MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Orthodontic Services for Treatment of Congenital Craniofacial Anomalies

Number 9.02.500

Effective Date January 1, 2014

Revision Date(s) 11/11/13; 09/09/13; 12/11/12; 04/10/12; 03/08/11; 02/09/10; 02/10/09; 06/10/08; 07/10/07; 07/11/06; 01/01/06

Replaces N/A

Policy

NOTE: The age restriction in this policy (members age 18 and under) does not apply to Oregon members. See Benefit Application section for state mandates for Oregon members.

Orthodontic services may be considered medically necessary for the treatment of cleft lip, cleft palate, cleft palate with alveolar ridge involvement, and certain congenital craniofacial anomalies* when a physical functional impairment exists.

*See below for a list of congenital disorders to which this policy applies.

For treatment of cleft palate and other congenital craniofacial /dentoalveolar anomalies the following may be considered medically necessary:

  • Alveolar ridge closure
  • An appliance for palatal expansion in preparation for bone graft surgery of the alveolar cleft in the pre-surgical and post-surgical period for primary and mixed dentitions
  • Interceptive orthodontic care, including full braces, in the mixed or early permanent dentition
  • Orthognathic surgery

This policy applies to the following list of congenital disorders that may have craniofacial anomalies:

  • Arthrogyposis
  • Amniotic band syndrome of face
  • Bird headed dwarfism (nanocephalic or primordial dwarfish)
  • Chondroectodermal dysplasia (Ellis-Van Crevald Syndrome)
  • Cleft lip
  • Cleft mandible
  • Cleft palate isolated
  • Craniofacial dysostosis (Crouzon’s Syndrome)
  • Craniofacial microsomia
  • Craniosynostosis
  • Hemifacial hyperplasia
  • Hemifacial microsomia
  • Klinefelter’s syndrome
  • Klippel-Fiel syndrome
  • Lateral or oblique facial clefting
  • Marfan Syndrome
  • Oculoauriculovertebral dysplasia (Goldenhar’s Syndrome)
  • Oculomandibulofacial syndrome (Hallermann Stiff Syndrome, Ullrich , et. al. Syndrome)
  • Pierre Robin syndrome
  • Treacher Collins syndrome
  • Trisomy 21 (Down Syndrome) - other trisomies reviewed on a case by case basis
  • Turner’s syndrome (X-O syndrome)

Note: Treatment for developmental maxillofacial conditions that result in overbite, crossbite, malocclusion, and/or irregularities of the teeth not related to a severe congenital craniofacial anomaly are not addressed in this policy.

Please refer to the Appendix for a list of definitions which apply to this policy.

Related Policies

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

This policy relates only to the services or supplies described herein. Coverage will vary according to each specific health plan and by line of business. (See Scope section).

The impairment caused by the congenital craniofacial anomaly must be at a severity level that impairs the member’s ability to eat normally, breath and/or speak normally.

For coverage of continued services the physical functional impairment must be disabling and the intent of ongoing treatment is to reach a specific functional goal.

Description

A person may need treatment for a severe congenital craniofacial anomaly from birth until adulthood. Depending on the severity of the functional impairment caused by the deformity, multiple surgeries and oral appliances may be needed for proper nutritional intake, swallowing, or for aspiration prevention.

Congenital defects can interfere with the normal development of the face and jaw and the person as a whole. For example, a person born with cleft/lip palate or other severe craniofacial anomalies has multiple and complex problems, including nutritional concerns, middle ear disease, hearing deficiencies, deviations in speech and resonance, dentofacial and orthodontic deformities, and psychosocial adjustment problems.

Due to the complexities of craniofacial anomalies a team of medical professionals collaborate to render a comprehensive diagnosis, determine treatment needs and priorities, and supervise long-term planning. Some of the professionals involved in the plan of treatment might include but are not limited to: plastic surgeon, otolaryngologist (ear, nose, and throat specialist), audiologist (specialist in treating hearing loss), speech-language pathologist (specialist in speech, language, cognitive-communication & swallowing disorders), oral/maxillofacial surgeon, orthodontist, pediatric/family dentist, dental hygienist, prosthodontist, geneticist/genetic counselor.(1) Medical management of children with cleft palate may involve what might otherwise be considered dental care.

