Prior Authorization Request (Orthognathic Surgery)

Document Title: Prior Authorization Request – Orthognathic Surgery

Patient Name: [Patient Name]

Date of Birth: [Date of Birth]

Insurance Member ID: [Member ID]

Requesting Surgeon: [Surgeon Name, Credentials, NPI]

Treating Orthodontist: [Orthodontist Name, Credentials / Not applicable]

Anticipated Surgery Date: [Date / TBD]

Urgency Level: [Standard / Expedited] (If expedited, include brief medical justification.)

Payer/Policy Reference: [Policy name and number, if known]

Executive Summary

• [Primary skeletal/dentofacial diagnosis with key objective measurement and date]
• [Primary functional impairment(s) and duration]
• [Conservative management tried, date ranges, and why insufficient]
• [Proposed procedure(s) and expected functional benefit]
• [Critical attachments referenced by attachment ID]

Clinical Indication and Problem Statement

(Include only applicable subsections below; omit non-applicable subsections entirely.)

Masticatory Dysfunction

[Description of eating/chewing impairment: inability to incise/masticate, food escape, choking during meals, required diet modifications]

[Duration and trajectory: onset, persistence, progression]

[Objective corroboration: weight/BMI changes with dates, nutritional concerns, clinical observations]

Intraoral Trauma

[Injury pattern: cheek/tongue/palatal trauma during normal function]

[Frequency and severity: bleeding, ulceration, infection history]

[Functional impact on eating/speaking; reference photo documentation attachment ID]

Dysphagia/Choking

[Symptom details, frequency, and food consistencies affected]

[Duration and workup to exclude alternative etiologies]

[Mechanistic linkage explaining how jaw correction addresses the underlying cause]

Speech Impairment

[Speech-language pathology evaluation: date, key findings, formal assessment results]

[Therapy trial: duration, techniques, and response]

[Causation statement: malocclusion is causative, non-surgical therapy is insufficient]

Temporomandibular Disorder

[Symptoms: painful chewing, joint pain, headaches attributed to TMJ]

[Objective findings: maximal interincisal opening in mm, lateral excursions in mm, joint sounds, imaging findings]

[Conservative therapy trials: NSAIDs, splint therapy, PT, avoidance measures with dates/durations and responses]

[Rationale for surgery: why orthodontic or splint management alone is inadequate]

Obstructive Sleep Apnea

[Sleep study summary: date, AHI/RDI, oxygen nadir, severity category]

[Anatomic obstruction and evaluations: airway levels assessed, ENT findings if available]

[Non-surgical treatment trial: CPAP/BiPAP settings, adherence data, outcomes]

[Linkage statement explaining how maxillomandibular advancement will improve airway patency]

Congenital/Cleft-Related Deformity

[Diagnosis and relevant history: craniofacial anomaly or cleft-related details, prior surgeries with dates]

[Current functional deficits: feeding, speech, occlusion-related impact]

[Team-based care context if applicable]

Post-Trauma or Reconstruction

[Index event and timeline: trauma/tumor/infection with dates, prior interventions]

[Current defect/deformity description: skeletal and occlusal issues]

[Functional deficits attributable to deformity: chewing, speech, airway, or pain]

Clinical Course and Prior Management

Date Range	Intervention	Provider	Response	Reason Insufficient
[Start–End]	[Conservative measure or orthodontic phase]	[Provider/Clinic]	[Objective/subjective response]	[Why it did not resolve functional impairment]
[Start–End]	[Conservative measure or orthodontic phase]	[Provider/Clinic]	[Objective/subjective response]	[Why it did not resolve functional impairment]

[Brief interpretation synthesizing why the clinical course supports surgical intervention]

(If external records are pending, state: "External records requested on [date]; pending.")

Objective Findings

Examination Findings

• Occlusal classification: [Angle classification, crossbite/open bite, midline discrepancy]
• Overjet/Overbite: [Measurements in mm; include negative values or open bite magnitude]
• Masticatory function: [Clinician-observed difficulties during exam]
• Soft tissue trauma: [Location, severity, frequency] (Include only if present.)
• TMJ exam: [ROM in mm, tenderness, joint sounds, deviations] (Include only if TMD is an indication.)

Cephalometric Analysis

Source/Date: [Analysis source and date] (If pending, state: "Cephalometric analysis pending; radiographs obtained on [date]; analysis expected by [date].")

