Clinical Policy: Orthognathic Surgery Form

CENTENE®
Corporation

Clinical Policy: Orthognathic Surgery
Reference Number: CP.MP.202
Date of Last Revision: 08/25

Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description
This policy describes the medical necessity requirements for orthognathic surgery.

Policy/Criteria

a. Intolerant to or failed a trial of PAP;
b. Has failed or is not a candidate for less invasive surgical procedures.

II. It is the policy of Centene Corporation that orthognathic surgery is not medically necessary when any of the following are present:
A. When the sole purpose is to improve individual appearance, regardless of whether they are associated with psychological disorders, because they are considered cosmetic in nature;
B. When the member/enrollee is still developing and the deformity could be corrected with less intrusive treatment (e.g., expander or head gear).

Background
Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both. The underlying abnormality may be present at birth or may become evident as the patient grows and develops or may be the result of traumatic injuries. The severity of these deformities precludes adequate treatment through dental treatment alone. Such skeletal abnormalities may cause difficulties with eating or chewing, abnormal speech patterns, or dysfunction of the temporomandibular joint (TMJ). The overall goal of treatment is to improve function through correction of the underlying skeletal deformity.¹

Abnormalities generally occur as a result of a differential in growth between the upper facial skeleton and the lower facial skeleton, resulting in a discrepancy of the normal relationship that exists between the upper jaw (maxilla) and lower jaw (mandible). Genetic predisposition and acquired causes can influence the normal growth of the facial skeleton from syndromes such as Apert and Crouzon or from facial clefts. Traumatic events can displace the normal structural elements or may disturb future normal growth. Other etiologies that can result in significant dentofacial anomalies include neoplasms, surgical resection and iatrogenic radiation. Developmental anomalies, however, are the most common condition. All of these deformities may result in diminished bite forces, restricted mandibular excursions, abnormal chewing patterns, speech deficits, malocclusions and/or abnormal facial appearance. There is a relationship between facial skeletal abnormalities and malocclusions, including Class II (disto-occlusion), Class III (mesio-occlusion) and open-bite (teeth do not meet) deformities.¹

The American Association of Oral and Maxillofacial Surgeons (AAOMS) classification of occlusion/malocclusion¹
Class I: Exists with the teeth in a normal relationship when the mesial-buccal cusp of the maxillary first permanent molar coincides with the buccal groove of the mandibular first molar.
Class II: Malocclusion occurring when the mandibular teeth are behind the normal relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw (Type I) or an excess of the upper jaw (Type 2).
Class III: Commonly referred to as an under bite, Class III malocclusion occurs when the lower dental arch is in front of (mesial to) the upper dental arch. People with this type of occlusion usually have a strong or protrusive chin, which can be due to either horizontal mandibular excess or horizontal maxillary deficiency.

CLINICAL POLICY
Orthognathic Surgery

Surgical Procedures
In orthognathic surgery, an osteotomy is made in the affected jaw, and the bones are repositioned in a more normal alignment. The bones are held in position with plates, screws and/or wires. Intermaxillary fixation, a procedure in which arch bars are placed on both jaws, may also be needed to provide added stability. Simultaneous osteotomies may be performed when deformities must be corrected in both jaws. Grafts from the ribs, hip or skull may be performed for patients with deficient bone tissue; alloplastic bone replacement may also be required. Orthognathic surgery is generally performed under general anesthesia on an inpatient basis.³ Although sometimes performed for cosmetic purposes, orthognathic surgery is generally considered to be medically necessary when performed to treat a significant abnormality that is causing considerable functional impairment.²,³

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. The following codes are for informational purposes only. They are current at time of review of this policy. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CLINICAL POLICY
Orthognathic Surgery

CLINICAL POLICY
Orthognathic Surgery

CLINICAL POLICY
Orthognathic Surgery

2. American Academy of Pediatric Dentistry. Management of the developing dentition and occlusion in pediatric dentistry. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:475-93.
3. Singh G, Kumar S, Gulati U. Orthognathic surgery. In: Singh G, ed. Textbook of orthodontics. 3rd ed. New Delhi India: Jaypee Brothers Medical Publishers (P) Ltd., 2015:298 to 307. ISBN 978-93-5152-440-3
4. Jandali D, Barrera JE. Recent advances in orthognathic surgery. Curr Opin Otolaryngol Head Neck Surg. 2020;28(4):246 to 250. doi:10.1097/MOO.0000000000000638
5. Chang YJ, Lai JP, Tsai CY, Wu TJ, Lin SS. Accuracy assessment of computer-aided three-dimensional simulation and navigation in orthognathic surgery (CASNOS). J Formos Med Assoc. 2020;119(3):701 to 711. doi:10.1016/j.jfma.2019.09.017
6. Lin HH, Lonic D, Lo LJ. 3D printing in orthognathic surgery - A literature review. J Formos Med Assoc. 2018;117(7):547 to 558. doi:10.1016/j.jfma.2018.01.008
7. Khechoyan DY. Orthognathic surgery: general considerations. Semin Plast Surg. 2013;27(3):133 to 136. doi:10.1055/s-0033-1357109
8. Abrahamsson C, Henriksson T, Bondemark L, Ekberg E. Masticatory function in patients with dentofacial deformities before and after orthognathic treatment-a prospective, longitudinal, and controlled study. Eur J Orthod. 2015;37(1):67-72. doi:10.1093/ejo/cju011
9. Huang CS, Hsu SS, Chen YR. Systematic review of the surgery-first approach in orthognathic surgery. Biomed J. 2014;37(4):184 to 190. doi:10.4103/2319-4170.126863
10. Buchanan, EP. Syndromes with craniofacial abnormalities. UpToDate. http://www.uptodate.com. Updated November 30, 2022. Accessed July 18, 2025.

Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to

CLINICAL POLICY
Orthognathic Surgery

applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.