The American Academy of Pediatric Dentistry (AAPD), in its efforts to promote optimal health for children with cleft lip/palate and other craniofacial anomalies, endorses the current statements of the American Cleft Palate-Craniofacial Association (ACPA):

“All dental specialists should ensure that:

  • As primary dentition erupts, the team evaluation should include a dental examination and, if such services are not already being provided, referral to appropriate providers for caries control, preventive measures, and space management.
  • Before primary dentition has completed eruption, the skeletal and dental components should be evaluated to determine if a malocclusion is present or developing.
  • Depending on the specific goals to be accomplished and the patient’s age when initially evaluated, orthodontic management of the malocclusion may be performed in the primary, mixed, or permanent dentition. In some cases, orthodontic treatment may be necessary in all 3 stages.
  • While continuous active orthodontic treatment from early mixed dentition to permanent dentition should be avoided, each stage of orthodontic therapy may be followed by retention and regular observation. Orthodontic retention for the permanent dentition may extend into adulthood.” (4)

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

Orthodontia services are generally excluded from coverage under member health plan contracts, except under the limited circumstances listed in other sections of this policy.

Claims for orthodontic services for the treatment of congenital craniofacial anomalies will accrue to the medical benefit regardless of whether an orthodontic benefit exists under a member’s dental plan.

This benefit is available to members 18 years of age and younger.

Oregon

Effective March 5, 2012 House Bill 4128 was signed into law. The law mandates coverage for dental and orthodontic services for the treatment of congenital craniofacial anomalies, without age restriction, if the services are medically necessary to restore function. More information regarding covered and non-covered services and other administrative criteria for Oregon can be found in House Bill 4128. (See References section.)

Rationale

This policy was originally created in 2006. Since that time the policy has been reviewed and updated using MEDLINE literature searches. The most recent search covered the period of January 2012 through November 2013.

Following is a summary of the key literature.

According to the National Institute of Dental and Craniofacial Research, there are more than 300 genetic syndromes that have an associated craniofacial, oral or dental component. Additionally, there are other isolated or non-syndrome related, craniofacial defects that are not part of a genetic syndrome. Craniofacial disorders require surgical, dental, speech, medical and behavioral interventions for short and long-term care planning.

Clefts of the lip and palate affect about 1/700 births with a wide variability related to geographic regions. Craniofacial disorders are often rare disorders and many have complex causes that involve both genetic and environmental factors and the interactions between the two. Increased risk for craniofacial disorders has been associated with variables such as the mother’s use of prescription drugs, alcohol, and tobacco, the mother’s nutritional status, and occupational exposures during pregnancy. (3)

World Health Organization (WHO)

The World Health Organization (WHO) human genetics programme: International Collaborative Research on Craniofacial Anomalies definition follows:

“Craniofacial anomalies (CFA) are a highly diverse group of complex congenital anomalies. Collectively, they affect a significant proportion of the world. Cleft lip and/or palate, for example, occurs in approximately 1 per 500-700 births, the ratio varying considerably across geographic areas or ethnic groupings. The costs incurred from CFA in terms of morbidity, health care, emotional disturbance, and social and employment exclusion, are considerable for affected individuals, their families and society. It is estimated that 80% of orofacial clefts are nonsyndromic and of multifactorial origin, both genetic and environmental, the latter being especially important in prevention”. (4)

Practice Guidelines and Position Statements

American Academy of Pediatric Dentistry (AAPD)

The American Academy of Pediatric Dentistry (AAPD), in its efforts to promote optimal health for children with cleft lip/palate and other craniofacial anomalies, endorses the current statements of the American Cleft Palate-Craniofacial Association (ACPA).

As members of the interdisciplinary team of physicians, dentists, speech pathologists, and other allied health professionals, pediatric dentists should provide dental services in close cooperation with their orthodontic, oral and maxillofacial surgery, and prosthodontic colleagues. All dental specialists should ensure that:

  • Dental radiographs, cephalometric radiographs, and other imaging modalities as indicated should be utilized to evaluate and monitor dental and facial growth and development. (American academy of pediatric dentistry endorsements 239).
  • Diagnostic records, including properly-occluded dental study models, should be collected at appropriate intervals for patients at risk for developing malocclusion or maxillary-mandibular discrepancies.
  • As primary dentition erupts, the team evaluation should include a dental examination and, if such services are not already being provided, referral to appropriate providers for caries control, preventive measures, and space management.
  • Before primary dentition has completed eruption, the skeletal and dental components should be evaluated to determine if a malocclusion is present or developing.
  • Depending on the specific goals to be accomplished and the patient’s age when initially evaluated, orthodontic management of the malocclusion may be performed in the primary, mixed, or permanent dentition. In some cases, orthodontic treatment may be necessary in all 3 stages.
  • While continuous active orthodontic treatment from early mixed dentition to permanent dentition should be avoided, each stage of orthodontic therapy may be followed by retention and regular observation. Orthodontic retention for the permanent dentition may extend into adulthood.
  • For some patients with craniofacial anomalies, functional orthodontic appliances may be indicated.
  • For patients with craniofacial anomalies, orthodontic treatment may be needed in conjunction with surgical correction of the facial deformity.
  • Congenitally missing teeth may be replaced with a removable appliance, fixed restorative bridgework, or osseointegrated implants.
  • Patients should be closely monitored for dental and periodontal disease.
  • Prosthetic obturation of palatal fistulae may be necessary in some patients.
  • A prosthetic speech device may be used to treat velopharyngeal inadequacy in some patients. (5)

American Association of Oral and Maxillofacial Surgeons (AAOMS)

In 2012 the AAMOS published the Parameters of Care: Clinical Practice Guidelines for Oral/Maxillofacial Surgery. The association references The American Cleft Palate-Craniofacial Association (ACPA) Parameters of Care and Team Standards (as noted above) for the multidisciplinary team management of patients with cleft and craniofacial deformities.

The AAMOS Parameters of care offers guidance on surgical correction of cleft and craniofacial deformities along with the need for determining the appropriate timing for intervention in children since growth affects surgery. In summary they state “the most significant difference between managing children and adults with cleft and craniofacial anomalies is the need to consider the fourth dimension of time/growth and development during treatment planning. This information affects the timing of operation and choice of proper procedure and proper hardware for stabilization. Genetic evaluation and counseling are also critical, as are psychological counseling and speech therapy when indicated. Outcomes assessment must include evaluation at the end of growth, number of operations required to achieve the final result, and success of preventive measures”. (6)

References

  1. "Dental Anomalies." Encyclopedia of Nursing & Allied Health. Ed. Kristine Krapp. Vol. 2. Gale Cengage, 2002. Available at URL address: http://www.enotes.com/dental-anomalies-reference/dental-anomalies. Last accessed August 2013.
  2. House Bill 4128, Treatment for craniofacial anomalies, 76th Oregon Legislative Assembly (2012). Available at URL address: http://www.leg.state.or.us:8765/query.html?col=3meas11&qt=house+bill+4128&charset=iso-8859-1. Last accessed August 2013.
  3. National Institute of Dental and Craniofacial Research: Data and Statistics. 2013. Available at URL address: http://www.nidcr.nih.gov/DataStatistics/. Last accessed August 2013.
  4. World Health Organization. Human Genetic programme: International Collaborative Research on Craniofacial Anomalies. Available at URL address: http://www.who.int/genomics/en/. Last accessed August 2013.
  5. American Academy of Pediatric Dentistry. Policy on Management of Patients with Cleft Lip/Palate and Other Craniofacial Anomalies. Council on Clinical Affairs; revised 2012. Available at URL address: http://www.aapd.org/media/Policies_Guidelines/E_CleftLip.pdf. Last accessed August 2013.
  6. Carlson ER, Sims PG et al. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS) 2012. Cleft and Craniofacial Surgery pp. e137 - e161. Available at URL address: http://www.aaoms.org/docs/resources/parcare_ver5.pdf. Last accessed August 2013.

Coding

Codes

Number

Description

CPT

0005M

Fetal aneuploidy (trisomy 21, 28 and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy

 

21141

Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), without bone graft

 

21142

Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft

 

21143

Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft

 

21145

Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

 

21146

Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft)

 

21147

Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies)

 

21150

Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome)

 

21151

Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)

 

21154

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I

 

21155

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I

 

21159

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

 

21160

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I

 

21172

Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)

 

21175

Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)

 

21179

Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)

 

21180

Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)

 

21181

Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous dysplasia), extracranial

 

21182

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm

 

21183

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm

 

21184

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm

 

21188

Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

 

21193

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

 

21194

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)

 

21195

Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

 

21196

Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation

 

21198

Osteotomy, mandible, segmental;

 

21199

Osteotomy, mandible, segmental; with genioglossus advancement

 

21206

Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

 

21208

Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

 

21209

Osteoplasty, facial bones; reduction

 

40650

Repair lip, full thickness; vermilion only

 

40652

Repair lip, full thickness; up to half vertical height

 

