DENTAL POLICY

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APPENDIX
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Orthognathic Surgery

Number 9.02.501

Effective Date April 14, 2014

Revision Date(s) N/A

Replaces N/A

Policy

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Orthognathic surgery may be considered medically necessary for correction of the following skeletal deformities of the maxilla or mandible when it is documented that these skeletal deformities are contributing to significant dysfunction, and where the severity of the deformities precludes adequate treatment through dental therapeutics and orthodontics alone:

Maxillary and/or Mandibular Facial Skeletal Deformities Associated with Masticatory Malocclusion

Orthognathic surgery may be considered medically necessary for correction of skeletal deformities of the maxilla or mandible when it is documented that these skeletal deformities are contributing to significant masticatory dysfunction, and where the severity of the deformities precludes adequate treatment through dental therapeutics and orthodontics:

  1. Antero-posterior discrepancies
  1. Maxillary/mandibular incisor relationship: overjet of 5 millimeter (mm) or more, or a 0 to a negative value (norm 2 mm),
  2. Maxillary/mandibular antero-posterior molar relationship discrepancy of 4 mm or more (norm 0 to 1 mm).

Note: These values represent 2 or more standard deviations (SDs) from published norms.

  1. Vertical discrepancies
  1. Presence of a vertical facial skeletal deformity which is 2 or more SDs from published norms for accepted skeletal landmarks
  2. Open Bite
  1. No vertical overlap of anterior teeth greater than 2 mm
  2. Unilateral or bilateral posterior open bite greater than 2 mm
  1. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch
  2. Supraeruption of a dento-alveolar segment due to lack of opposing occlusion creating dysfunction not amenable to conventional prosthetics.
  1. Transverse discrepancies
  1. Presence of a transverse skeletal discrepancy which is 2 or more SDs from published norms.
  2. Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth.
  1. Asymmetries
  1. Antero-posterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.

Facial Skeletal Discrepancies Associated with Documented Sleep Apnea, Airway Defects, and Soft Tissue Discrepancies

Orthognathic surgery may be considered medically necessary when it is documented that mandibular and maxillary deformities are contributing to airway dysfunction, where such dysfunction is not amenable to non-surgical treatments, and where it is shown that orthognathic surgery will decrease airway resistance and improve breathing. Required documentation would include failures of non-surgical treatments for obstructive sleep apnea.

Orthognathic surgery may be considered medically necessary for patients with underlying craniofacial skeletal deformities that are contributing to obstructive sleep apnea. (Sleep apnea is addressed in separate policies. See Related Policies.)

NOTE: Before surgery, members should be properly evaluated to determine the cause and site of their disorder and appropriate non-surgical treatments attempted when indicated.

Myofascial Pain Dysfunction

Orthognathic surgery for treatment of myofascial pain dysfunction is considered investigational.

NOTE: Temporomandibular joint disease (TMJ) is addressed in a separate policy. (See Related Policies.)

Speech Impairments

Orthognathic surgery may be considered medically necessary for treatment of speech impairments accompanying severe cleft deformity.

NOTE: Pre-surgical orthodontic treatment is usually recommended. (See Policy Guidelines.)

Orthognathic surgery is considered investigational for correction of articulation disorders and other impairments in the production of speech.

Orthognathic surgery for correction of distortions within the sibilant sound class or for other distortions of speech quality (e.g., hyper-nasal or hypo-nasal speech) is considered not medically necessary.

Unaesthetic Facial Features and Psychological Impairments

Orthognathic surgery is considered cosmetic for correction of unaesthetic facial features, regardless of whether these are associated with psychological disorders.

Mentoplasty or genial osteotomies/ostectomies (chin surgeries) are considered cosmetic when performed as an isolated procedure to address genial hypoplasia, hypertrophy, or asymmetry, and may be considered cosmetic when performed with other surgical procedures.

No benefits are available for orthognathic surgery when performed primarily for cosmetic purposes. (Cosmetic services are addressed in a separate policy. See Related Policies.)

Orthognathic surgery is considered investigational for all other indications.

The use of condylar positioning devices in orthognathic surgery is considered investigational.

