Obtain prior authorization via online tool

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products; use the payer’s online authorization tool (effective 7/1/2026 the online tool contains the medical criteria sources for codes in the Coding Section).

• Medicare Advantage: prior authorization required via the online tool.
• Commercial Products: prior authorization recommended via the online tool.
• Effective 7/1/2026: medical criteria moved to the Prior Authorization online tool.

Include LeFort III CPT codes when requesting authorization

The policy references LeFort III reconstruction CPTs used for midface reconstruction that include bone grafting and autograft harvest; list of relevant CPTs is provided in the Coding section and should be included in authorization submissions.

• Key CPTs referenced for LeFort III procedures include 21154, 21155, 21159, 21160.
• Descriptions explicitly note requiring bone grafts and include obtaining autografts.
• Include these CPTs when preparing prior authorization requests for midface reconstruction.

Reference listed procedure CPTs on submissions

This section lists CPT procedure codes for midface reconstruction and related osteotomies; providers must reference these CPTs in claims and authorization requests even though explicit authorization rules are not stated in these chunks.

• CPTs shown repeatedly include 21155, 21159, 21160, 21188.
• The policy text enumerates procedure descriptors alongside CPT codes — cite the exact CPTs on submissions.

Use exact CPT for LeFort types and mandibular rami osteotomies

The document lists CPTs for LeFort types and mandibular rami osteotomy (with and without bone graft); include the specific CPT code(s) that match the operative procedure in any authorization or claim.

• Mandibular rami codes include 21193 (without bone graft) and 21194 (with bone graft).
• LeFort-related CPTs include 21154, 21155, 21159, 21160 and related osteotomy codes such as 21188.

Confirm authorization requirements under related prior authorization policy

Prior authorization for orthognathic reconstruction codes is referenced for Medicare Advantage and Commercial Products; consult and comply with the Prior Authorization of Services, Treatments or Procedures policy and use the online tool.

• Policy states prior authorization is referenced for reconstruction midface and mandibular rami codes under Medicare Advantage and Commercial Products.
• Related internal policy 'Prior Authorization of Services, Treatments or Procedures' applies — consult it as needed.

Consult online tool and prior authorization policy for authoritative instructions

Failure to find explicit authorization or denial instructions in these chunks indicates the provider must consult the online authorization tool and related prior authorization policy for authoritative instructions rather than relying on the CPT listings in this excerpt.

• The excerpts repeat CPT descriptors without authorization/denial instructions.
• Consult the Prior Authorization of Services, Treatments or Procedures policy and the online tool for authoritative instructions.

Do not assume per-code authorization rules from this CPT list alone

This excerpt lists numerous CPT procedure codes but does not explicitly state prior authorization requirements for each listed code; providers must rely on the online authorization tool and related prior authorization policy for definitive requirements.

• The policy text enumerates CPTs (e.g., 21159–21196) but in these chunks does not declare per-code authorization rules.
• Use the online tool to determine whether a specific CPT requires prior authorization.

Follow the related Prior Authorization policy and online tool

The related policy 'Prior Authorization of Services, Treatments or Procedures' applies to these services; if the online tool shows authorization is required, obtain authorization before providing services to Medicare Advantage members.

• Providers should consult the Prior Authorization of Services, Treatments or Procedures policy for applicability.
• For Medicare Advantage members, failure to obtain required authorization may result in denial or nonpayment.

Submit authorization requests via the online authorization tool

Participating providers must use the payer’s online authorization tool to meet medical criteria and prior authorization requirements; submit requests through that tool rather than relying on the document text.

• Online tool is the source of medical criteria effective 7/1/2026.
• Use the participating provider online authorization workflow for submissions.

Document autograft harvesting when performed

Procedure descriptions explicitly state that LeFort III reconstruction may include obtaining autografts for bone grafting; document and support autograft harvesting in operative reports when relevant to CPTs that include autograft language.

