Archived Policies - Surgery
This policy is no longer scheduled for routine literature review and update.
NOTE: 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.
NOTE: For criteria for orthognathic surgery related to the temporomandibular joint (TMJ), see medical policy SUR705.010, Temporomandibular Joint (TMJ) Disorders (TMJD).
NOTE: 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 the following criteria are met:
1.) Surgery is proposed for correction skeletal deformities when it is documented that:
2.) Skeletal deformity falls under one of the following categories:
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:
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.
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.
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.
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:
Dental anatomic terms
Upper and lower arch dentition
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.
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.
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.
The American Association of Oral and Maxillofacial Surgeons (AAOMS) has published Criteria for Orthognathic Surgery (2008), which relate verifiable clinical measurements to significant facial skeletal deformities:
The 2008 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 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. 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. “…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. In addition, preoperative examination and evaluation are critical aspects of orthognathic surgery. 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. Given these factors, the decision to proceed with orthognathic surgery should be made with caution, and should be made to correct functional impairment.
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, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21110, 21230
ICD-9 Diagnosis Codes
Refer to the ICD-9-CM Manual
ICD-9 Procedure Codes
ICD-10 Diagnosis Codes
Refer to the ICD-9-CM Manual
ICD-10 Procedure Codes
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>.
Proffit WR, White RP Jr. Who needs surgical-orthodontic treatment? Int J Adult Orthodon Orthognath Surg 1990; 5(2):81-9.
Vallino LD. Speech, velopharyngeal function, and hearing before and after orthognathic surgery.
J Oral Maxillofac Surg 1990 Dec;48(12):1274-81; discussion 1281-2.
Throckmorton GS, Ellis E 3rd, Sinn DP. Functional characteristics of retrognathic patients before and after mandibular advancement surgery. J Oral Maxillofac Surg. 1995 Aug; 53(8):898-908; discussion 908-9.
Throckmorton GS, Buschang PH, Ellis E 3rd. Morphologic and biomechanical determinants in the selection of orthognathic surgery procedures. J Oral Maxillofac Surg 1999 Sep; 57(9):1044-56; discussion 1056-7.
Janulewicz, J., Costello, B.J., et al. The effects of Le Fort I osteomoties on velopharyngeal and speech functions in cleft patients. J Oral Maxillofac Surg (2004 March) 62(3):308-14.Patel, eMedicine - K.P., and A. Gassman. Craniofacial, Orthognathic Surgery. eMedicine Specialties (2006 September 6). Available at <http://www.emedicine.com> (accessed 2008 December 1).
The American Association of Oral and Maxillofacial Surgeons. Criteria for orthognathic surgery. Rosemont, IL 2008 Available at <http://www.aaoms.org> (accessed 2008 December 1).
The American Association of Oral and Maxillofacial Surgeons. Guidelines to the evaluation of impairment of the oral and maxollifacial region. Rosemont, IL 2008 Available at <http://www.aaoms.org> (accessed June 2012).
8/1/2012 Literature reviewed. No change
5/15/2009 New medical document