Orthognathic Surgery Form

Orthognathic Surgery

Last Review Date: April 10, 2026 
Number: MG.MM.SU.59d

Medical Guideline Disclaimer The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
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Background Orthognathic surgery A class of surgical procedures designed to realign the maxillofacial skeletal structures with each other and with the other craniofacial structures. This surgery usually involves the maxilla and/or mandible, but other bony components may be involved as well.
Orthognathic surgery can be performed to correct malocclusion, which cannot be improved with routine orthodontic therapy and where the functional impairments are directly caused by the malocclusion. The surgical goal is to improve function through correcting the underlying skeletal deformity that contributes to chewing, breathing and swallowing dysfunction.
Maxillary surgery A type of orthognathic surgery that may be necessary to improve the facial contour and normalize dental occlusion when there is a relative antero-posterior or lateral deficiency, or asymmetry, of the midface region. This is done by surgically moving the maxilla with sophisticated bone mobilization techniques and fixing it securely into place.
Mandibular surgery Can be performed in conjunction with or separate from maxillary surgery. The mandible can be advanced, set back, tilted or augmented with bone grafts. A combination of these procedures may be necessary. Following any significant surgical movement of the mandible, fixation may be accomplished with mini- plates and screws or with a combination of interosseous wires and intermaxillary fixation (IMF). Rigid fixation (screws and plates) has the advantage of needing limited or no IMF. However, if interosseous wiring is used, IMF is maintained for approximately 6 weeks.

Malocclusion Imperfect contact with the mandibular and maxillary teeth. • Class II malocclusion: Occurs when the mandibular teeth are distal or behind the normal relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw or an excess of the upper jaw, and therefore, presents two types: (1) Division I is when the mandibular arch is behind the upper jaw with a consequential protrusion of the upper front teeth. (2) Division II exists when the mandibular teeth are behind the upper teeth, with a retrusion of the maxillary front teeth. Both of these malocclusions have a tendency toward a deep bite because of the uncontrolled migration of the lower front teeth upwards. Commonly referred to as an overbite. • 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. Commonly referred to as an under bite. • Cross bite. Occlusion Bringing the opposing surfaces of the teeth of the two jaws (mandible and maxilla) into contact with each other. Supraeruption The occurrence of a tooth continuing to grow out of the gum if the opposing tooth in the opposite jaw is missing. Genioplasty Plastic surgery of the chin (See Limitations/Exclusions)

Related Medical Guidelines Cosmetic and Reconstructive Surgery Procedures

Guideline Note: Expenses associated with the pre-and-post surgical orthodontic component of are considered dental in nature and not covered under the member’s Medical Benefit. I. Orthognathic surgery is medically necessary for correcting the following skeletal deformities of the maxilla or mandible when the deformities are directly attributable to significant dysfunction that precludes dental/orthodontic therapeutics or when intra-oral trauma to soft tissues occurs through mastication secondary to malocclusion: A. Anteroposterior discrepancies defined as either:

1. Maxillary/mandibular incisor relationship; any:
   a. Horizontal overjet of ≥ 5 millimeter (mm) b. Zero to a negative value (norm 2mm)
2. Maxillary/mandibular anteroposterior molar relationship discrepancy of ≥ 4 mm (norm is 0–1 mm) Numeric values above represent ≥ 2 standard deviations (SDs) from published norms. B. Vertical discrepancies; defined as any:
3. Vertical facial skeletal deformity of ≥ 2 SDs from norms for accepted skeletal landmarks
4. Open Bite; either: a. No vertical overlap of anterior teeth
   b. Unilateral or bilateral posterior open bite > 2 mm
5. Deep overbite with impingement or irritation of buccal, palatal or lingual soft tissues of the opposing arch
6. Supraeruption of a dentoalveolar segment secondary to lack of opposing occlusion that creates dysfunction not amenable to conventional prosthetics