Related Policies

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2.01.21

Temporomandibular Joint Dysfunction (TMJ)

2.01.503

Polysomnography and Home Sleep Study for Diagnosis of Obstructive Sleep Apnea

7.01.101

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

9.02.500

Orthodontic Services for Treatment of Congenital Craniofacial Anomalies

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

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Orthodontic Treatment Prior to Orthognathic Surgery

Note: Expenses associated with the orthodontic phase of care (both pre- and post-surgical) are considered dental in nature and are not covered under medical benefits. (See policy 9.02.500 - Orthodontic Services for Treatment of Congenital Craniofacial Anomalies for coverage exclusions.)

Orthodontic treatment may be needed prior to orthognathic surgery to position the teeth in a manner that will provide for an adequate occlusion following surgical repositioning of the jaws. For plans that require precertification, orthognathic surgery must be precertified prior to pre-surgical orthodontic treatment. The interim occlusion that is achieved by orthodontic treatment may be dysfunctional prior to the completion of the orthognathic surgical phase of the treatment plan. Therefore, all requests for orthognathic surgery must be reviewed/pre-service determination by the Company’s professional services review unit prior to the initiation of pre-surgical orthodontic care. Failure to obtain pre-service determination for orthognathic surgery prior to orthodontic care may result in the denial of benefits.

Documentation Requirements

Orthognathic surgery may be subject to precertification review in plans that include precertification requirements. The following documentation should be forwarded to the Company’s professional services review unit for review:

  • A written explanation of the member's clinical course, including dates and nature of any previous treatment;
  • Physical evidence of a skeletal, facial or craniofacial deformity defined by study models and pre-orthodontic imaging; and
  • A detailed description of the functional impairment considered to be the direct result of the skeletal abnormality.

Description

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Background

Orthognathic surgery is the revision 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.  These surgical procedures are intended (i) to correct skeletal jaw and cranio-facial deformities that may be associated with significant functional impairment, and (ii) to reposition the jaws when conventional orthodontic therapy alone is unable to provide a satisfactory, functional dental occlusion within the limits of the available alveolar bone. 

Congenital or developmental defects can interfere with the normal development of the face and jaws.  These birth defects may interfere with the ability to chew properly, and may also affect speech and swallowing.  In addition, trauma to the face and jaws may create skeletal deformities that cause significant functional impairment.  Functional deficits addressed by this type of surgery are those that affect the skeletal masticatory apparatus such that chewing, speaking and/or swallowing are impaired.

Certain jaw and cranio-facial deformities may cause significant functional impairment.  These deformities include apertognathia (either lateral or anterior not correctable by orthodontics alone), significant asymmetry of the lower jaw, significant class 2 and class 3 occlusal discrepancies, and cleft palate. Orthognathic surgery may help to reduce the flattening of the face that is characteristic of severe cleft deformity. Treatment approaches include maxillary advancement, a type of orthognathic surgery which surgically moves the maxilla and fixes it securely into place using sophisticated bone mobilizing techniques. This method of surgery is used when there is need to improve the facial contour and normalize dental occlusion due to relative deficiency of the mid-face region. The approach utilized is case dependent and may include surgery on the mandible, depending on the soft tissue profile of the face and/or severity of an occlusal discrepancy, and problems present in the lower face. By using osteotomy techniques along with bone and cartilage grafts, the upper and lower jaws and facial skeletal framework are moved and appropriately reconstructed.

Studies demonstrate that persons with vertical hyperplasia of the maxilla have an associated increase in nasal resistance, as do persons with maxillary hypoplasia with or without clefts. Following orthognathic surgery, such individuals routinely demonstrate decreases in nasal airway resistance and improved respiration.

Scope

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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. This policy does not apply to Medicare Advantage.

Benefit Application

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Refer to member contract language for benefit determination on orthognathic surgery.

Precertification requests or claims for orthognathic surgery are subject to review by the Company’s professional review unit.

Rationale

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This policy was developed based upon a consideration of peer reviewed literature conducted through February 2014. A literature survey was using PUBMED and MEDLINE database.