Parameter	Value
Anteroposterior discrepancy (e.g., ANB, Wits)	[Value and units]
Vertical discrepancy (e.g., mandibular plane angle, open bite magnitude)	[Value and units]
Transverse discrepancy/asymmetry (e.g., midline shifts)	[Value and units]
Dentoalveolar compensation (incisor angulations)	[Value and units]

[Statement on whether measurements reflect compensated or decompensated dental positions and how this was accounted for]

Skeletal Maturity

(Include for adolescent or young adult patients when payer requires growth completion documentation.)

Patient age: [Age]

Supporting evidence: [Wrist/hand radiograph findings with date and/or serial cephalometric stability] (If not required per payer policy or patient age, state briefly why documentation is unnecessary.)

Assessment

• [Diagnosis 1] (ICD-10: [Code]): [Documented deformity] → [Resulting functional impairment] → [Why conservative management is insufficient] → [Why surgical correction is expected to improve function]
• [Diagnosis 2] (ICD-10: [Code]): [Linkage statement as above] (Include additional diagnoses only if applicable.)

(Use clinical judgment language when making inferences. Cite source data by date. Do not assert findings without documented evidence.)

Treatment Plan

• Proposed procedures: [Planned surgical procedures in plain language]
• Orthodontic coordination: [Pre-surgical orthodontics status: complete / in progress; post-surgical plan and anticipated timelines]
• Planned skeletal movements: [Direction and magnitude in mm] (If not finalized, state: "To be finalized after final records.")
• Expected functional outcomes: [Specific improvements tied to documented impairments: chewing, speech, airway, TMJ function]
• Alternatives considered: [Non-surgical options and why inadequate to restore function]
• Genioplasty: [Not included / Included as functional-adjunctive (state rationale) / Included as cosmetic] (Include only if genioplasty is part of surgical plan.)

Payer Criteria Crosswalk

Criterion	Patient Evidence	Supporting Attachment
Documented skeletal/dentofacial deformity	[Specific measurements and exam findings with dates]	[Attachment ID(s)]
Functional impairment with duration/severity	[Detailed functional limitations and duration]	[Attachment ID(s)]
Conservative management trial and failure	[Interventions, dates, outcomes]	[Attachment ID(s)]
Skeletal maturity	[Age and supporting studies with dates]	[Attachment ID(s)]
Expected functional improvement from surgery	[Clear linkage of procedure to functional gains]	[Attachment ID(s)]

(If payer-specific criteria are unknown, apply standard orthognathic medical necessity criteria.)

Attachments

(Include applicable attachments; omit items marked "Not Clinically Indicated" unless payer specifically requires.)

• [A1] Clinical photographs (extraoral and intraoral) – [Date] – [Attached / Requested / Pending]
• [A2] Panoramic radiograph – [Date] – [Attached / Requested / Pending]
• [A3] Lateral cephalometric radiograph – [Date] – [Attached / Requested / Pending]
• [A4] Cephalometric analysis and tracings – [Date] – [Attached / Requested / Pending]
• [A5] Prediction tracings/surgical planning documents – [Date] – [Attached / Requested / Pending]
• [A6] Orthodontist letter and treatment summary – [Date] – [Attached / Requested / Pending]
• [A7] Sleep study report and CPAP/BiPAP adherence data – [Date] – [Attached / Requested / Pending] (If OSA indication)
• [A8] Speech-language pathology evaluation – [Date] – [Attached / Requested / Pending] (If speech indication)
• [A9] ENT evaluation – [Date] – [Attached / Requested / Pending] (If airway assessment applicable)
• [A10] TMJ imaging/reports – [Date] – [Attached / Requested / Pending] (If TMD indication)
• [A11] Relevant external records – [Date] – [Attached / Requested / Pending]

Attestation

I attest that the information provided is accurate and complete to the best of my knowledge. The requested orthognathic surgery is intended to treat significant functional impairment resulting from documented skeletal/dentofacial deformity and is not requested for cosmetic purposes. I am available for peer-to-peer review.

Surgeon Signature: ____________________________ Date: [Date]

Name/Credentials/NPI: [Surgeon Name, Credentials, NPI]

Contact for Peer-to-Peer: [Phone] | [Secure Fax] | [Email]