Sunflower Health Plan Orthognathic Surgery (PDF) Form

This policy describes the medical necessity requirements for orthognathic surgery to improve form and function through correction of an underlying skeletal deformity.1 Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that orthognathic surgery is medically necessary when all of the following are met: A. When any of the following skeletal deformities (associated with masticatory malocclusion) are present: 1. Anteroposterior discrepancy, one of the following: a. Maxillary/mandibular incisor relationship: overjet of greater than 5 mm, or a zero to negative value (norm = 2 mm); b. Maxillary/mandibular anteroposterior molar relationship discrepancy of greater than 4 mm (norm = 0 to 1 mm); 2. Vertical discrepancy, one of the following: a. Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks; b. Open bite with no vertical overlap of anterior teeth or unilateral or bilateral posterior open bite greater than 2 mm; c. Deep overbite with impingement of palatal soft tissue; d. Supraeruption of a dentoalveolar segment resulting from lack of occlusion when dentition in segment is intact; 3. Transverse discrepancy, one of the following: a. Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms; b. Total bilateral palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth; 4. Anteroposterior, transverse or lateral asymmetries greater than 3 mm, with concomitant occlusal asymmetry. B. Presence of any of the following functional impairments: 1. Persistent difficulties with mastication and swallowing after causes such as neurological or metabolic diseases have been excluded; 2. Malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity; 3. Speech dysfunction directly related to a jaw deformity as determined by a speech and language pathologist; 4. Myofascial pain secondary to facial skeletal deformity that has persisted for at least six months, despite conservative treatment such as physical therapy and splints; Page 1 of 7 CLINICAL POLICY Orthognathic Surgery 5. Airway obstruction, such as obstructive sleep apnea, documented by polysomnogram, when both of the following criteria are met: a. Criteria for positive airway pressure (PAP) met and individual has proved intolerant to or failed a trial of PAP; b. Individual has failed prior less invasive surgical procedures OR has craniofacial skeletal abnormalities that are associated with a narrowed posterior airway space and tongue-base obstruction. II. It is the policy of Centene Corporation that orthognathic surgery is not medically necessary when any of the following are present: A. When the sole purpose is to improve appearance, regardless of whether it is associated with psychological disorders, because it is considered cosmetic in nature; B. When the member/enrollee is still developing and the deformity could be corrected with less intrusive treatment (e.g., expander or head gear). Background Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both. The underlying abnormality may be present at birth or may become evident as the patient grows and develops or may be the result of traumatic injuries or systemic diseases. Often, the severity of these deformities precludes adequate treatment through dental treatment alone. Such skeletal abnormalities may cause difficulties with eating or chewing, abnormal speech patterns, or dysfunction of the temporomandibular joint (TMJ). The overall goal of treatment is to improve function through correction of the underlying skeletal deformity.1 Abnormalities generally occur as a result of a differential in growth between the upper facial skeleton and the lower facial skeleton, resulting in a discrepancy of the normal relationship that exists between the upper jaw (maxilla) and lower jaw (mandible). Genetic predisposition and environmental factors can influence the normal growth of the facial skeleton. Genetic causes can include cleft palate and other syndromes, such as Apert and Crouzon.1,9 Traumatic events can displace the normal structural elements or may disturb future normal growth. Other etiologies that can result in significant dentofacial anomalies include neoplasms, surgical resection and iatrogenic radiation. Developmental anomalies, however, are the most common condition. All of these deformities may result in diminished bite forces, restricted mandibular excursions, abnormal chewing patterns, speech deficits, malocclusions and/or abnormal facial appearance. There is a relationship between facial skeletal abnormalities and malocclusions, including Class II (disto-occlusion), Class III (mesio-occlusion) and open-bite (teeth do not meet) deformities.1 The American Association of Oral and Maxillofacial Surgeons (AAOMS) classification of occlusion/malocclusion1 Class I: Exists with the teeth in a normal relationship when the mesial-buccal cusp of the maxillary first permanent molar coincides with the buccal groove of the mandibular first molar. Class II: Malocclusion occurring when the mandibular teeth are behind the normal relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw (Type 1) or an excess of the upper jaw (Type 2). Class III: Commonly referred to as an under bite, 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 Page 2 of 7 CLINICAL POLICY Orthognathic Surgery usually have a strong or protrusive chin, which can be due to either horizontal mandibular excess or horizontal maxillary deficiency. Surgical Procedures In orthognathic surgery, an osteotomy is made in the affected jaw, and the bones are repositioned in a more normal alignment. The bones are held in position with plates, screws and/or wires. Intermaxillary fixation, a procedure in which arch bars are placed on both jaws, may also be needed to provide added stability. Simultaneous osteotomies may be performed when deformities must be corrected in both jaws. Grafts from the ribs, hip or skull may be performed for patients with deficient bone tissue; alloplastic bone replacement may also be required. Orthognathic surgery, which was initially introduced in the 19th century, is generally performed under general anesthesia on an inpatient basis.7 The gold standard for treatment of malocclusion is orthodontic management followed by surgery; however, over the last few decades, support has been increasing for a surgery first approach.8 Although sometimes performed for cosmetic purposes, orthognathic surgery is generally considered to be medically necessary when performed to treat a significant abnormality (e.g., mandible forward to cranial base, increase mandibular length, short ramal length or obtuse gonial angle) that is causing considerable functional impairment.7,9 Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2022, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. The following codes are for informational purposes only. They are current at time of review of this policy. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT®* Codes 21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21121 Genioplasty; sliding osteotomy, single piece 21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) 21125 Augmentation, mandibular body or angle; prosthetic material 21127 Augmentation, mandibular body or angle; prosthetic; 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; two pieces, segment movement in any direction, without bone graft Page 3 of 7 CLINICAL POLICY Orthognathic Surgery CPT®* Codes 21143 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft 21145 Reconstruction midface, LeFort I; single piece, segment in any direction, requiring bone grafts (includes obtaining autografts) 21146 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e,g., ungrafted unilateral alveolar cleft) 21147 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., 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 21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I 21160 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), 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 (e.g., 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 (include obtaining graft) 21215 Graft, bone; mandible (includes obtaining graft) 21244 Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate) 21245 Reconstruction of mandible or maxilla, superiosteal implant; partial Page 4 of 7 CLINICAL POLICY Orthognathic Surgery CPT®* Codes 21246 Reconstruction of mandible or maxilla, superiosteal implant; complete 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., 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 Reviews, Revisions, and Approvals Policy developed. All instances of “member” replaced with “member/enrollee.” Transferred to CNC template from WellCare CCG HS-87. References reviewed and updated. Annual review complete. Updated 1.A.1.a. from >5mm to ≥5mm and updated 1.A.1.b.>4mm to ≥4mm. Added, "or irritation of buccal or lingual soft tissues of the opposing arch" to 1.A.2.c. Specified "maxillary" palatal cusp in 1.A.3.b. Minor verbiage updates with no clinical significance. Added CPT codes 21120, 21121, 21122, 21123, 21159, and 21160. Removed CPT codes 21248 and 21249. Removed ICD-10 code table. References reviewed, updated, and reformatted. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Reviewed by specialist. Annual review completed. Reformatted criteria II. and added II.B. as additional non-medically necessary indication. Additional minor rewording with no clinical significance. Background updated. CDT codes removed from policy. References revised and updated. Reviewed by external and internal specialists. Annual review. Added CPT codes 21248 and 21249. References reviewed and updated. Review Date 3/11 10/20 Approval Date 3/11 10/20 10/21 10/21 10/22 10/22 10/23 10/23