department, Houston Methodist Hospital, Professor of Oral and Maxillofacial Surgery, Houston Methodist Academic Institute, Houston, TX; and Professor of Clinical Surgery (Oral and Maxillofacial Surgery), Weill-Cornell Medical College, New York, NY. 3. Former Advanced Oral and Maxillofacial Surgery Fellow, Houston Methodist Hospital, Houston, TX. 4. Professor and Chairman, Department of Orthodontics, University of Texas Houston Health Science Center School of Dentistry, Houston, TX. 5. Director of Surgical Planning Laboratory, Oral and Maxillofacial Surgery Department, Houston Methodist Hospital, Houston, TX; Professor of Oral and Maxillofacial Surgery, Houston Methodist Academic Institute, Houston, TX; and Professor of Surgery (Oral and Maxillofacial Surgery), Weill-Cornell Medical College, New York, NY. Electronic address: JXia@HoustonMethodist.org.
Abstract
PURPOSE: The purpose of this study was to assess the validity of the medical insurance guidelines for orthognathic surgery used by the major American medical insurance companies. MATERIALS AND METHODS: This study assessed the validity of the medical insurance guidelines for orthognathic surgery used by Aetna, Anthem Blue Cross Blue Shield (BCBS), Cigna, Humana, and UnitedHealthcare (UHC). To evaluate the validity, we calculated the approval and denial rates of the 5 guidelines when we used them to assess the medical necessity for a control group of carefully selected patients. Patients were included in the control group if they met the criteria of a "prudent provider," crafted for this study. All rejected cases were analyzed to determine the root cause of the denials. The validity of the guidelines was also ascertained by determining their completeness and correctness. RESULTS: The current study proves that no insurance guideline is in agreement with the criteria of a "prudent provider." When applied to carefully chosen patients, the requirements of BCBS, Aetna, Humana, and Cigna produce modest rejection rates of 6 to 12%. UHC is an outlier. Its guideline rejects 86% of patients, a rate about 7 times higher than its peers. Insurance guidelines disqualified patients for 3 different reasons: 1) no significant jaw deformity, 2) no demonstrable health impairment, and 3) the etiology of the condition is not a covered benefit. Additional evaluations demonstrate that the private insurance guidelines are incomplete, and at times, incorrect. CONCLUSIONS: This study shows that the medical insurance guidelines for orthognathic surgery used by the major American medical insurance plans need revision. The most consequential flaw was considering etiology in judging medical necessity. Fortunately, only one company adopted this policy. Moreover, all guidelines have omissions and errors in the way jaw deformity is determined and how health impairment is determined.
PURPOSE: The purpose of this study was to assess the validity of the medical insurance guidelines for orthognathic surgery used by the major American medical insurance companies. MATERIALS AND METHODS: This study assessed the validity of the medical insurance guidelines for orthognathic surgery used by Aetna, Anthem Blue Cross Blue Shield (BCBS), Cigna, Humana, and UnitedHealthcare (UHC). To evaluate the validity, we calculated the approval and denial rates of the 5 guidelines when we used them to assess the medical necessity for a control group of carefully selected patients. Patients were included in the control group if they met the criteria of a "prudent provider," crafted for this study. All rejected cases were analyzed to determine the root cause of the denials. The validity of the guidelines was also ascertained by determining their completeness and correctness. RESULTS: The current study proves that no insurance guideline is in agreement with the criteria of a "prudent provider." When applied to carefully chosen patients, the requirements of BCBS, Aetna, Humana, and Cigna produce modest rejection rates of 6 to 12%. UHC is an outlier. Its guideline rejects 86% of patients, a rate about 7 times higher than its peers. Insurance guidelines disqualified patients for 3 different reasons: 1) no significant jaw deformity, 2) no demonstrable health impairment, and 3) the etiology of the condition is not a covered benefit. Additional evaluations demonstrate that the private insurance guidelines are incomplete, and at times, incorrect. CONCLUSIONS: This study shows that the medical insurance guidelines for orthognathic surgery used by the major American medical insurance plans need revision. The most consequential flaw was considering etiology in judging medical necessity. Fortunately, only one company adopted this policy. Moreover, all guidelines have omissions and errors in the way jaw deformity is determined and how health impairment is determined.
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