Humana Orthognathic Surgery - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals. There are no NCDs and/or LCDs for Orthognathic Surgery. Description Orthognathic Surgery Page: 2 of 5 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 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. Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria: Orthognathic Surgery The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically Orthognathic Surgery Page: 3 of 5 necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage