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HealthPartners

Coverage criteria policies

Dental Services - Orthognathic surgery

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Orthognathic surgery is not a covered benefit under many plans. Please verify benefits prior to submitting a prior authorization request. If benefits are available, prior authorization is required for Orthognathic Surgery.

HealthPartners medical plans do not cover orthodontic treatment provided as an adjunct to orthognathic surgery, because such treatment is considered dental in nature and, therefore, not covered under the medical benefit.

Coverage

  • Orthognathic Surgery must be received from an in-network orthognathic surgery provider under many benefit plans. We encourage members to check your member contract or call Member Services to identify any provider network limitations specific to your plan.
  • Coverage is for charges directly related to orthognathic surgery only--such as surgeons, anesthesia, and hospital expenses.
  • Corrective orthognathic surgery: Surgery done in conjunction with orthodontic treatment that is intended to correct skeleto-dental disharmonies that provide a mild to moderate improvement in function and/or appearance of the smile and facial profile. This treatment may apply to both Class II and Class III malocclusions and may be desired by the member following orthodontic treatment to create a more ideal relationship and appearance of the teeth and jaws. A severe facial deformity and documented functional impairment are not part of this category for review. Should a member be able to chew and swallow adequately the occlusion is deemed to be functional and not present with a severe facial deformity then the request for surgery will not meet coverage criteria.
  • Medically necessary orthognathic surgery: Surgery done in the presence of a severe facial deformity and functional impairment and may also meet additional coverage criteria as described below. Intended candidates for this surgery must also demonstrate difficulty chewing and/or swallowing as documented by the member’s referring primary care physician or dental provider and this condition must have been documented in the member’s treatment record for more than 12 months prior to the surgery request. Should a functional, though not ideal, occlusion and jaw relationship be present the case would not qualify for coverage. Approval is reserved for those cases evaluated to be severe and with no treatment, the member is considered medically compromised.

Orthognathic Surgery is generally covered subject to the indications listed below and per your plan documents. If coverage for orthognathic surgery is available, required clinical/radiographic documentation accompanying the request must be dated within the previous 24 months; the following clinical documentation is required to support medical necessity for orthognathic surgery:

  1. Medical history and physical examination with reference to symptoms related to the orthognathic deformity
  2. Description of specific anatomic deformity present
  3. Lateral and anterior-posterior cephalometric radiographs
  4. Cephalometric tracings
  5. Copy of medical records from treating physician documenting evaluation, diagnosis and previous management of the severe functional medical impairment(s)
  6. Diagnostic quality (clear) photographs that fully demonstrate the dental occlusion

Indications that are covered

  1. Orthognathic Surgery will generally be covered when both a severe facial deformity AND a functional impairment exist. There must be a reasonable probability that a functional occlusion cannot be obtained with orthodontic treatment alone.
    A functional impairment consists of two or more of the following criteria, A-E:
    1. Difficulty with chewing or swallowing, with symptoms being documented by the referring primary care physician or dentist. These symptoms must have persisted for greater than 12 months. This documentation must accompany the request for service and cannot be documentation provided by the consulting surgeon alone. Other causes of swallowing difficulty, choking or chewing problems must be ruled out through physical exam and/or appropriate diagnostic study (these include but are not limited to, allergies, neurologic disease, metabolic disease, or hypothyroidism) and those findings must accompany the surgery request.
    2. Documented malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity.
    3. Presence of a severe Class II malocclusion with an overjet >9mm with palatal impingement; severe Class III malocclusion with a negative overjet >3.5mm; or an anterior open bite >4mm.
    4. Documented speech impairment secondary to a malocclusion, severe cleft deformity or jaw deformity as determined by a multidisciplinary team (e.g., speech pathologist or therapist along with a cleft palate or craniofacial specialist) to determine if improvement can be expected from surgery.
    5. Airway obstruction (such as obstructive sleep apnea), when documented by a polysomnogram or home sleep study with a specific diagnosis made by a sleep medicine physician and BOTH of the following:
      1. Criteria for continuous positive airway pressure (CPAP) device are satisfied and documentation demonstrates a previously failed trial of CPAP
        -AND-
      2. Documentation demonstrates the member previously failed less invasive surgical procedures or has craniofacial skeletal abnormalities that are associated with a narrowed posterior airway space and tongue-based obstruction.
  2. Requests for orthognathic surgery/orthodontic treatment plan MUST be submitted for preauthorization and approved by HealthPartners PRIOR to initiation of orthodontic treatment. (Cases submitted for surgery subsequent to orthodontic treatment to align and level teeth for orthognathic surgery may not be covered). If at time of review orthodontic treatment has commenced, initial pretreatment records MUST be provided with request.

