Medical Policies - Surgery
*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*
CAREFULLY REVIEW: Coverage for orthognathic surgery may be dependent on benefit plan language (i.e., may be subject to the provisions of a cosmetic or reconstructive surgery benefit), and/or may be subject to legislative mandates. Please refer to the benefit plan language and/or legislative mandates to determine terms, limitations, and conditions of coverage.
This medical policy does NOT address Gender Reassignment Services (Transgender Services). This medical policy IS NOT TO BE USED for Gender Reassignment Services. Refer to SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery and Related Services
NOTE 1: For criteria for orthognathic surgery related to the temporomandibular joint (TMJ), see medical policy SUR705.010, Temporomandibular Joint (TMJ) Disorders (TMJD).
NOTE 2: For criteria for orthognathic surgery related to sleep apnea, see medical policy SUR706.009, Sleep Related Breathing Disorders, Medical and Surgical Management.
Maxillary and/or Mandibular Facial Deformities Associated with Masticatory Malocclusion:
When not specifically excluded from coverage in a health benefit contract, orthognathic surgery may be considered medically necessary when ALL the following criteria are met:
1) Surgery is proposed for correction of skeletal deformities when it is documented that:
• These facial skeletal deformities are contributing to significant functional impairment, defined as persistent difficulties with mastication and swallowing as manifested by inability to incise and/or chew solid foods, choking on incompletely masticated solid foods, and/or damage to soft tissue during mastication; AND
• Deformity and impairment are not correctable with non-surgical modalities (e.g., dental therapeutics, orthodontics); AND
2) Skeletal deformity falls under one of the following categories:
• Anteroposterior discrepancies (NOTE 3: These values represent two or more standard deviations from published norms):
o Maxillary/mandibular incisor relationship: overjet of 5 mm or more, or a 0 to a negative value (norm = 2 mm); or
o Maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm = 0 to 1 mm); OR
• Vertical discrepancies:
o Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks; or
o Open bite with no vertical overlap of anterior teeth or unilateral or bilateral posterior open bite greater than 2 mm; or
o Deep overbite with impingement of palatal soft tissue; or
o Supraeruption of a dentoalveolar segment resulting from lack of occlusion when dentition in segment is intact; OR
• Transverse discrepancies:
o Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms; or
o Total bilateral maxillary 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; OR
o Anteroposterior, transverse or lateral asymmetries greater than 3 mm, with concomitant occlusal asymmetry.
Orthognathic surgery may be considered medically necessary for treatment of speech dysfunction that is directly related to a facial skeletal deformity, as determined by a speech and language pathologist (e.g., sibilant distortions, velopharyngeal distortion).
Orthognathic surgery is considered not medically necessary for correction of articulation disorders and other speech impairments that are not related to facial skeletal deformity.
Aesthetic and Psychological Indications:
Orthognathic surgery is considered cosmetic when performed in the absence of significant functional impairment, including but not limited to:
• When used for altering or improving bite; or
• When performed solely for the purpose of improving or altering appearance or self-esteem; or
• To treat psychological or psychosocial symptoms or complaints related to the member’s appearance.
Genioplasty (chin augmentation/implant) performed alone or in conjunction with other orthognathic surgical procedures is considered cosmetic. EXCEPTION: See Medical Policy SUR717.001 Gender Assignment Surgery and Gender Reassignment Surgery with Related Services.
Orthognathic surgery is considered not medically necessary for any other indication.
The word orthognathics originated from the Greek words for “straight” and “jaw”. Orthognathic surgery is the surgical correction of abnormalities of the mandible (lower jaw), maxilla (upper jaw), or both. The underlying abnormality may be present at birth, may become evident as an individual grows and develops, or may be the result of traumatic injuries. Orthognathic surgery is performed to correct malocclusion or deformity that is related to functional impairment, and that cannot be improved with routine dental or orthodontic therapy. (1)
Maxillofacial deformities can be divided broadly into three major categories: dental dysplasias, skeletal dysplasias, and dentoskeletal dysplasias. Dental dysplasias are malocclusions that result from abnormal spatial relationship of the dentition and not from the skeletal position of the upper and lower jaws. These can be corrected with orthodontic treatment. In patients with skeletal dysplasia, the dentition is in good alignment, but the maxilla and/or mandible are dysplastic. Skeletal dysplasias require correcting the skeletal deformity without altering the occlusion. In dentoskeletal dysplasias, the dentition is malpositioned within each arch and with each other. Additionally, the skeletal relationship of the upper and lower jaws is abnormal; correction requires aligning the dentition within each arch with orthodontic treatment and restoring the maxillary-mandibular dental relationship with skeletal osteotomies and repositioning. (1)
Skeletal/facial anomalies are referenced as spatial (refers to space) planes: horizontal, vertical, transverse, or a combination. Examples of conditions for which orthognathic surgery is used are mandibular prognathism, crossbite, open bite, overbite, underbite, mandibular deformity, and maxillary deformity. Orthognathic procedures include osteotomy, ostectomy, or osteoplasty, and the insertion of material to hold bones together such as plates, screws, and wires. Depending on the severity of the deformity, several surgical methods may be used. In addition, orthognathic surgery is usually preceded by orthodontic therapy to attempt to correct malocclusion by conservative therapy or in preparation for surgery; orthodontic therapy may also be required in the post-operative phase. (1)
Universal dental notation is the most common system for numerically identifying permanent dentition. The maxillary dentition is numbered sequentially from 1-16 starting with the right maxillary third molar as 1. The numbering system continues from 17-32 beginning with the left mandibular third molar as 17.
