Benefits for orthognathic surgery may vary between groups and contracts. Refer to the member's Evidence of Coverage, Subscriber Agreement, or Member Certificate for the applicable surgical benefits and coverage determinations; those documents supersede this policy for benefit limits and member financial responsibility. Providers should verify member-specific benefits and eligibility by contacting the payer's provider call center prior to authorization or scheduling. Effective 7/1/2026, the detailed medical criteria previously in this policy are no longer maintained here and have been moved to the payer's online Prior Authorization of Services, Treatments or Procedures tool; use that tool for medical necessity requirements and supporting documentation guidance when requesting authorization.

Coverage of services described in the Coding Section depends on meeting the medical criteria in the online authorization tool for participating providers. When submitting an authorization request, include documentation demonstrating that the online-tool medical criteria were satisfied; failure to obtain any required prior authorization may result in denial of coverage or payment liability to the provider or member.

The extracted policy text does not list explicit exclusions to coverage for the procedures described in the Coding Section. The document's content in these sections is limited to procedure and CPT code listings (midface reconstruction, LeFort osteotomies, mandibular rami osteotomies, sagittal split procedures, and related grafting/internal fixation variants) and does not identify specific conditions or scenarios that are excluded from coverage.

Although no formal exclusions are stated here, providers must still confirm coverage and any contract-specific exclusions in the member's Evidence of Coverage or Subscriber Agreement. Also, some services that are medically necessary may nevertheless be non‑covered benefits under a member's plan; such situations are governed by the member's benefit documents.

The policy excerpts do not enumerate explicit exclusions for mandibular rami procedures. The code descriptions distinguish procedures performed without bone graft (e.g., reconstruction of mandibular rami via horizontal, vertical, C, or L osteotomy without bone graft) from those with bone graft (codes that include obtaining graft/autografts), but the text does not state that either approach is excluded from coverage.

When coding and submitting claims, ensure the CPT selection accurately reflects whether a bone graft (including autograft harvest) and/or internal rigid fixation were performed, as code choice affects both authorization review and claims processing.

No explicit exclusions are stated in the sections containing the procedure code listings for midface reconstruction, LeFort osteotomies, and mandibular reconstruction. The document provides CPT descriptors and repeated code listings but does not contain language that designates specific diagnoses, indications, or circumstances as excluded.

Providers should assume that coverage determinations require review under the online prior authorization criteria and that absence of an exclusion in these excerpts does not guarantee payment without meeting the applicable medical criteria.

The sections comprised primarily of CPT procedure listings do not state explicit exclusion conditions; they are focused on enumerating codes used for midface and mandibular reconstructive procedures (including LeFort I/III, other midface osteotomies, mandibular ramus osteotomies, sagittal split procedures, and segmental osteotomies). There are no additional exclusion statements in these code‑listing passages.

For authorization and billing purposes, use the listed CPT codes that most precisely describe the operative procedure performed and consult the online authorization tool and related Prior Authorization policy to determine whether prior approval is required.

The code lists in these chunks do not include formal exclusion language; they present CPT codes and their brief descriptors for orthognathic and craniofacial procedures. However, the overall policy clarifies that some services, even if medically necessary, may be non‑covered under a member's subscriber or employer agreement and therefore not payable by the plan.

Always verify the member's benefits and any plan exclusions before providing services. If a service is determined to be not medically necessary or is a non‑covered benefit, providers may not bill the member unless the member was informed in advance and agreed in writing to self‑pay, per the policy guidance.

The document's procedure and CPT code sections do not present explicit coverage exclusions. Content is limited to listing CPT codes (for example, codes for mandibular rami osteotomies, sagittal split procedures, and midface osteotomies) and associated descriptors that note whether grafting or internal fixation was included.

Because the excerpts lack exclusion statements, providers should rely on the online prior authorization tool and the member's benefit documents to determine coverage. Incomplete or incorrect coding may lead to claim processing issues, so ensure documentation and code selection match the operative report (including whether bone grafts or internal fixation were performed).

The policy does not include separate sections listing coverage criteria or medical necessity rules within these excerpts; rather, it directs providers to the online Prior Authorization of Services, Treatments or Procedures tool for the operative medical criteria. Effective 7/1/2026, the prior medical criteria in this policy are no longer in use and providers must use the online authorization tool to determine medical necessity for services listed in the Coding Section.

