Negative of coverage in orthognathic surgery by health plans

Marília de Oliveira Coelho Dutra Leal, Gilberto Paiva de Carvalho, Cláudio Roberto Pacheco Jodas, Rubens Gonçalves Teixeira, Eduardo Daruge Júnior

Survey of the jurisprudence of the Court of Justice of São Paulo, 2014, in lawsuits of negative coverage of orthognathic surgery by Private Health Care Plans. Documentary analysis through access to the page www.tjsp.jus.br; search in the field “Jurisprudência (Pesquisa livre)”. Use of the keywords: buco maxilo facial AND plano de saúde AND negativa de cobertura; survey of processes; data collection of specific processes of orthognathic surgery: sex of the applicant, month of the trial, Private Health Care Plans involved, region of origin, outcome of the action for the patient, motivation of the negative and legislation used. There were 106 judgments (58 were orthognathic surgery). The Unimed System accounted for 36% of these processes. Only two decisions were unfavorable to patients. The “Need for an accredited professional to evaluate the choice of procedure and/or material (Medical Board)” was the justification most used by the PPAS to deny surgeries, followed by “No contractual coverage/list of procedures of the National Agency of Supplementary Health (ANS)”. The legislations most cited in the proceedings were from ANS. There was a high incidence of orthognathic surgery in the Court of Justice of São Paulo, 2014. Of the decisions, 96% were favorable to the patients.

Keywords: Orthognathic surgery. Prepaid health plans. Health services coverage. Oral surgical procedures.

How to cite: Leal MOCD, Carvalho GP, Jodas CRP, Teixeira RG, Daruge Júnior E. Negative of coverage in orthognathic surgery by health plans. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):18-24. DOI: https://doi.org/10.14436/2358-2782.4.2.018-024.oar

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