Humana Orthognathic Surgery Form

Description

Orthognathic surgery corrects abnormalities of the mentum (chin), the mandible (lower jaw) and/or the maxilla (upper jaw) which are severe enough to preclude adequate treatment by dentistry or orthodontics alone. The defects may be congenital (present at birth), become evident with growth and development, or may be due to traumatic injury. Orthodontic therapy to correct occlusion (bite alignment) may be necessary prior to orthognathic surgery.

During the procedure, an oral and maxillofacial surgeon repositions the affected areas (mentum, mandible and/or maxilla) to approximate normal alignment and structure, sometimes adding, removing or reshaping bone. Synthetic prosthetic materials may be used along with surgical plates, screws, wires, and rubber bands to hold the jaws into the new position. Oral surgical splints may also be fabricated to offer perioperative and/or postoperative support to ensure satisfactory surgical outcomes. The most common surgical technique is known as the LeFort I osteotomy, though there are variations of this technique that may be performed, depending on the exact indications for the surgery.

Orthognathic Surgery

Effective Date: 03/01/2023

Revision Date: 03/01/2023

Review Date: 03/01/2023

Policy Number: HUM-0341-024

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Orthognathic surgery may also be performed as a surgical treatment for obstructive sleep apnea (OSA). OSA is a common sleep disorder where deformities in the upper airway anatomy cause breathing to become difficult and noisy. An individual with OSA may also experience apneic episodes which can last from 10 to 60 seconds at a time with up to 120 incidents per hour during sleep. As a result, oxygen levels in the bloodstream fall, which may lead to high blood pressure, stroke, heart attack, and/or abnormal heart rhythms.

Common orthognathic surgeries performed for OSA include:

• Mandibular osteotomy moves the lower jaw as one unit either forward or backwards by way of bilateral incisions into the gums behind the molars and lengthwise down the jawbone.
• Maxillary osteotomy moves the upper jaw as one unit either forward or backwards by way of incisions into the gums above the upper teeth and into the jawbone.
• Maxillomandibular advancement increases airway by advancing the maxilla and mandible by means of Le Fort I maxillary and sagittal-split mandibular osteotomies.

For information regarding other surgical treatments for OSA, please refer to Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments Medical Coverage Policy.

For information regarding genioplasty, please refer to Cosmetic and Reconstructive Surgery Medical Coverage Policy.

Coverage Determination

Orthodontic treatment that is provided as an adjunct to orthognathic surgery is considered dental in nature and therefore, not covered under the medical benefit.

Orthognathic Surgery

Effective Date: 03/01/2023

Revision Date: 03/01/2023

Review Date: 03/01/2023

Policy Number: HUM-0341-024

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Any state mandates for orthognathic surgery take precedence over this medical coverage policy.

Commercial Plan members: requests for orthognathic surgery for treatment of OSA require review by a medical director.

Documentation Requirements

Providers must submit the following at the time of the preauthorization request:

• Detailed description of the functional impairment* considered to be the direct result of the skeletal abnormality; AND
• Physical evidence of a skeletal, facial or craniofacial deformity defined by cephalometric measurement tracings

Humana members may be eligible under the Plan for orthognathic surgery for maxillary and/or mandibular facial skeletal deformities causing a functional impairment* of masticatory malocclusion or those with a diagnosis of OSA who have had a failure of or intolerance to** a 90 consecutive day trial of positive airway pressure (PAP) therapy, for the following indications⁴:

1. Anteroposterior discrepancies:
   • Maxillary/mandibular anteroposterior molar relationship discrepancy of 4 millimeters (mm) or more (normal is 0 – 1 mm); OR
   • Maxillary/mandibular incisor relationship: horizontal overjet of 5 mm or more or a 0 to a negative value (normal is 2 mm); OR
2. Vertical discrepancies:
   • Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch; OR
   • Open bite with no vertical overlap of anterior teeth; OR
   • Presence of a vertical facial skeletal deformity which is 2 or more standard deviations from published norms for accepted skeletal landmarks; OR
   • Supraeruption of a dentoalveolar segment due to lack of occlusion; OR
   • Unilateral or bilateral posterior open bite greater than 2 mm; OR
3. Transverse discrepancies:
   • Presence of a transverse skeletal discrepancy which is 2 or more standard deviations from published norms; OR
   • Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater; OR
   • Unilateral discrepancy of 3 mm or greater, given the axial inclination of the posterior teeth; OR
4. Asymmetries:
   • Anteroposterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry

PAP failure or intolerance may be demonstrated by the following:

• Abnormal nasal, sinus or palatal structures (eg, deviated septum, swollen turbinates, high arching upper palate); OR
• Continued apneas, despite compliance (greater than 4 hours per night, 5 nights per week for a minimum of one month) with prescribed therapy and equipment adjustments including mask and/or pressure settings if medically appropriate; OR
• Excessive daytime sleepiness or level of sleepiness as measured by sleep measurement scale (eg, Epworth Sleepiness Scale, Psychomotor Vigilance Task, Stanford Sleepiness Scale); OR

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Frequent awakenings (eg, greater than or equal to 5 times in a night); OR
• Inability to tolerate the sensation of pressure or noise from the PAP device or a sense of claustrophobia; OR
• Persistent nasal or upper airway dryness or congestion; OR
• Snoring or choking episodes during sleep

Humana members may be eligible under the Plan for orthognathic surgery for maxillary and/or mandibular skeletal abnormalities due to trauma (eg, fracture) or illness (eg, neoplasm, osteonecrosis) causing a functional impairment* of masticatory occlusion.

Humana members may be eligible under the Plan for reconstructive orthognathic surgery for cleft palate and/or craniofacial syndromes causing a functional impairment* of masticatory occlusion including, but not limited to, craniofacial microsomia, midface hypoplasia, Pierre Robin syndrome and Treacher Collins syndrome. *Functional impairment is defined as a direct and measurable reduction in physical performance of an organ or body part.

Humana members may be eligible under the Plan for oral surgical splints when used in conjunction with orthognathic surgery that meets any of the criteria listed above.

Coverage Limitations

Humana members may NOT be eligible under the Plan for orthognathic surgery for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for oral surgical splints for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for endosteal (dental) implants as these are generally excluded by certificate. Please refer to the member's individual certificate for the specific definition.

Computed tomography (CT) scan including, but may not be limited to, CT guided planning and three-dimensional (3D) modeling during any phase of treatment or treatment planning is considered integral to the primary procedure and not separately reimbursable.

Additional Information about Abnormalities of the Jaw may be Found from the Following Websites: Background

• American Association of Oral and Maxillofacial Surgeons
• American Cleft Palate-Craniofacial Association
• American Society of Plastic Surgeons
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.