Orthognathic Surgery—50%

Services Must Be Precertified With the Medical Review Agency

Benefits are provided for the usual, customary and reasonable charges (as determined by this plan) for services and supplies provided by a physician or dentist for orthognathic surgery. Services and supplies are covered at 50 percent with a lifetime maximum of $5,000. These services always require 50 percent coinsurance and these coinsurance expenses do apply toward the $2,300 annual coinsurance maximum. If expenses exceed the $5,000 lifetime maximum, this plan will not pay the additional costs.

For the purpose of this plan, orthognathic surgery or surgical orthodontics refers to those surgical procedures necessary to correct the malposition of the maxilla (upper jaw bone) or the mandible (lower jaw bone). Treatment is covered when necessary to correct the following: a congenital defect or anomaly with severe functional or skeletal discrepancies; or trauma leading to an acquired defect with severe functional or skeletal discrepancies to the maxillo-facial complex. Surgical treatment must be in association with conventional orthodontics. Covered services and supplies include:

• Examinations, laboratory services, x-rays, the administration of general anesthesia, the surgical procedure(s), and any complications thereof.
• Hospital or outpatient surgical services and supplies including surgical splints, stents and appliances.

Benefits are not provided for:

1. Any service or supply primarily for cosmetic purposes including any direct or indirect complications thereof.
2. Any treatment for a relapse of a previous orthognathic surgery.
3. Dental services, except as provided for under "Dental Benefits" on pages 95-104.