Orientation with respect to intraoral anatomy is referenced to the following terms:
• Mesial - Toward the dental mid line.
• Distal - Away from the dental mid line.
• Labial - Toward the lips.
• Buccal - Toward the cheek.
• Apex - Toward the root tip.
• Lingual - Toward the tongue.
• Incisal - Toward the biting surface (anterior dentition).
• Occlusal - Toward the biting surface (posterior dentition).
• Angulation - Mesiodistal tipping of the long axis of the tooth.
• Inclination - Labiolingual or buccolingual tipping of the long axis of the tooth.
Dental Anatomic Terms
• Cusp - Pronounced elevation on the occlusal surface.
• Groove - Depression on the occlusal surface.
• Crown - Visible portion of the tooth covered by enamel.
• Cingulum - Bulbous convexity of the cervical one third of the lingual surface of anterior dentition.
• Cervix (neck) - Junction of the crown and root.
• Root - Portion of the tooth covered by cementum within the alveolar bone.
• Curvature of the dental arches - Normal reciprocal curvature in the dental arches with the maxilla convex and the mandible concave (allows the dentition maximal contact during function).
• Curve of Spee - Normal curvature of the dental arch in the sagittal plane.
• Curve of Wilson - Normal curvature of the dental arch in the coronal plane.
• Class I (neutro-occlusion): The mesiobuccal cusp of the maxillary first molar articulates within the mesiobuccal groove of the mandibular first molar.
• Class II (disto-occlusion): The mandibular first molar articulates distal to the mesiobuccal cusp of the maxillary first molar, i.e., the mandibular teeth are behind the normal relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw or an excess of the upper jaw; may be referred to as a deep bite deformity.
• Class III (mesio-occlusion): The mesiobuccal groove of the mandibular first molar is mesial to the mesiobuccal cusp of the maxillary first molar, i.e., the lower dental arch is in front of the (mesial to) the upper dental arch. People with this type of malocclusion usually have a strong or protrusive chin commonly referred to as an underbite.
Upper and Lower Arch Dentition
• Overjet - Horizontal distance between the incisal edges of the maxillary incisor to the mandibular incisor.
• Overbite - Vertical distance between the incisal edge of the maxillary incisor and the mandibular incisor.
• Crossbite - Lingual-buccal malposition of the normal relationship between the upper and lower dentition (negative overjet).
• Deep bite - Condition of excessive overbite.
• Open bite - Condition of negative overbite (teeth do not meet).
• Ortho-Panorex x-rays provide an overview of the stage of dental development, the mandibular anatomy, and gross pathology. Specific films such as occlusal and periapical views can be obtained to further assess the dentition, supporting bone, and interdental spaces.
• Cephalometric x-rays are standardized skull and/or facial views that allow for comparison over time to assess growth in an individual and for comparison of that individual against standardized population norms.
• Periapical films are obtained to determine if sufficient space exists for interdental osteotomies.
• On occasion, hand wrist films are useful to help determine skeletal age based on the known timing of sequential closure of the epiphyseal growth plates. However, typically facial skeletal maturity is determined by comparison of serial lateral cephalometric films obtained at 6-month intervals.
• Three-dimensional computerized tomography is being increasingly used for surgical evaluation and planning in academic university settings. In the future, such three-dimensional visualization of the patient's anatomic deformity is likely to replace today's conventional two-dimensional cephalometric analysis.
