Anthem Blue Cross Connecticut CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery Form

This document addresses medically necessary, reconstructive and cosmetic procedures involving the mandible, maxilla or both, with the exception of orthognathic surgery for the treatment of temporomandibular disorders or obstructive sleep apnea. This document does not apply to temporomandibular disorders, obstructive sleep apnea or orthodontia (braces) services.

Note: Please see the following related documents for additional information:

• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
• CG-SURG-09 Temporomandibular Disorders

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.

Clinical Indications

Medically Necessary:

Mandibular/Maxillary (orthognathic) surgery is considered medically necessary to treat a significant functional impairment when the procedure can be reasonably expected to improve the functional impairment. Significant functional impairment includes any one of the following (I, II, III, or IV below):

1. Dysphagia when all of the following criteria (A, B and C) are met:
   1. Symptoms related to difficulty chewing such as: choking due to incomplete mastication, or difficulty swallowing chewed solid food, or ability to chew only soft food or reliance on liquid food; and
   2. Symptoms must be documented in the medical record, must be significant and must persist for at least 4 months; and
   3. Other causes of swallowing or choking problems have been ruled out by history, physical exam and appropriate diagnostic studies;
      or
2. Speech abnormalities determined by a speech pathologist or therapist to be due to a malocclusion and not helped by orthodontia or at least 6 months of speech therapy.
   or
3. Intra-oral trauma while chewing related to malocclusion (for example, loss of food through the lips during mastication, causing recurrent damage to the soft tissues of the mouth during mastication).
   or
4. Masticatory dysfunction or malocclusion* when criteria A, B, and C below are met:
   1. Completion of skeletal growth with long bone x-ray or serial cephalometrics showing no change in facial bone relationships over the last 3- to 6-month period (Class II malocclusions and individuals aged 18 and over do not require this documentation); and
   2. Documentation of malocclusion with either intra-oral casts (if applicable), bilateral lateral x-rays, cephalometric radiograph with measurements, panoramic radiograph or tomograms; and
   3. Any one of the following described (1, 2, 3 or  4):
      1. Anteroposterior discrepancies defined as either of the following (a or b):
         1. Maxillary/Mandibular incisor relationship (established norm = 2 mm) defined as one of the following:
            1. Horizontal overjet of 5 mm or more, or
            2. Horizontal overjet of zero to a negative value. (Note: Overjet up to 5 mm may be treatable with routine orthodontic therapy); or
         2. Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm 0 to 1 mm).
      2. Vertical discrepancies defined as any of the following (a, b, c, or d):
         1. Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks; or
         2. Open bite, (defined as one of the following (i or ii):
            1. No vertical overlap of anterior teeth; or
            2. Unilateral or bilateral posterior open bite greater than 2 mm; or
         3. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch; or
         4. Supra-eruption of a dentoalveolar segment due to lack of occlusion.
      3. Transverse discrepancies defined as either of the following (a or b):
         1. Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms; or
         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.
      4. Asymmetries defined as the following:
         1. Anteroposterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.

*When the condition involves treatment of skeletal deformity, the deformity must be documented either by computed tomography (CT), magnetic resonance imaging (MRI), or x-ray.

Reconstructive:

Mandibular/maxillary (orthognathic) surgery is considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.

Cosmetic and Not Medically Necessary:

Mandibular/Maxillary (orthognathic) surgery is considered cosmetic and not medically necessary when intended to change a physical appearance that would be considered within normal human anatomic variation.

A genioplasty (or anterior mandibular osteotomy) is considered cosmetic and not medically necessary when not associated with masticatory malocclusion.