In practice, the Coding Section enumerates the CPT procedures that fall under the scope of the policy (midface reconstruction, LeFort I/III, other midface osteotomies, mandibular rami reconstruction, sagittal split, segmental osteotomies, and related grafting/internal fixation variations). Medical necessity determinations for these codes require meeting the online‑tool criteria and providing supporting documentation with the authorization request.

Coverage of the listed procedures is contingent on meeting the medical criteria in the payer's online prior authorization tool. The policy states: “Covered when ALL of the following are met per online authorization tool”, and providers must include documentation that demonstrates compliance with those online criteria when submitting an authorization request.

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products through the online tool. Failure to obtain required prior authorization for Medicare Advantage members may result in denial of coverage; refer to the Prior Authorization of Services, Treatments or Procedures policy for specific authorization processes and any additional requirements.

Any services determined to be not medically necessary, or medically necessary services that are non‑covered benefits under a member's subscriber or employer agreement, are not guaranteed for payment by the plan. The policy instructs providers to confirm coverage through member benefit documents and to contact the provider call center for member‑specific eligibility and benefit information.

If a service is determined to be not medically necessary or a non‑covered benefit, providers may not collect payment from the member unless the member was informed in advance and provided written consent to self‑pay. The medical policy is informational and does not replace provider judgment or member benefit terms.

Operationally, the policy has a material change effective 7/1/2026: the medical criteria previously included in this document will be retired. Providers must use the payer's online Prior Authorization of Services, Treatments or Procedures tool for the medical criteria that govern coverage and prior authorization decisions for the CPT codes listed in the Coding Section.

Prior authorization remains required for Medicare Advantage Plans and recommended for Commercial Products. Providers should follow the online tool's guidance, submit the required documentation demonstrating the online‑tool criteria have been met, and consult the Prior Authorization policy referenced in this medical policy for process details.

Within the provided excerpts there are no explicit statements labeling procedures as not medically necessary. The policy instead centralizes medical necessity determinations in the online authorization tool and removes in‑document clinical criteria as of 7/1/2026.

Because the text does not list 'not medically necessary' conditions here, providers should assume that determinations of medical necessity (or lack thereof) will be made during the online authorization review and that services may be denied if they do not meet the online criteria.

These chunks do not include explicit statements that certain procedures are not medically necessary. The content focuses on procedure descriptions and CPT code listings (including midface reconstruction and mandibular procedures with or without bone grafts), with no in‑policy 'not medically necessary' language in the extracted text.

Providers should rely on the online prior authorization criteria to define the clinical situations that meet medical necessity; absence of 'not medically necessary' language in these sections does not imply universal coverage.

No 'not medically necessary' determinations appear in the code‑listing portions of the document. The policy's approach in these excerpts is to present procedure codes and descriptors; the clinical criteria that would support or deny medical necessity are accessed via the online authorization tool.

For cases where a service may be considered not medically necessary after review, note that such determinations affect payment and billing — follow the payer's guidance on member notification and possible written consent to bill the member if appropriate.

The code lists and procedure descriptions provided do not assert any items as 'not medically necessary'. Instead, the policy indicates that coverage decisions depend on meeting the online prior authorization tool criteria and on the member's benefit documents.

If a service is subsequently determined to be not medically necessary or is a non‑covered benefit, providers should follow payer instructions regarding notification and billing; do not assume coverage solely because a CPT code appears in the policy.

The document does not contain explicit 'not medically necessary' language in the provided excerpts. It emphasizes that medical necessity criteria have been relocated to the online authorization tool and that providers must meet those criteria to obtain coverage for services listed in the Coding Section.

Services determined not to be medically necessary are not guaranteed for payment and may not be charged to the member unless the member agreed in writing to self‑pay in advance. Always confirm authorization and benefit status prior to providing treatment.

Services captured by this policy may still be subject to benefit exclusions or limits specific to a member's contract. The policy repeatedly advises providers to consult the member's Evidence of Coverage, Subscriber Agreement, or Member Certificate for contract‑specific limitations, which take precedence over this medical policy.

Before scheduling or performing orthognathic procedures, verify member benefits and any applicable exclusions, preauthorization requirements, and prior authorization processes using the payer's provider call center or online systems.

Orthognathic surgery refers to the surgical correction of abnormalities of the maxilla and/or mandible. This policy indicates that specific medical criteria that previously appeared in the document have been removed and will be available through the payer's online prior authorization tool effective 7/1/2026.