C. Transverse discrepancies; defined as either:

1. Transverse skeletal discrepancy ≥ 2 SDs from norms
2. Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of ≥ 4 mm, or unilateral discrepancy ≥ 3 mm (given normal axial inclination of the posterior teeth) D. Asymmetries; defined as anteroposterior, transverse or lateral asymmetries > 3 mm with concomitant occlusal asymmetry such as a maxillary cant or a cross-bite malocclusion II. Facial Skeletal Discrepancies Associated with Documented Sleep Apnea, Airway Defects, and Soft Tissue Discrepancies Orthognathic surgery is considered medically necessary for members with underlying congenital and acquired (i.e., post-traumatic or post-ablative) craniofacial skeletal deformities that are contributing to obstructive sleep apnea or other demonstrated significant functional deficiency. (See MCG # A-0247 Mandibular Osteotomy, # A-0248 Maxillomandibular Osteotomy and Advancement, or # SG-HNS Head and Neck Surgery or Procedure, as applicable) III. Speech Impairments
   Orthognathic surgery is medically necessary for the treatment of speech abnormalities (as determined by a speech pathologist or therapist) when the impairment is secondary to a malocclusion (e.g., from cleft deformity), and when post-surgical improvement can be expected (as determined by a speech pathologist) which is refractory to either:
3. Orthodontia management

4. At least 6 months of speech therapy

   Limitations/Exclusions

5. Orthognathic surgery is considered cosmetic (and therefore not medically necessary) when anatomic variation is normal, and the member wishes to alter physical appearance in order to improve aesthetics. (Psychological motivation [e.g., self-esteem] is not a factor for plan-consideration).
6. Three-dimensional virtual treatment planning of orthognathic surgery regarded as investigational and not medically necessary, as effectiveness has not been established.
7. Orthognathic surgery is considered investigational for correcting articulation disorders (except in the presence of severe cleft palate; indicated above) and other impairments in the production of speech due to insufficient evidence of therapeutic value in the published peer-reviewed medical literature.
8. Orthognathic surgery is not considered medically necessary for the correction of sibilant sound-class distortions or other speech quality distortions (e.g., hyper-nasal or hypo-nasal speech) because the distortions do not cause functional impairment.

5. Condylar positioning devices in orthognathic surgery are experimental and investigational because their effectiveness in orthognathic surgery has not been established

6. Genioplasty is considered cosmetic and not medically necessary.
   Revision History Apr. 10, 2026 Regarding medical record documentation, clarified objective findings to include examples such as difficulty with mastication, speech, swallowing, and nutrition Removed temporomandibular joint (TMJ) disease or myofascial pain dysfunction from Limitations/Exclusions Apr. 11, 2025 Amended/reworded maxillary advancement definition Added cross bite as a type of malocclusion Added cephalometric analysis as required documentation Jul. 28, 2023 Substituted link to Obstructive Sleep Apnea policy with references to MCG criteria in Section II — Facial Skeletal Discrepancies Associated with Documented Sleep Apnea, Airway Defects, and Soft Tissue Discrepancies Apr. 14, 2023 Added that post-surgical improvement should be determined by a speech pathologist RE speech impairments Added maxillary cant and cross-bite malocclusion as examples of asymmetries
   Added clarification that plaster, printed, or digital study models may be submitted as evidentiary documentation Mar. 8, 2019

   Added “palatal” to vertical discrepancies definition related to deep overbite Added congenital, acquired, or other demonstrated significant functional deficiency, that contributes to obstructive sleep apnea (regarding craniofacial skeletal deformities)
   Added photographic to documentation section

   Applicable Procedure Codes 21076 Impression and custom preparation; surgical obturator prosthesis 21079 Impression and custom preparation; interim obturator prosthesis 21080 Impression and custom preparation; definitive obturator prosthesis 21081 Impression and custom preparation; mandibular resection prosthesis 21082 Impression and custom preparation; palatal augmentation prosthesis 21083 Impression and custom preparation; palatal lift prosthesis 21125 Augmentation, mandibular body or angle; prosthetic material 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) 21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, 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) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) 21150 Reconstruction midface, LeFort II; anterior intrusion (eg, 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 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 (eg, 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) 21244 Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) 21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial 21246 Reconstruction of mandible or maxilla, subperiosteal implant; complete 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete 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 (eg, for treatment of benign masseteric hypertrophy); extraoral approach 21296 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach 21299 Unlisted craniofacial and maxillofacial procedure 42226 Lengthening of palate, and pharyngeal flap 42227 Lengthening of palate, with island flap 42235 Repair of anterior palate, including vomer flap 42280 Maxillary impression for palatal prosthesis 42281 Insertion of pin-retained palatal prosthesis Applicable ICD-10 Diagnosis Codes