• CPT descriptors repeat “includes obtaining autografts” for codes such as 21154, 21155, 21159, 21160 and 21188.
• If autograft harvest is performed, ensure operative notes record the autograft procedure to support CPTs that include autograft language.

No additional submission form specified in this excerpt

No specific documentation submission requirements or forms are specified in the provided text; however, authorization and coverage decisions rely on the online tool and related policies rather than additional document-specific submission instructions.

• Chunks do not provide explicit supporting-document checklists or submission forms.
• Rely on the online authorization tool and related prior authorization policy for documentation guidance.

Match operative details to CPT descriptors on submissions

The policy lists procedure/CPT descriptors and operative contexts (LeFort I/III, forehead advancement, mandibular rami osteotomy); when seeking authorization or filing claims, include operative details that map the procedure performed to the CPT descriptor.

• CPT descriptors include context such as “with forehead advancement (mono bloc)” and “with or without LeFort I.”
• Include operative details (e.g., whether forehead advancement or bone grafting occurred) in the submission.

Include operative details that justify reconstruction and bone graft CPTs

Operative documentation should include details that justify use of reconstruction and bone graft CPT codes (for example: whether LeFort III was performed, whether LeFort I was combined, forehead advancement (mono bloc), and whether autografts were obtained).

• Record whether the procedure was LeFort I, LeFort III (extracranial or extra/intracranial), or other midface osteotomy.
• Document if forehead advancement (mono bloc) was performed and whether bone grafting or autograft harvest occurred to support CPTs that include those elements.

Retain complete operative records; use online tool to verify required documentation

The excerpt does not include explicit documentation requirements for authorization; providers should use the online authorization tool for criteria and retain detailed operative notes to support coding and medical necessity determinations.

• Chunks explicitly lack stated documentation requirements — retain full operative reports.
• Use the online tool to determine what documentation is required for authorization decisions.

Verify eligibility and benefits with provider call center

Verify member-specific eligibility and benefits before scheduling procedures by contacting the provider call center; benefits and coverage are determined by the member’s subscriber agreement or employer agreement.

• Contact the provider call center for member-specific benefits and coverage decisions.
• Benefits are determined by the member’s subscriber agreement, member certificate, or employer agreement and may vary by contract.

Prior authorization failure may lead to denial/nonpayment

Failure to obtain prior authorization via the online tool when required for Medicare Advantage members may lead to denial or nonpayment; obtain required authorization before providing services to Medicare Advantage members.

• The policy states prior authorization is required for Medicare Advantage and that failure to obtain it may result in denial or nonpayment.
• Obtain authorization in advance for Medicare Advantage patients as indicated by the online tool.

No explicit per-code authorization/denial rules in CPT listings

The chunks do not list explicit authorization or denial triggers within the CPT listings; absence of per-code rules in these excerpts means rely on the online authorization tool for authorization triggers and denial criteria.

• These sections primarily enumerate CPTs and procedural descriptors and do not provide explicit per-code authorization or denial rules.
• Use the online authorization tool (and related policy) to identify authorization triggers and denial criteria.

Risk of denial for incomplete documentation linking CPTs to indications

Absent complete documentation linking the billed CPTs to medically necessary indications (as determined by the online tool or other policy sections), claims billed using the listed CPT codes may be denied; ensure clinical indications and operative details are documented.

• The policy warns claims may be denied if documentation does not link procedures to medically necessary indications.
• Provide thorough clinical indication documentation and operative details to support medical necessity for listed CPTs.

Member billing risk — obtain written consent before billing member for non‑covered services

If services are determined to be not medically necessary or otherwise non‑covered, providers may not bill members unless prior written consent has been obtained; confirm coverage and obtain written consent if member will be financially responsible.

• Policy states providers may not charge the member for services determined to not be medically necessary unless the member agreed in writing in advance.
• Obtain and document prior written consent if the member will accept financial responsibility for non-covered services.