40654

Repair lip, full thickness; over 1/2 vertical height, or complex

 

40700

Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral

 

40701

Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure

 

40702

Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages

 

40720

Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure

 

40761

Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle

 

40799

Unlisted procedure, lips

CDT

D0330

Panoramic radiographic image

 

D0340

Cephalometric radiographic image

 

D0350

Oral/facial photographic images

 

D0470

Diagnostic Casts

 

D7283

Placement of device to facilitate eruption of impacted tooth

 

D8010

Limited Orthodontic Treatment of the Primary Dentition

 

D8020

Limited Orthodontic Treatment of the Transitional Dentition

 

D8030

Limited Orthodontic Treatment of the Adolescent Dentition

 

D8040

Limited Orthodontic Treatment of the Adult Dentition

 

D8050

Interceptive Orthodontic Treatment of the Primary Dentition

 

D8060

Interceptive Orthodontic Treatment of the Transitional Dentition

 

D8070

Comprehensive Orthodontic Treatment of the Transitional Dentition

 

D8080

Comprehensive Orthodontic Treatment of the Adolescent Dentition

 

D8090

Comprehensive Orthodontic Treatment of the Adult Dentition

 

D8210

Removable Appliance Therapy

 

D8220

Fixed Appliance Therapy

 

D8660

Pre-orthodontic Treatment Visit

 

D8670

Periodic Orthodontic Treatment Visit

 

D8680

Orthodontic Retention

 

D8690

Orthodontic Treatment

 

D8691

Repair of Orthodontic Appliance

 

D8692

Replacement of Lost or Broken Retainer

 

D8693

Rebonding or recementing; and/or repair, as required, of fixed retainers

 

D8999

Unspecified Orthodontic Procedure

ICD-9 Procedure

   

ICD-9 Diagnosis

749

Cleft palate and cleft lip

 

756.0

Anomalies of the skull and face bones

 

756.16

Klippel-Feil syndrome

 

756.55

Chondroectodermal dysplasia (Ellis-van Creveld syndrome)

 

758.0

Down’s syndrome (Trisomy 21 or 22)

 

758.1

Patau’s syndrome (Trisomy 13)

 

758.2

Edward’s syndrome (Trisomy 18)

 

758.6

Gonadal Dygenesis (Turner’s syndrome)

 

758.7

Klinefelter’s syndrome

HCPCS

   

Type of Service

Medical / Dental

 

Place of Service

Inpatient

Outpatient

Office

 

Appendix

Definitions

Alveolar with Cleft Palate: a congenital birth defect that occurs when the tissues of the palate do not join (fuse) together as expected during fetal development, resulting in a split (cleft) in the palate. It may involve only the uvula or extend through the entire palate.

Appliance Placement: the application of orthodontic attachments to the teeth for the purpose of correcting dentofacial abnormalities.

Arthrogryposis: a term used to describe a number of rare conditions characterized by stiff joints and abnormally developed muscle.

Cleft: an opening or fissure involving the dentition and supporting structures, especially one occurring in utero. These can be:

  1. Cleft lip;
  2. Cleft palate (involving the roof of the mouth); or
  3. Facial clefts (e.g., macrostomia).

Cleft Lip: a congenital birth defect that occurs when the tissues of the lip do not join (fuse) together as expected during fetal development, resulting in a split (cleft) in the lip. An incomplete cleft lip can range from a slight indentation to a notch in the upper lip on one side only. A complete cleft lip is a deep split in the lip that extends into one or both sides of the nose.

Cleft Palate or Cleft Palate with Alveolar: a congenital birth defect that occurs when the tissues of the palate do not join (fuse) together as expected during fetal development, resulting in a split (cleft) in the palate. It may involve only the uvula or extend through the entire palate.

Comprehensive Full Orthodontic Treatment: utilizing fixed orthodontic appliances for treatment of the permanent dentition leading to the improvement of a client's severe handicapping craniofacial dysfunction and/or dentofacial deformity, including anatomical and functional relationships.

Craniofacial: affecting the cranium (skull) and face.

Craniofaciay Anomaly: a congenital condition or physical disorder identifiable at birth that affects the body structures of the face or head, including but not limited to cleft palate, cleft lip, and other syndromes such as hemifacial microsomnia, craniosynostosis, arthrogryposis and Marfan Syndrome.

