Orthognathic Surgery Form

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Orthognathic Surgery - Medical Policy
Updated Revision Effective: November 1, 2024 Policy Number:

UM294POL

Approval Date: 7/30/2024

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Orthognathic surgery is surgery to correct conditions of the jaw. The surgical revision by ostectomy, osteotomy or osteoplasty of the upper jaw (maxilla) and/or the lower jaw (mandible) is intended to alter the relationship of the jaws and teeth. These surgical procedures are intended to correct skeletal jaw and cranio-facial deformities that may be associated with significant functional impairment, and 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 a 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.

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 Line of Business

Commercial:

 HNE has adopted InterQual* criteria for the following procedures:

o Mandible bone augmentation: CP:Procedures, Bone Augmentation, Mandible o Maxilla bone augmentation: CP:Procedures, Bone Augmentation, Maxilla o Orthognathic Surgery and Jaw realignment Surgery:
 CP:Procedures, Maxillomandibular Advancement, LeFort I Osteotomy  CP:Procedures, Maxillomandibular Advancement, Osteotomy, Sagittal Split, Mandible Ramus for Maxillomandibular Advancement o Genioglossal advancement, Genioglossus advancement, Jaw realignment surgery, Orthognathic surgery, Osseous genioplasty, Sliding genioplasty:  CP:Procedures, Osteotomy, Anterior Segment, Mandible  CP:Procedures, Osteotomy, Anterior Segment, Mandible, Osteotomy, Mandible, Segmental with Genioglossus Advancement  CP:Procedures, Osteotomy, Anterior Segment, Mandible, Hyoid Myotomy and Suspension o Subapical anterior maxillary segmental osteotomy: CP:Procedures, Osteotomy, Anterior Segment, Maxilla o Maxillary Corticotomy: CP:Procedures, Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy o Total Joint Replacement (TJR) of Temporomandibular Joint (TMJ): CP:Procedures, Reconstruction, Temporomandibular Joint (TMJ)

Medicaid – BeHealthy:

 HNE has adopted InterQual* criteria for the following procedures:

o Mandible bone augmentation: CP:Procedures, Bone Augmentation, Mandible o Maxilla bone augmentation: CP:Procedures, Bone Augmentation, Maxilla o Orthognathic Surgery and Jaw realignment Surgery:
 CP:Procedures, Maxillomandibular Advancement, LeFort I Osteotomy  CP:Procedures, Maxillomandibular Advancement, Osteotomy, Sagittal Split, Mandible Ramus for Maxillomandibular Advancement o Genioglossal advancement, Genioglossus advancement, Jaw realignment surgery, Orthognathic surgery, Osseous genioplasty, Sliding genioplasty:  CP:Procedures, Osteotomy, Anterior Segment, Mandible  CP:Procedures, Osteotomy, Anterior Segment, Mandible, Osteotomy, Mandible, Segmental with Genioglossus Advancement  CP:Procedures, Osteotomy, Anterior Segment, Mandible, Hyoid Myotomy and Suspension o Subapical anterior maxillary segmental osteotomy: CP:Procedures, Osteotomy, Anterior Segment, Maxilla o Maxillary Corticotomy: CP:Procedures, Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy o Total Joint Replacement (TJR) of Temporomandibular Joint (TMJ): CP:Procedures, Reconstruction, Temporomandibular Joint (TMJ)

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Medicare:

 HNE has adopted InterQual* criteria for the following procedures:

o Mandible bone augmentation: CP:Procedures, Bone Augmentation, Mandible o Maxilla bone augmentation: CP:Procedures, Bone Augmentation, Maxilla o Orthognathic Surgery and Jaw realignment Surgery:
 CP:Procedures, Maxillomandibular Advancement, LeFort I Osteotomy  CP:Procedures, Maxillomandibular Advancement, Osteotomy, Sagittal Split, Mandible Ramus for Maxillomandibular Advancement o Genioglossal advancement, Genioglossus advancement, Jaw realignment surgery, Orthognathic surgery, Osseous genioplasty, Sliding genioplasty:  CP:Procedures, Osteotomy, Anterior Segment, Mandible  CP:Procedures, Osteotomy, Anterior Segment, Mandible, Osteotomy, Mandible, Segmental with Genioglossus Advancement  CP:Procedures, Osteotomy, Anterior Segment, Mandible, Hyoid Myotomy and Suspension o Subapical anterior maxillary segmental osteotomy: CP:Procedures, Osteotomy, Anterior Segment, Maxilla o Maxillary Corticotomy: CP:Procedures, Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy o Total Joint Replacement (TJR) of Temporomandibular Joint (TMJ): CP:Procedures, Reconstruction, Temporomandibular Joint (TMJ)

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

Policy

I. Mandible bone augmentation

A. Health New England has adopted following InterQual criteria.

o CP:Procedures, Bone Augmentation, Mandible (CPT 21120, 21121, 21122, 21123, 21125, 21127, 21215, 21244, and 21245)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Mandible bone augmentation for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

II. Maxilla bone augmentation

A. Health New England has adopted following InterQual criteria.CN836

o CP:Procedures, Bone Augmentation, Maxilla (CPT 21208, 21210 and 21348)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