G47.33 Obstructive sleep apnea (adult) (pediatric)

M26.00 Unspecified anomaly of jaw size M26.01 Maxillary hyperplasia M26.02 Maxillary hypoplasia M26.03 Mandibular hyperplasia M26.04 Mandibular hypoplasia M26.05 Macrogenia M26.06 Microgenia M26.07 Excessive tuberosity of jaw M26.09 Other specified anomalies of jaw size M26.10 Unspecified anomaly of jaw-cranial base relationship M26.11 Maxillary asymmetry M26.12 Other jaw asymmetry M26.19 Other specified anomalies of jaw-cranial base relationship M26.20 Unspecified anomaly of dental arch relationship M26.211 Malocclusion, Angle's class I M26.212 Malocclusion, Angle's class II M26.213 Malocclusion, Angle's class III M26.219 Malocclusion, Angle's class, unspecified M26.220 Open anterior occlusal relationship M26.221 Open posterior occlusal relationship M26.23 Excessive horizontal overlap M26.24 Reverse articulation M26.25 Anomalies of interarch distance M26.29 Other anomalies of dental arch relationship M26.30 Unspecified anomaly of tooth position of fully erupted tooth or teeth M26.31 Crowding of fully erupted teeth M26.32 Excessive spacing of fully erupted teeth M26.33 Horizontal displacement of fully erupted tooth or teeth M26.34 Vertical displacement of fully erupted tooth or teeth M26.35 Rotation of fully erupted tooth or teeth M26.36 Insufficient interocclusal distance of fully erupted teeth (ridge) M26.37 Excessive interocclusal distance of fully erupted teeth M26.39 Other anomalies of tooth position of fully erupted tooth or teeth M26.4 Malocclusion, unspecified M26.50 Dentofacial functional abnormalities, unspecified M26.51 Abnormal jaw closure M26.52 Limited mandibular range of motion M26.53 Deviation in opening and closing of the mandible

M26.54 Insufficient anterior guidance M26.55 Centric occlusion maximum intercuspation discrepancy M26.56 Non-working side interference M26.57 Lack of posterior occlusal support M26.59 Other dentofacial functional abnormalities M26.70 Unspecified alveolar anomaly M26.71 Alveolar maxillary hyperplasia M26.72 Alveolar mandibular hyperplasia M26.73 Alveolar maxillary hypoplasia M26.74 Alveolar mandibular hypoplasia M26.79 Other specified alveolar anomalies M26.81 Anterior soft tissue impingement M26.82 Posterior soft tissue impingement M26.89 Other dentofacial anomalies M26.9 Dentofacial anomaly, unspecified Q35.1 Cleft hard palate Q35.3 Cleft soft palate Q35.5 Cleft hard palate with cleft soft palate Q35.7 Cleft uvula Q35.9 Cleft palate, unspecified Q36.0 Cleft lip, bilateral Q36.1 Cleft lip, median Q36.9 Cleft lip, unilateral Q37.0 Cleft hard palate with bilateral cleft lip Q37.1 Cleft hard palate with unilateral cleft lip Q37.2 Cleft soft palate with bilateral cleft lip Q37.3 Cleft soft palate with unilateral cleft lip Q37.4 Cleft hard and soft palate with bilateral cleft lip Q37.5 Cleft hard and soft palate with unilateral cleft lip Q37.8 Unspecified cleft palate with bilateral cleft lip Q37.9 Unspecified cleft palate with unilateral cleft lip

Yamada K, Hanada K, Hayashi T, Ito J. Condylar bony change, disk displacement, and signs and symptoms of TMJ disorders in orthognathic surgery patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 91(5):603-610.