Prior authorization required for covered CPT codes

Prior authorization is required to confirm that selection criteria are met for the covered CPT codes listed (e.g., 20692, 20693, 20694, 20696, 20697) before payment will be made.

• Submit prior authorization to verify medical necessity per the policy’s covered-indication criteria (congenital deformity with functional impairment).
• Include planned CPT codes (e.g., 20692–20697) on the authorization request.

Clinical Policy Bulletin note on prior authorization and plan scope

Clinical Policy Bulletins are developed to assist in administering plan benefits and provide a general, partial description of plan coverage; they do not constitute a contract and do not specify every plan’s prior authorization rules.

• Use the CPB to guide benefit administration but verify specific prior authorization requirements with the member’s plan.
• Participating providers remain responsible for medical advice and treatment; CPBs may be updated and are subject to change.

Prior authorization — related Aetna resources

This section provides links to Aetna resources (glossary, mobile app, program provisions, legal notices, privacy center, state directory) but does not itself specify additional prior authorization requirements.

• Use the listed Aetna resources to find plan provisions and member-specific benefit details that may include prior authorization processes.
• Links: Glossary; Aetna Mobile App; Program Provisions; Legal Notices; Privacy Center; State Directory.

Conventional alternatives expected before distraction osteogenesis

When less extensive corrective options (for example, conventional orthognathic surgery or grafting techniques) can achieve the needed result for smaller deformities, those conventional therapies are expected before distraction osteogenesis.

• Orthognathic surgery is able to correct smaller mandibular deformities; distraction is reserved when greater than 10 mm lengthening or when superior results are achievable only with distraction.
• AAOMS guidance: use distraction primarily when it achieves superior results compared with conventional techniques.

Required clinical documentation for authorization

Providers must document the congenital diagnosis and the functional impairment showing that distraction osteogenesis is uniquely indicated, and include the surgical plan (device type — internal vs external — and anticipated distraction length/rate).

• Document the specific congenital indication (eg, Pruzansky Grade I/IIa hemifacial microsomia, severe micrognathia with airway obstruction, mandibular deficiency >10 mm).
• Include planned device type (internal or external), anticipated distraction length, and planned distraction rate in the clinical justification.

Follow plan benefit documentation and program provisions

Providers should follow the member’s plan benefit documentation and program provisions referenced by Aetna; this CPB is a partial, general description and does not guarantee coverage.

• Verify member-specific benefits and any exclusions (for example, dental implant or orthodontic exclusions) in the plan’s program provisions before scheduling.
• Use Aetna’s program provisions and plan disclosures to determine benefit applicability.

Links to Aetna member/provider resources

Aetna provides links to resources for members and providers (glossary, mobile app, program provisions, legal notices, privacy center, state directory) for reference when preparing authorizations and verifying benefits.

• Key resources: Aetna Glossary; Aetna Mobile App; Program Provisions; Legal Notices; Privacy Center; State Directory.
• Use these links to locate plan disclosures, nondiscrimination notices, and member-specific information that may affect coverage adjudication.

Triggers for claim denial

Requests for distraction osteogenesis for acquired craniofacial defects, obstructive sleep apnea, preparation for dental implants/orthodontic care when excluded by the plan, or procedures billed with listed not-covered codes are subject to denial.

• Examples of not-covered CPT/HCPCS/ICD-10 codes include 0232T, 0481T, S9055 and ICD-10 codes such as G47.33, M95.2, Z41.1.
• Confirm the indication is one of the congenital indications with functional impairment and that the procedure and diagnosis codes used are covered per the CPB before billing.

CPB administrative disclaimer affecting coverage adjudication

Clinical Policy Bulletins are intended to assist with administering plan benefits and do not constitute a contract; participating providers remain independent contractors and are responsible for treatment decisions.

• Do not treat the CPB as a guarantee of coverage—verify member benefits and obtain required authorizations.
• Be aware CPBs may be updated and are a partial description of plan benefits.

External links disclaimer

Aetna is not responsible for the content, accuracy, or privacy practices of non‑Aetna sites linked from the policy; leaving the Aetna site may affect reliance on external information.

• When using external links (eg, for manufacturer or clinical resources), confirm details directly with the source and with Aetna plan provisions as needed.