Health First Orthognathic (Jaw) Surgery Form

Orthognathic Surgery Medical Necessity and Coverage

Orthognathic surgery may be considered medically necessary when the clinical criteria described in this policy are met. This coverage is in addition to that for jaw surgery for acute traumatic injury, post-surgical sequela, and to remove cancerous or non-cancerous tumors and cysts.

Services that do not meet defined criteria are not considered medically necessary and are not covered.

Definitions:

Orthognathic Surgery – Jaw surgery that corrects abnormalities of the mandible, maxilla, or both. The abnormality may be present at birth and become evident as the patient grows or may be the result of a traumatic injury that includes conditions related to structure, growth, sleep apnea, TMJ (temporomandibular joint) and occlusion. Due to the severity of these deformities, dental treatment alone is precluded.

Clinical Criteria: (Indications/Limitations)

1. Orthognathic Surgery is considered medically necessary when all the following criteria are met:
   1. A severe maxillary and/or mandibular skeletal deformity associated with masticatory malocclusion exists. Severity is established when one or more of the following discrepancies or asymmetries is present:
      1. Anteroposterior discrepancies
         1. Maxillary/Mandibular incisor relationship: overjet of 5mm or more, or a 0 to a negative value (norm 2mm)
         2. Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm 0 to 1mm).
         3. These values represent two or more standard deviations from published norms.
      2. Vertical discrepancies
         1. Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks.
         2. Open Bite
         3. No vertical overlap of anterior teeth
         4. Unilateral or bilateral posterior open bite greater than 2mm
         5. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch
         6. Supra-eruption of a dentoalveolar segment due to lack of occlusion.
      3. Transverse discrepancies

         Transverse discrepancy is an abnormality of development in transverse plane. In orthodontic diagnosis and treatment planning, the emphasis is placed on recognizing asymmetry and achieving symmetric results with dental midlines coincident with each other and with the facial midline.

         1. Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms
         2. Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, or a unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth
      4. Asymmetries
         1. Anteroposterior, transverse or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry
   2. A functional impairment exists as defined below: (one or more)
      1. Member has difficulty chewing or swallowing, with symptoms documented in the medical or dental record and persisting for at least 12 months. Other causes of swallowing, choking, or chewing problems must be ruled out through physical exam and/or appropriate diagnostic study;
      2. Member has documented malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity;
      3. Member has airway obstruction (such as obstructive sleep apnea), when documented by a polysomnogram, and BOTH of the following:
         1. Criteria for continuous positive airway pressure (CPAP) device AND
         2. Documentation demonstrates the member previously failed less invasive surgical procedures or has craniofacial skeletal abnormalities associated with a narrowed posterior airway space and tongue-based obstruction.
      4. Member has speech impairment associated with severe cleft deformity or skeletal malocclusion
   3. Standardized Imaging: X-Rays, Computed tomography (CT) scans, photographs of teeth and jaw are required to be submitted as part of prior authorization request for consideration of medical necessity.
   4. A reasonable probability exists that function cannot be obtained with orthodontic treatment alone.

      If orthodontic treatment is required in relation to the requested orthognathic surgery, documented evidence of the arrangement for such treatment must be provided or the orthognathic surgery will not be considered medically necessary. Orthodontic treatment is not covered under the medical benefits of any Health First Health Plan.