The elements of the facial skeleton can be repositioned, redefining the face through a variety of well-established osteotomies, including LeFort (I, II, and III) osteotomies, maxillary segmental osteotomies, sagittal split osteotomy of the mandibular ramus, vertical ramal osteotomy, inverted L- and C-osteotomies, mandibular body segmental osteotomies, and mandibular symphysis osteotomies. Most maxillofacial deformities can be managed with three basic osteotomies: the midface with the LeFort I osteotomy, the lower face with the sagittal split ramal osteotomy of the mandible, and the horizontal osteotomy of the symphysis of the chin. (1)
The LeFort osteotomies are named after the three classic lines of weakness of the facial skeleton described by Rene LeFort in 1901. The LeFort I osteotomy allows for correction primarily at the occlusal level affecting the upper lip position, nasal tip and alar base region, and the columella labial angle without altering the orbitozygomatic region. The LeFort II osteotomy allows the surgeon to alter the nasomaxillary projection without altering the orbital volume and zygomatic projection. Complete craniofacial dysjunction by the LeFort III osteotomy allows the surgeon to alter the orbital position and volume, zygomatic projection, position of the nasal root, frontonasal angle, and position of the maxilla and to lengthen the nose. These standard LeFort osteotomies may be modified for a specific clinical situation. For most midfacial maxillofacial deformities, the LeFort I osteotomy and its variations are adequate. (1)
Currently, the sagittal split ramal osteotomy is the primary choice for correcting most cases of mandibular retrognathism and prognathism. In extreme cases of mandibular prognathism, some surgeons prefer the intraoral vertical osteotomy or the inverted L-osteotomy. In situations of mandibular advancement in which the mandibular rami are hypoplastic and cannot be sagittally split, the inverted L- and the C-osteotomy with bone grafts are preferred. (1)
Over the last several years, timing of surgical intervention has evolved to handle dento-maxillofacial deformities. Six new timing schemes have emerged: “surgery-first”, “surgery-early”, “surgery-late”, “surgery-last”, “surgery-only”, and “surgery-never”. Patient gender, age at time of surgery, main treatment motivation, orthodontic treatment, and number of orthodontic appointments are considered as part of the timing of orthognathic surgery, which requires a team approach with the patient, orthodontist and surgeon. (7)
• Alveolar or Alveolus - The portion of the upper and lower jaws that contain the teeth and form the dental arches.
• Apertognathia - A type of malocclusion characterized by the premature occlusion of posterior teeth and the absence of anterior occlusion; sometimes referred to as open bite.
• Dentition - The natural teeth, as considered collectively, in the dental arch; may be deciduous, permanent, or mixed.
• Dysplasia - Abnormal tissue development.
• Genial - Pertaining to the chin.
• Genioplasty - Surgical alteration of the chin; also called mentoplasty.
• Hyperplasia - An abnormal increase in cells in an organ or a tissue with consequent enlargement.
• LeFort - An operation for reconstruction of the midface in which the teeth-bearing part of the maxilla is separated from its bony attachments and repositioned.
• Mandible - Lower jaw.
• Maxilla - Upper jaw.
• Mentoplasty - Surgical alteration of the chin; also called genioplasty.
• Masticatory - Refers to masticatory muscles or chewing.
• Maxillary hyperplasia - Overgrowth of the maxilla, or upper jaw, often presenting as excess vertical height of the maxilla.
• Maxillary hypoplasia - An abnormally small or posteriorly positioned maxilla, or upper jaw, often accompanying cleft palate or other craniofacial syndromes.
• Micrognathia - An abnormally small mandible or lower jaw.
• Occlusal - In dentistry, pertaining to the contacting surfaces of opposing occlusal units (teeth or occlusion rims) or the masticating surfaces of the posterior teeth.
• Occlusion - The way the teeth bite or come together. Occlusions may be normal or abnormal (malocclusion) and are classified as Class I, Class II, or Class III.
• Malocclusion - Any deviation from a physiologically acceptable relationship of the upper and lower teeth with each other.
• Orthodontics - The dental specialty and practice of preventing and correcting irregularities of the teeth, as by the use of braces.
• Osteotomy - The incision, sectioning, or cutting of a bone, without removing any of its parts, for the purpose of repositioning it into a structurally correct location with itself and adjacent structures (bone cut).
• Ostectomy - The excision, sectioning, or cutting of a bone for the purpose of removing a portion of the bone and repositioning it into a more structurally balanced relationship with itself and adjacent structures (bone removal).
• Osteoplasty - A surgical procedure that is designed to change or modify the shape or configuration of a bone (bone graft).
• Prognathia - An abnormally large mandible or lower jaw.
• Prosthodontics - The dental specialty concerned with the making of artificial replacements for missing parts of the mouth and jaw -- called also prosthetic dentistry, prosthodontia.