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C. Maxilla bone augmentation for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

III. Orthognathic Surgery and Jaw realignment Surgery

A. Health New England has adopted following InterQual criteria.

o CP:Procedures, Maxillomandibular Advancement, LeFort I Osteotomy (CPT 21141, 21142, 21143, 21145, 21146, and 21147) o CP:Procedures, Maxillomandibular Advancement, Osteotomy, Sagittal Split, Mandible Ramus for Maxillomandibular Advancement (CPT 21193, 21194, 21195, and 21196)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Orthognathic surgery and Jaw realignment surgery for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

IV. Genioglossal advancement, Genioglossus advancement, Jaw realignment surgery, Orthognathic
surgery, Osseous genioplasty, Sliding genioplasty

A. Health New England has adopted following InterQual criteria.

o CP:Procedures, Osteotomy, Anterior Segment, Mandible (CPT 21198 and 21199) o CP:Procedures, Osteotomy, Anterior Segment, Mandible, Osteotomy, Mandible, Segmental with Genioglossus Advancement (CPT 21198, and 21199)

o CP:Procedures, Osteotomy, Anterior Segment, Mandible, Hyoid Myotomy and Suspension (CPT 21120, 21121, 21122, 21123, 21198 and 21199)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Genioglossal advancement, Genioglossus advancement, Jaw realignment surgery, Orthognathic surgery, Osseous genioplasty, Sliding genioplasty for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

V. Subapical anterior maxillary segmental osteotomy

A. Health New England has adopted following InterQual criteria.

o CP:Procedures, Osteotomy, Anterior Segment, Maxilla (CPT 21188 and 21206)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Subapical anterior maxillary segmental osteotomy for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

VI. Maxillary Corticotomy

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A. Health New England has adopted following InterQual criteria.

o CP:Procedures, Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy (21188, 21206, and 21299)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Maxillary Corticotomy for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

VII. Total Joint Replacement (TJR) of Temporomandibular Joint (TMJ)

A. Health New England has adopted following InterQual criteria.

o CP:Procedures, Reconstruction, Temporomandibular Joint (TMJ) (21193, 21194, 21195, 21196, 21244, 21245, 21246, 21247, 21248, 21249, and 21255)

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Total Joint Replacement (TJR) of Temporomandibular Joint (TMJ) for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

Policy Guidelines and Definitions

Definitions:

Mandible: The horseshoe-shaped bone forming the lower jaw

Maxilla: A paired bone that forms the skeletal base of the upper face, roof of the mouth, sides of the nasal cavity and floor of the orbit (contains the eye); the upper jaw

Ostectomy: Excision of a bone or part of a bone

Osteoplasty: Surgical repair or alteration of bone

Osteotomy: An operation in which a bone is cut to allow the bone to be repositioned; for example, to shorten, lengthen

Coding Guidance

The following codes are reviewed on a case-by-case basis to determine medical necessity versus cosmetic using Medical Necessity or Cosmetic and Reconstructive Procedures policies

21150, 21151, 21154, 21155, 21159, 21160

The following codes are NOT covered under MassHealth:

21121, 21122, 21245, 21246, 21248, 21249

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https://www.mass.gov/doc/physician-phy-subchapter-6/download

Code
Description
PA 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) Yes 21121 Genioplasty; sliding osteotomy, single piece Yes 21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin Yes 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) Yes 21125 Augmentation, mandibular body or angle; prosthetic material Yes 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) Yes 21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), without bone graft Yes 21142 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft Yes 21143 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft Yes 21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) Yes 21146 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft) Yes 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 Yes 21150 Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome) Yes 21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining Autografts Yes 21154 Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I Yes 21155 Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I Yes 21159 Reconstruction midface, LeFort III; (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I Yes 21160 Reconstruction midface, LeFort III; (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I Yes 21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) Yes 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft Yes 21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) Yes 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation Yes 21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation Yes 21198 Osteotomy, mandible, segmental Yes

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Code
Description
PA 21199 Osteotomy, mandible, segmental; with genioglossus advancement Yes 21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) Yes 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) Yes 21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Yes 21215 Graft, bone; mandible (includes obtaining graft) Yes 21244 Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate) Yes 21245 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) Yes 21246 Reconstruction of mandible or maxilla, subperiosteal implant; complete Yes 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) Yes 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial Yes 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete Yes 21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) Yes 21299 Unlisted craniofacial and maxillofacial procedure Yes 21348 Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) Yes

CPT® Copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

See applicable InterQual criteria

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 2/2007 Initial Policy Date 03/2022 Medicaid non-covered CPT codes link added under CPT code section

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Date Update 04/2023 No changes. 1/2024 Added Line of Business Section Updated this section to add reference to the Cosmetic policy: The following codes are reviewed on a case-by-case basis to determine medical necessity versus cosmetic using Medical Necessity or Cosmetic and Reconstructive Procedures policies.

07/2024 All InterQual criteria listed. Coding table updated, added CPT 21348 to PA list. Minor edits to definitions.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.