Indications that are not covered

  1. Orthodontic treatment pre and post orthognathic surgery is not covered under this medical benefit. Associated orthodontic and/or dental orthopedic treatment including rapid maxillary expansion to eliminate functional crossbites is not covered.
  2. If the member’s condition requires orthodontic treatment, the member must demonstrate that this orthodontic care has been arranged. If the member does not have a clear plan to acquire the required pre and post orthodontic treatment associated with the surgery, orthognathic surgery will not be covered.
  3. Orthognathic surgery is generally not covered for the following conditions:
    1. Primarily to provide a cosmetic improvement with only a limited (mild to moderate) improvement in function. Examples are genioplasty (surgical correction of the bony contour of the chin) and midface vertical height reduction, and other orthodontic occlusal deficiencies that can be compensated by orthodontic treatment alone. Presence of a skeletal mal-relationship alone is not justification for approval unless it is deemed severe enough that surgery is medically necessary to create dental compensation/function.
    2. Posterior cross bite with functional intercuspation (surgically assisted rapid palatal expansion [SARPE] prior to orthodontic treatment is not a covered service).
    3. When used in conjunction with distraction osteogenesis techniques (techniques which induce new bone formation by dividing a bone and applying tension through an external fixation device to lengthen the bone).
  4. Orthognathic surgery is generally not a treatment for temporomandibular disorder (TMD). Any TMD related symptoms must be evaluated before prior authorization for orthognathic surgery. If a treating surgeon or orthodontist recommends that orthognathic surgery be undertaken in the presence of TMD related symptoms, the member may be referred to an appropriate network TMD clinic for evaluation before starting prior authorization for orthognathic surgical care.

Definitions

Orthognathic literally means straight jaws.

Orthognathic surgery involves widening, shortening, or lengthening the bones, in any dimension, in the upper or lower jaws to correct severe skeletal facial deformities. Trauma, congenital or acquired conditions and severe disproportional growth of the bones in the face and jaw can cause these skeletal deformities.

Treatment of severe skeletal facial deformities may require dental, orthodontic or surgical treatments. Surgery is performed when the severe facial deformity causes demonstrable difficulty in breathing, chewing, and swallowing and when the deformity is determined to be too severe for correction by orthodontics alone (as determined upon review by a licensed orthodontist and dentist).

Functional impairment refers to the difficulties that substantially interfere with or limit speech, chewing, and swallowing.

Sleep Medicine Physician is defined as a physician who is Board eligible or certified by the American Board of Sleep Medicine, or a pulmonologist or neurologist whose residency/fellowship included specialized training in sleep disorders and whose practice is comprised of at least 25% of sleep medicine.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Procedure Codes:

Codes

Description

21110

Application of interdental fixation device, non-fracture or dislocation

21125

Augmentation, mandibular body or angle; prosthetic material

21127

Augmentation, mandibular body or angle; with bone graft

21141

Le Fort 1 single piece

21142

Le Fort 1 two pieces, without bone graft

21143

Le Fort 1 three pieces, without bone graft

21145

Le Fort 1 with bone graft

21146

Le Fort 1 two pieces

21147

Le Fort 1 three or more pieces

21150

Le Fort II, anterior intrusion

21151

Le Fort II, any direction, requiring bone grafts

21154

Le Fort III, requiring bone grafts without Le Fort I

21155

Le Fort II, requiring bone grafts with Le Fort I

21159

Le Fort III, requiring bone grafts without Le Fort I

21160

Le Fort III, requiring bone grafts with Le Fort I

21188

Reconstruction midface, osteotomies (other than Le Fort type) and bone grafts

21193

Bilateral Vertical Osteotomy (reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy without bone graft)

21194

Bilateral Vertical Osteotomy (reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy with bone graft)

21195

Reconstruction of the mandibular rami and/or body, sagittal split, without internal rigid fixation

21196

Sagittal Split Osteotomy with rigid fixation

21198

Mandibular Osteotomy

21206

Osteotomy, maxilla, segmental

21208

Osteoplasty, facial bones; augmentation

21209

Osteoplasty, facial bones; reduction

21210

Graft, bone; nasal, maxillary or malar areas

21215

Graft, bone; mandible

21247

Reconstruction of mandibular condyle with bone and cartilage autografts

CDT Codes:

Codes

Description

D7940

osteoplasty for orthognathic deformities

D7941

osteotomy-mandibular rami

D7943

osteotomy - mandibular rami with bone graft

D7944

osteotomy-Segmented or subapical

D7945

osteotomy-body of mandible

D7946

LeFort I maxilla, total

D7947

LeFort I maxilla, segmented

D7948

LeFort II of LeFort III without bone graft

D7949

D7949-LeFort II of LeFort III with bone graft

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

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Association of Oral and Maxillofacial Surgeons. Recommended Criteria for Orthognathic Surgery. Retrieved August 4, 2015, from http://www.aaoms.org/practice-resources/aaoms-advocacy-and-position-statements/clinical-resources
  2. Buchanan, E. and Hollier, L. Syndromes with craniofacial abnormalities. In: UpToDate, Weisman, L. and Firth, H. (Ed), UpToDate, Waltham, MA. (Accessed on July 13, 2017).