• Retrognathia - A posteriorly positioned mandible, or lower jaw; most common problem for which orthognathic surgery is performed (sometimes referred to over bite).
• Sibilant sound distortions - Children with repaired clefts that involve the gum ridge (alveolar ridge) will distort the sounds "s, z, ch, j (as in “judge”), sh, zh." These sounds are called "sibilants."
• Velopharyngeal distortion - Pertaining to the soft palate (velum palatinum) and the pharyngeal walls.
The medical policy was created in May 2009 and based on scientific literature. This medical policy has been regularly updated with searches of the MedLine database with the most recent on March 14, 2017. The following is a summary of key literature and practice guidelines to date.
Studies demonstrate the altered speech production may be associated with facial skeletal deformities, the most common impairment of which is a distortion within the sibilant sound class. (2) Such studies also demonstrate the beneficial effects of orthognathic surgery on speech production, documenting improvement in a high percentage of patients after the correction of abnormal jaw relationships. In the age of information, the ability to accurately communicate with an articulate speech pattern is of great importance. Prior to surgery, speech evaluation should be obtained to demonstrate the nature of the problem and to determine if improvement can be expected.” A 2004 study by, Janulewicz et al., (3) “…confirmed previous findings that patients with clefts of the lip and palate or palate alone are predisposed to velopharyngeal function alteration after maxillary advancement, particularly with borderline function preoperatively. However, the results show that surgical correction of skeletal relationships and occlusion may translate into improvement in certain aspects of speech disorders.”
Risk factors for postoperative complications are many, including underlying medical condition, bleeding dyscrasias, factors that affect normal wound healing, a patient with unrealistic expectations, a noncompliant patient, and patients with poor oral hygiene. (1) This was confirmed in a systematic review reported on by Jadrsejewski et al. in 2015. (7) A total of 1924 publications were identified, yielding the 44 articles for the final analysis. A large number of varied complications were identified and associated with orthognathic surgery. Prevention and correct patient selection should reduce complications and increase the safety of orthognathic procedures. The outcome of the surgical procedure depends on many factors before, during, and after treatment, as the success of each phase of treatment depends on the success of the preceding phase. There exists a potential for relapse even in the most ideal situations and with the use of rigid internal fixation. Soft tissue forces directed against the vector of the surgical movement are significant. Generally, the most stable moves are superior and posterior maxillary impactions and mandibular setback. Maxillary and mandibular advancements are inherently less stable. (4-6) Given these factors, the decision to proceed with orthognathic surgery should be made with caution, and should be made to correct functional impairment.
Surgery-first has emerged as advantageous protocol to shorten treatment times and provide for immediate esthetic improvements. A 2016 study from Peira-Guijarro et al. conducted a systematic review of surgery-first treatment for 15 years. (8) The authors identified 179 publications, yielding the final 11 articles meeting the strict selection criteria determined by the study group. In total, 295 patients were managed with surgery-first approach. A Class III malocclusion was the most prevalent underlying malocclusion (84.7%). Total treatment duration was shorter in the surgery-first patients than in those treated conventionally. Similarities were documented within the articles regarding patient selection criteria, inclusion or exclusion, orthodontic and surgery protocols, and the stability of results. The conclusion reported by the authors, studies show satisfactory outcomes and high acceptance. However, the surgery-first results should be interpreted with caution because of the wide varieties of study designs and outcome variables, reporting bias, and lack of prospective long-term follow-ups. The results did not include whether study designs followed the accepted patient selection criteria widely followed from the American Association of Oral and Maxillofacial Surgeons.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in March 2017 found the clinical studies listed below in Table 1.
Table 1. Summary of Key Trials (9)
Distraction Versus Orthognathic Surgery – Which One is Better for Cleft Palate Patients
(results not available)
Clinical Effectiveness of Late Maxillary Protraction for Cleft Lip and Palate
NCT: national clinical trial.
Practice Guidelines and Position Statements
American Association of Oral and Maxillofacial Surgeons (AAOMS)
The AAOMS has published Criteria for Orthognathic Surgery (2015), which relate verifiable clinical measurements to significant facial skeletal deformities. (10) The guidelines state, “Prior to surgical treatment, such patients should be properly evaluated to determine the cause and site of their disorder with appropriate non-surgical treatment attempted when indicated. The AAOMS considers the following as indications for orthognathic surgery:
A. “Anteroposterior discrepancies: established norm=2mm
1. Maxillary/Mandibular incisor relationship:
a. Horizontal overjet of 5 mm or more,
b. Horizontal overjet of zero to a negative value.
2. Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm 0 to 1 mm).
