OriginalArticle
Negative of coverage in orthognathic
surgery by health plans MARÍLIA DE OLIVEIRA COELHO DUTRA LEAL1,2,3 | GILBERTO PAIVA DE CARVALHO3,4,5 | CLÁUDIO ROBERTO PACHECO JODAS6,7 | RUBENS GONÇALVES TEIXEIRA8,9 | EDUARDO DARUGE JÚNIOR10,11
ABSTRACT 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.
Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba, Programa de Pós-graduação em Biologia Buco-Dental – Histologia (Piracicaba/SP, Brazil). Specialist in Oral and Maxillofacial Surgery, Faculdade São Leopoldo Mandic (Campinas/SP, Brazil). 3 Instituto Médico Legal (Boa Vista/RR, Brazil). 4 Doctorate degree in Oral and Dental Biology – Anatomy, Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil). 5 Universidade Federal de Roraima, Centro de Ciências da Saúde, Curso de Enfermagem, Disciplinas de Anatomia, Morfologia e Fisiologia (Boa Vista/RR, Brazil). 6 Doctorate degree in Orthodontics, Faculdade São Leopoldo Mandic (Campinas/SP, Brazil). 7 Faculdade São Leopoldo Mandic, Programa de Pós-graduação em Odontologia e Departamento de Cirurgia e Traumatologia Bucomaxilofaciais (Campinas/SP, Brazil). 8 Complexo Hospitalar Edivaldo Orsi, Serviço de Cirurgia e Traumatologia Bucomaxilofaciais (Campinas/SP, Brazil). 9 Doctorate degree in Dentistry, Universidade Federal do Rio de Janeiro (Rio de Janeiro/RJ, Brazil). 10 Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba, Programa de Pós-graduação em Biologia Buco-Dental, Disciplina de Odontologia Legal (Piracicaba/SP, Brazil). 11 Doctorate degree in Dental Radiology, Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil). 1
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 MayAug;4(2):18-24. DOI: https://doi.org/10.14436/2358-2782.4.2.018-024.oar
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© Journal of the Brazilian College of Oral and Maxillofacial Surgery
Submitted: May 25, 2015 - Revised and accepted: January 25, 2018
» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.
Contact address: Marilia de Oliveira Coelho Dutra Leal Faculdade de Odontologia de Piracicaba - Unicamp/ Departamento de Morfologia, Av. Limeira, 901, Areião, Piracicaba/SP – CEP: 13.414-903 E-mail: marilialeal@hotmail.com
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J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):18-24