Evidence presented in the literature supports the relationship between facial skeletal abnormalities and malocclusions, which includes Class II, Class III, asymmetry and open bite deformities. Studies indicate a strong correlation between the degree of occlusion present in an individual and the efficiency of chewing, bite force and restriction of mandibular excursions. Findings indicate the presence of a variety of functional impairments associated with facial skeletal abnormalities and malocclusions, including diminished bite forces, restricted excursions and abnormal chewing patterns. The result of orthognatic surgery has led to significant improvement in the types of skeletal deformities that contribute to chewing, breathing, and swallowing dysfunctions in cases where dental therapeutics or orthodontics have failed.

References

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  1. McCarthy JG, Stelnicki EJ, Grayson BH. Distraction osteogenesis of the mandible: A ten-year experience. Semin Orthod. 1999;5(1):3-8.
  2. Baker NJ, David S, Barnard DW, et al. Occlusal outcome in patients undergoing orthognathic surgery with internal fixation. Br J Oral Maxillofac Surg. 1999;37(2):90-93.
  3. Bennett ME, Phillips CL. Assessment of health-related quality of life for patients with severe skeletal disharmony: A review of the issues. Int J Adult Orthodon Orthognath Surg. 1999;14(1):65-75.
  4. Cope JB, Samchukov ML, Cherkashin AM. Mandibular distraction osteogenesis: A historic perspective and future directions. Am J Orthod Dentofacial Orthop. 1999;115(4):448-460.
  5. Drew SJ, Schwartz MH, Sachs SA. Distraction osteogenesis. N Y State Dent J. 1999;65(1):26-29.
  6. Buttke TM, Proffit WR. Referring adult patients for orthodontic treatment. J Am Dent Assoc. 1999;130(1):73-79.
  7. Davies J, Turner S, Sandy JR. Distraction osteogenesis--a review. Br Dent J. 1998;185(9):462-467.
  8. Barkate HE. Orthognathic surgery by distraction osteogenesis: A literature review. Dentistry. 1997;17(3):14, 16-18.
  9. Lupori JP, Van Sickels JE, Holmgreen WC. Outpatient orthognathic surgery: Review of 205 cases. J Oral Maxillofac Surg. 1997;55(6):558-563.
  10. Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 1995;10(2):97-107.
  11. Ruhl CM, Bellian KT, Van Meter BH, et al. Diagnosis, complications, and treatment of dentoskeletal malocclusion. Am J Emerg Med. 1994;12(1):98-104.
  12. Sinn DP, Ghali GE. Advances in orthognathic surgery. Curr Opin Dent. 1992;2:38-41.
  13. Hunt OT, Johnston CD, Hepper PG, et al. The psychosocial impact of orthognathic surgery: A systematic review. Am J Orthod Dentofacial Orthop. 2001;120(5):490-497.
  14. Tulloch JF, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. Am J Orthod Dentofacial Orthop. 2004;125(6):657-667.
  15. Fedorowicz Z, Nasser M, Newton T, Oliver R. Resorbable versus titanium plates for orthognathic surgery. Cochrane Database Syst Rev. 2007;(2):CD006204.
  16. Costa F, Robiony M, Toro C, et al. Condylar positioning devices for orthognathic surgery: A literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(2):179-190.
  17. Kang SH, Yoo JH, Yi CK. The efficacy of postoperative prophylactic antibiotics in orthognathic surgery: A prospective study in Le Fort I osteotomy and bilateral intraoral vertical ramus osteotomy. Yonsei Med J. 2009;50(1):55-59.
  18. Danda AK, Wahab A, Narayanan V, Siddareddi A. Single-dose versus single-day antibiotic prophylaxis for orthognathic surgery: A prospective, randomized, double-blind clinical study. J Oral Maxillofac Surg. 2010;68(2):344-346.
  19. Dan AE, Thygesen TH, Pinholt EM. Corticosteroid administration in oral and orthognathic surgery: A systematic review of the literature and meta-analysis. J Oral Maxillofac Surg. 2010;68(9):2207-2220.
  20. Garg M, Cascarini L, Coombes DM, et al. Multicentre study of operating time and inpatient stay for orthognathic surgery. Br J Oral Maxillofac Surg. 2010;48(5):360-363.
  21. Pineiro-Aguilar A, Somoza-Martín M, Gandara-Rey JM, Garcia-Garcia A. Blood loss in orthognathic surgery: A systematic review. J Oral Maxillofac Surg. 2011;69(3):885-892.
  22. Danda AK, Ravi P. Effectiveness of postoperative antibiotics in orthognathic surgery: A meta-analysis. J Oral Maxillofac Surg. 2011;69(10):2650-2656.
  23. Mattos CT, Vilani GN, Sant'Anna EF, et al. Effects of orthognathic surgery on oropharyngeal airway: A meta-analysis. Int J Oral Maxillofac Surg. 2011;40(12):1347-1356.
  24. Lye KW. Effect of orthognathic surgery on the posterior airway space (PAS). Ann Acad Med Singapore. 2008;37(8):677-682.
  25. Won CH, Li KK, Guilleminault C. Surgical treatment of obstructive sleep apnea: Upper airway and maxillomandibular surgery. Proc Am Thorac Soc. 2008;5(2):193-199.
  26. Hassan T, Naini FB, Gill DS. The effects of orthognathic surgery on speech: A review. J Oral Maxillofac Surg. 2007;65(12):2536-2543.
  27. Van Lierde KM, Schepers S, Timmermans L, et al. The impact of mandibular advancement on articulation, resonance and voice characteristics in Flemish speaking adults: A pilot study. Int J Oral Maxillofac Surg. 2006;35(2):137-144.
  28. Chanchareonsook N, Samman N, Whitehill TL. The effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status: A critical review. Cleft Palate Craniofac J. 2006;43(4):477-487.
  29. American Academy of Oral and Maxillofacial Surgeons (AAOMS). Criteria for orthognathic surgery. Reimbursement and Appeal Resources. Health Policy and Third Party Payor Relations Resources. Rosemont, IL: AAOMS; 2002. Available at: http://www.aaoms.org/docs/practice_mgmt/ortho_criteria.pdf. Last accessed March 24, 2014.
  30. American Society of Plastic and Reconstructive Surgeons (ASPRS). Orthognathic Surgery: Recommended Criteria for Third-Party Payer Coverage. Arlington Heights, IL: ASPRS; September 1997.