Craniofacial Team: a cleft palate/maxillofacial team or an American Cleft Palate Association-certified craniofacial team. These teams are responsible for the management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated management, promote parent-professional partnership, and make appropriate referrals to implement and coordinate treatment plans.

Craniosynostosis: a birth defect that causes one or more sutures on a baby's head to close earlier than normal.

Dental Dysplasia: an abnormality in the development of the teeth.

Dentition: the development of teeth, the number of teeth and their arrangement in the mouth.

EPSDT: the department's early and periodic screening, diagnosis, and treatment program for clients twenty years of age and younger (as described in chapter 388-534 WAC):

Hemifacial Microsomnia: a developmental condition involving the first and second brachial arch. This creates an abnormality of the upper and lower jaw, ear, and associated structures (half or part of the face appears smaller sized).

Interceptive Orthodontic Treatment: means procedures to lessen the severity or future effects of a malformation and to affect or eliminate the cause. Such treatment may occur in the primary or transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of isolated dental cross-bite, or recovery of recent minor space loss where overall space is adequate.

Le Fort system: guide to placement of osteotomies in the midface. The classifications are I-IV depending on the severity and location of the deformity.

Limited Transitional Orthodontic Treatment: orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed only at the existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.

Malocclusion: improper alignment of biting or chewing surfaces of upper and lower teeth.

Marfan Syndrome: a genetic disorder in which the body's connective tissue is abnormal, most often affecting the connective tissue of the heart and blood vessels, eyes, bones, lungs, and covering of the spinal cord. Because the condition affects many parts of the body, it can cause many complications.

Maxillofacial: relating to the jaws and face.

Occlusion: the relation of the upper and lower teeth when in functional contact during jaw movement.

Oral and Maxillofacial Surgeon: dental specialist who manages the diagnosis and surgical treatment of deformities of the mouth and supporting structures.

Orthodontics: treatment involving the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.

Orthodontist: a dentist who specializes in orthodontics, who is a graduate of a postgraduate program in orthodontics that is accredited by the American Dental Association, and who meets state licensure requirements.

Orthognathic Surgery: corrective jaw surgery by ostectomy, osteotomy or osteoplasty of the upper jaw (maxilla) and/or the lower jaw (mandible) intended to alter the relationship of the jaws and teeth. Orthognatic surgery is used in the treatment of congenital conditions like cleft palate by restructuring the jaw through cutting the bone and repositioning the bone segments. The objective is to improve the ability to chew, swallow, speak and breathe.

History

Date

Reason

06/14/05

Add to Medical Section - New Policy. Approved 6/14/05; publish January 1, 2006.

07/11/06

Replace Policy - Policy reviewed; no change to policy statement; Scope and Disclaimer updated.

07/10/07

Replace Policy - Policy updated with literature review; no change in policy statement.

06/10/08

Replace Policy - Policy updated with literature search; no change in policy statement.

02/10/09

Replace Policy - Policy updated with literature review, no change to policy statement.

02/09/10

Replace Policy - Policy updated with literature search. No change to policy statement.

03/08/11

Replace Policy - Policy updated with literature review; no change in policy statement.

04/25/12

Replace policy. Policy updated with literature review; no change in policy statement.

12/11/12

Replace policy. Title revised to “Orthodontic Services for Treatment of Severe Congenital Craniofacial Anomalies”. “Repair of cleft palate” is deleted from the title. Policy statement reformatted for clarity. To comply with the Oregon mandate the benefit application section notes that age restriction for benefit coverage does not apply for Oregon members. At the request of MPC Trisomies 13-15, 18 are removed from the list of congenital disorders and will be reviewed on a case by case basis. Description section revised with further information about craniofacial anomalies. Definitions added to the Appendix section. Reference 1, 2, 4 added. CPT codes for cleft palate surgery added. Policy statement revised as noted.

07/12/13

Coding update. MAAA code 0005M added to the policy.

09/27/13

Replace policy. Policy reviewed. Rationale section updated based on a literature review through July 2013, reformatted for readability. Reference 3, 6 added; others renumbered/removed. Policy statement unchanged.

11/11/13

Replace policy. Policy updated to expand coverage for medically necessary services to those members aged 18 years and younger, to align with the Affordable Health Care Act, when criteria are met. The policy update is effective January 1, 2014; Oregon state mandate continues to have no age limit. CDT codes added to the policy. Title changed to “Orthodontic Services for Treatment of Congenital Craniofacial Anomalies”. Definitions added to the Appendix section.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
©2013 Premera All Rights Reserved.