Harvard Pilgrim HealthCare Medical Policy

Subject: Orthognathic Surgery for Severe Oral-Maxillofacial Functional Disorders

Authorization: Prior authorization is required for orthognathic surgery requested for members enrolled in commercial (HMO, POS, and PPO) products.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

For this policy, The Plan draws upon the following InterQual® criteria:

• Osteotomy, Anterior Segment, Mandible
• Osteotomy, LeFort I
• Osteotomy, Sagittal Split, Mandible Ramus
• Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy

For this policy, The Plan draws upon the following InterQual® criteria, which has been customized:

• Bone Augmentation, Mandible
• Bone Augmentation, Maxilla
• Osteotomy, Anterior Segment, Maxilla