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CurrentAmbetter NevadaPolicy CP.MP.202

Orthognathic Surgery (PDF)

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Defines medical necessity criteria and non-covered indications for orthognathic (jaw) surgery, lists relevant CPT codes for procedures, and provides background and coding implications for Ambetter Nevada (Centene-affiliated) health plans.

Policy Summary

PayerAmbetter Nevada

PolicyOrthognathic Surgery (PDF)

Policy CodePolicy CP.MP.202

Change TypeRevisions and coding updates

Effective Date

Last ReviewAug 25, 2024

Next Review Date

Key ActionProviders must document one of the specified skeletal deformities with the exact measurement thresholds (e.g., incisor overjet ≥5 mm, molar discrepancy ≥4 mm, transverse or vertical deviations ≥2 SD, asymmetry >3 mm).

SourceLink

POLICY UPDATE CHANGES

Updated I.A.1.b. from greater than 4 mm to 4 mm or greater and I.A.1.a. from >5mm to ≥5mm in earlier revisions; multiple annual reviews with minor verbiage updates.

Added CPT codes 21120, 21121, 21122, 21123, 21159, and 21160 during prior updates.

Updated I.B.5.a to 'Intolerant to or failed a trial of PAP' and I.B.5.b to 'Has failed....less invasive surgical procedures.'

≥5Incisor overjet threshold (mm)

≥4Molar discrepancy threshold (mm)

>=2 SDVertical/transverse deviation threshold

>3Asymmetry threshold (mm)

Coverage Summary

Background: Orthognathic surgery corrects maxillary and/or mandibular skeletal abnormalities that cause functional impairments such as difficulties with eating/chewing, speech abnormalities, or TMJ dysfunction. Procedures may be considered medically necessary when significant functional impairment is present and the policy measurement thresholds are met (for example, incisor overjet ≥ 5 mm, molar AP discrepancy ≥ 4 mm, transverse/vertical deviations ≥ 2 standard deviations, or asymmetry > 3 mm).

Scope: This policy applies to Ambetter Nevada / Centene-affiliated health plans and defines coverage stance as covered_with_criteria, outlining the specific clinical and measurement criteria that must be documented to determine medical necessity for orthognathic (jaw) surgery.

Thresholds and Required Duration

Incisor overjet≥ 5 mm

Molar discrepancy (anteroposterior)≥ 4 mm

Vertical/transverse deviation≥ 2 standard deviations from published norms

Palatal cusp to mandibular fossa discrepancy (bilateral)

Policy Summary

PayerAmbetter Nevada

PolicyOrthognathic Surgery (PDF)

Policy CodePolicy CP.MP.202

Change TypeRevisions and coding updates

Effective Date

Last ReviewAug 25, 2024

Next Review Date

SourceLink

On This Page

Coding

Referenced CPT codes (informational; inclusion/exclusion does not guarantee coverage)CPT

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; 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.
21143	Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft.

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Provider Actions

Documentation Required

Document skeletal deformity and measurements

Providers must document the presence of one of the specified skeletal deformities using the exact measurement thresholds called out in the policy. Examples include: incisor overjet ≥ 5 mm (or zero to negative value), maxillary/mandibular anteroposterior molar relationship discrepancy ≥ 4 mm, vertical or transverse skeletal discrepancies ≥ 2 standard deviations from published norms, total bilateral palatal cusp to mandibular fossa discrepancy ≥ 4 mm (or unilateral ≥ 3 mm), and asymmetries > 3 mm. Also document specific vertical findings (open bite with no anterior vertical overlap or posterior open bite > 2 mm; deep overbite with impingement of palatal soft tissue; supraeruption of a dentoalveolar segment).

Documentation Required

Document functional impairment

Document at least one qualifying functional impairment linked to the skeletal deformity. Acceptable documentation includes notes showing persistent mastication and swallowing difficulties after exclusion of neurologic/metabolic causes, evidence of malnutrition/significant weight loss/failure-to-thrive secondary to the deformity, a speech dysfunction assessment and determination by a speech-language pathologist, myofascial pain persisting for ≥ 6 months despite compliant conservative therapy, or obstructive sleep apnea documented by polysomnogram with required additional documentation of PAP trial results and surgical candidacy as noted elsewhere in the policy.

Documentation Required

Conservative therapy documentation for myofascial pain

For myofascial pain related to facial skeletal deformity, document at least six months of compliant conservative therapy prior to consideration of orthognathic surgery. The policy explicitly requires persistence of myofascial pain for at least six months despite compliant conservative treatment.

Physical therapy
Splints

Documentation Required

Polysomnogram and PAP trial documentation for OSA-related cases

For airway obstruction/obstructive sleep apnea indications, document the polysomnogram (PSG) demonstrating OSA and provide evidence of intolerance to or failure of a PAP trial. Also document failure of, or ineligibility for, less invasive surgical procedures when applicable.

Billing Rule

Use referenced CPT codes for claims

Report the referenced CPT codes when submitting claims for orthognathic procedures. These codes are provided for informational purposes and inclusion or exclusion does not guarantee coverage — providers should reference the most up-to-date coding guidance prior to claim submission.

Background

Orthognathic surgery is performed to correct abnormalities of the mandible, maxilla, or both when skeletal discrepancies cause functional problems that cannot be managed by dental treatment alone.

Typical operative approach: an osteotomy is made in the affected jaw with repositioning of bone segments and stabilization using plates, screws, wires, and/or intermaxillary fixation; bone grafts (autograft/allograft) or alloplastic implants may be used when bone is deficient.

Setting and anesthesia: orthognathic procedures are generally performed on an inpatient basis under general anesthesia.

Clinical rationale: significant dentofacial skeletal deformities disrupt the normal maxillomandibular relationship and can lead to diminished bite force, restricted mandibular movement, abnormal chewing, swallowing and speech dysfunction, malocclusion, and TMJ problems—correction of the underlying skeletal deformity aims to restore function.

Revision History

10/21revised

Updated I.A.1.a from >5 mm to ≥5 mm and I.A.1.b from >4 mm to ≥4 mm; added 'or irritation of buccal or lingual soft tissues of the opposing arch' to I.A.2.c; specified 'maxillary' palatal cusp in I.A.3.b; added CPT codes 21120, 21121, 21122, 21123, 21159, and 21160; removed CPT codes 21248 and 21249.

10/23revised

Annual review: Updated Criteria I.A.1.b from greater than 4 mm to 4 mm or greater; updated I.A.2.c to include irritation of buccal or lingual soft tissues of the opposing arch; added clarifying language to I.A.3.b; added CPT codes 21248 and 21249.

08/24revised

Annual review: Updated I.A.1.b wording to 4 mm or greater; updated I.A.2.c to include irritation of buccal or lingual soft tissues and clarified I.A.3.b; minor verbiage updates; references reviewed and updated.

08/25revisedLatest

Annual review: Minor verbiage updates with no impact to criteria; updated I.A.2.c wording to 'with impingement of palatal soft tissue'; updated I.B.5.a to 'Intolerant to or failed a trial of PAP' and I.B.5.b to 'Has failed or is not a candidate for less invasive surgical procedures.'

Orthognathic Surgery (PDF)

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Coverage Summary

Medically Necessary Criteria

Not Medically Necessary / Exclusions

Coding

Provider Actions

Background

Definitions

Revision History