Coding

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Codes

Number

Description

CPT

21083

Impression and custom preparation; palatal lift prosthesis

 

21084

Impression and custom preparation; speech aid prosthesis

 

21085

Impression and custom preparation; oral surgical splint

 

21088

Impression and custom preparation; facial prosthesis

 

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) (eg, 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

 

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

 

21210

Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

 

21215

Graft, bone; mandible (includes obtaining graft)

 

21230

Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

 

21235

Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

 

21240

Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

 

21242

Arthroplasty, temporomandibular joint, with allograft

 

21243

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

 

21247

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)

 

21255

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

 

21270

Malar augmentation, prosthetic material

 

21275

Secondary revision of orbitocraniofacial reconstruction

 

21295

Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); extraoral approach

 

21296

Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); intraoral approach

 

42200 - 42281

Palatoplasty for cleft palate, code range

ICD-9 Diagnosis

327.23

Obstructive sleep apnea (adult) (pediatric)

 

524.00 - 524.29

Dentofacial anomalies, including malocclusion; major anomalies of jaw size, code range

 

524.4

Malocclusion, unspecified

 

524.50 - 524.59

Dentofacial functional abnormalities, code range

 

749.00 - 749.04

Cleft palate, code range

 

749.20 - 749.25

Cleft palate with cleft lip, code range

 

784.5

speech disturbance

 

786.00 - 786.09

Dyspnea and respiratory abnormalities, code range

HCPCS

D5954 - D5959

Palatal augmentation and lift prosthesis

 

D7940 - D7955

Other repair procedures

 

D8010 - D8999

Orthodontics

Type of Service

Dental

 

Place of Service

Inpatient / Outpatient

 

Appendix

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N/A

History

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Date

Reason

04/14/14

New policy. Add to Dental section. Orthognathic surgery may be considered medically necessary for correction of the certain skeletal deformities of the maxilla or mandible when it is documented that these skeletal deformities are contributing to significant dysfunction, and where the severity of the deformities precludes adequate treatment through dental therapeutics and orthodontics alone when criteria are met.

01/22/15

Update Related Policies. Change title to 2.01.503.


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).
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