3. These values represent two or more standard deviations from published norms.”
B. “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:
a. No vertical overlap of anterior teeth.
b. Unilateral or bilateral posterior open bite greater than 2mm.
c. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch.
d. Supraeruption of a dentoalveolar segment due to lack of occlusion.”
C. “Transverse discrepancies:
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 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth.”
1. Anteroposterior, transverse or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry.”
The 2015 AAOMS criteria also has the following position on orthognathic surgery for facial skeletal discrepancies associated with documented speech impairments: “Abnormal jaw relationships affect many of the structures involved in the production of speech, including the position of the lips, tongue and soft palate. Studies demonstrate that altered speech production may be associated with facial skeletal deformities, the most common impairment of which is distortion within the sibilant sound class.” (7)
The American Association of Oral and Maxillofacial Surgeons Guidelines: Criteria for Orthognathic Surgery and Evaluation of Impairment of the Oral and Maxillofacial Region, has been the criterion standard and widely adopted for patient surgical selection. The literature is sufficient to determine the net health outcomes for orthognathic surgery for selected patients when dental and/or orthodontic treatment is prevented due to the severity of the impairments and deformities. Therefore, orthognathic surgery is considered medically necessary when meeting specific criteria.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21230, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215
[Deleted 7/2015: S8262]
ICD-9 Diagnosis Codes
Refer to the ICD-9-CM manual
ICD-9 Procedure Codes
Refer to the ICD-9-CM manual
ICD-10 Diagnosis Codes
Refer to the ICD-10-CM manual
ICD-10 Procedure Codes
Refer to the ICD-10-CM manual
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. Patel KP, Morris DA, et al. Craniofacial, Orthognathic Surgery. eMedicine Specialties. Updated Oct 05, 2016. Available at <http://www.emedicine.com> (accessed – 2017 March 14).
2. Vallino LD. Speech, velopharyngeal function, and hearing before and after orthognathic surgery. J Oral Maxillofac Surg. Dec 1990; 48(12):1274-81; discussion 1281-2. PMID 2231145
3. Janulewicz J, Costello BJ, Buckley MJ, et al. The effects of Le Fort I osteomoties on velopharyngeal and speech functions in cleft patients. J Oral Maxillofac Surg. Mar 2004; 62(3):308-14. PMID 15015163
4. Throckmorton GS, Ellis E 3rd, Sinn DP. Functional characteristics of retrognathic patients before and after mandibular advancement surgery. J Oral Maxillofac Surg. Aug 1995; 53(8):898-908; discussion 908-9. PMID 7629618
5. Throckmorton GS, Buschang PH, Ellis E 3rd. Morphologic and biomechanical determinants in the selection of orthognathic surgery procedures. J Oral Maxillofac Surg. Sep 1999; 57(9):1044-56; discussion 1056-7. PMID 10484105
6. Proffit WR, White RP Jr. Who needs surgical-orthodontic treatment? Int J Adult Orthodon Orthognath Surg. 1990; 5(2):81-9. PMID 2074379
7. Jadrzejewski M, Smekta T, Sporniak-Tutak K, et al. Preoperative, intraoperative, and postoperative complications in orthognathic surgery: a systematic review. Clin Oral Investig. Jun 2015; 19(5):969-77. PMID 25804886
8. Hernandez-Alfaro F, Guijarro-Martinez R. On a definition of the appropriate timing for surgical intervention in orthognathic surgery. Int J Oral Maxillofac Surg. Jul 2014; 43(7):846-55. PMID 24631424
9. ClinicalTrials.gov – Orthognathic Surgery. (2017 March 14). Available at <https://clinicaltrials.gov> (accessed – 2017 March 15)
10. The American Association of Oral and Maxillofacial Surgeons. Criteria for orthognathic surgery (2015). Available at <http://www.aaoms.org> (accessed - 2017 March 14).
|6/15/2018||Reviewed. No changes.|
|5/15/2017||Document updated with literature review. The following changes were made to Coverage: 1) Removed criteria statement requiring malnutrition and 2) Added coverage statement considering genioplasty to be cosmetic when performed alone or in conjunction with other orthognathic surgical procedures, along with exception note referring to SUR717.001.|
|10/15/2016||Document updated with literature review. The following criteria was added to coverage, “malnutrition, such as significant weight loss, failure to thrive,” has been moved from being included in the following criteria statement “under surgery is proposed for correction skeletal deformities when it is documented that… facial skeletal deformities are contributing to significant functional impairment…” to a separate criteria statement.|
|5/15/2015||Reviewed. No changes.|
|1/1/2015||Document updated with literature review. Coverage unchanged.|
|8/1/2012||Literature reviewed. No change|
|5/15/2009||New medical document|