Orthognathic Surgery
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This policy governs medical coverage and prior authorization requirements for orthognathic (jaw) surgery for Medicare Advantage and commercial members of Blue Cross & Blue Shield of Rhode Island, specifying documentation, coverage criteria, and covered CPT codes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Orthognathic Surgery
Medical necessity criteria for orthognathic surgery
Covered when ALL of the following are met
Applies to Medicare Advantage and Commercial Products; prior authorization required for Medicare Advantage and recommended for Commercial via the payer's online tool.
Published norms per Epker, Fish & Stella and Proffit, Sarver & White.
Under Blue Cross & Blue Shield of Rhode Island, procedures performed solely to improve appearance when done in conjunction with orthognathic surgery are not covered. Examples of these non-covered cosmetic procedures include rhinoplasty for nose reshaping, osteoplasty for facial bone reductions performed for cosmetic reasons, genioplasty to improve the appearance of the chin, and rhytidectomy (face‑lift).
Services determined to be not medically necessary or services which are non‑covered benefits are excluded from payment under this policy. Benefits and eligibility are determined by the member’s subscriber agreement, member certificate, or employer agreement; providers should verify member‑specific benefits via the provider call center. If services are determined to be not medically necessary (or are non‑covered benefits), the provider may not charge the member unless the member was informed and provided written agreement in advance to assume financial responsibility.
Orthognathic surgery performed in the absence of significant physical functional impairment is considered cosmetic and not medically necessary. The procedure should be reserved for deformities that produce functional problems (for example, impairments of chewing, swallowing, speech, or pain) that cannot be adequately treated with dental or orthodontic therapies alone.
If services are determined to be not medically necessary, they may not be paid by Blue Cross & Blue Shield of Rhode Island and the provider may not bill the member unless the member was informed and provided written agreement to accept financial responsibility prior to receiving the service. The fee for non‑covered preoperative and postoperative phases is the responsibility of the patient and should be discussed by the surgeon with the patient prior to surgery.
Coding and Objective Thresholds
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, without bone graft. |
| 21142 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft. |
| 21143 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft. |
| 21145 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts). |
| 21146 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts). |
| 21147 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts). |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion. |
| 21151 | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts). |
| 21154 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I. |
| 21155 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I. |
Provider Requirements, Prior Authorization, and Billing Risks
Obtain prior authorization via payer online tool
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products; it must be obtained via the payer's online tool for participating providers (see Related Policies).
- Required for Medicare Advantage; recommended for Commercial.
- Must be obtained via the payer's online/web-based tool for participating providers.
Use the web‑based preauthorization tool and related policy
Follow the payer's separate “Preauthorization via Web‑Based Tool for Procedures” policy and use the online tool referenced in Related Policies to submit authorization requests.
- Providers must follow the related web‑based preauthorization policy when submitting requests through the online tool.
Preoperative and non‑surgical phases are patient financial responsibility
Pre‑operative phases (Phase 1 monitoring/work‑up, Phase 2 pre‑operative records/stabilization) and Phase 4 post‑op after 90 days are not covered benefits; fees for these phases are the patient’s responsibility and must be discussed prior to surgery.
- Phase 1 (pre‑operative monitoring/work‑up) is noncovered and may last 1–3 years.
- Phase 2 (pre‑op records/stabilization) is noncovered; activities include model surgery, tracings, and fixation device fabrication.
- Phase 4 (post‑op after 90 days) is noncovered; monitoring for 1–3 years is the patient’s responsibility.
- Surgeon must discuss fees for phases 1, 2, and 4 with the patient prior to surgery.
Provide required presurgical films, photos and documentation within 6 months
Submit required presurgical documentation completed within six (6) months of case submission: frontal and profile smiling photos; presurgical frontal and lateral cephalograms; panoramic film; consultation letter with diagnostic/treatment plan; and prediction tracing using the presurgical cephalogram.
- Frontal and profile smiling photographs.
- Presurgical frontal and lateral cephalograms.
- Panoramic film.
- Consultation letter (diagnosis and treatment plan).
- Prediction tracing using the presurgical cephalogram.
- All documentation must be completed within six (6) months of submitting the case for review.
Verify member eligibility and benefits
Verify member-specific benefits and eligibility before scheduling or providing services; benefits are determined by the member's subscriber certificate, member agreement, and/or employer agreement, which supersede this policy.
- For member‑specific coverage questions, call the provider call center.
- Subscriber agreement, member certificate, and employer agreement determine benefits and supersede this policy.
Risk of denial for missing prior authorization or incomplete documentation
Failure to obtain required prior authorization (for Medicare Advantage; recommended for commercial) or failure to provide the required presurgical documentation within six months may result in denial of coverage.
- Prior authorization is required for Medicare Advantage and recommended for Commercial; obtain via online tool.
- Incomplete or missing required documentation submitted outside the six‑month timeframe risks denial.
Do not bill member for non‑covered or not medically necessary services without written consent
If services are determined to be not medically necessary or are non‑covered benefits, they may not be paid and the provider may not charge the member unless the member was informed and provided written agreement in advance to continue at their own expense.
- Providers may not bill members for services determined not medically necessary unless the member was informed and agreed in writing in advance.
- Noncovered cosmetic procedures performed with orthognathic surgery (e.g., rhinoplasty, genioplasty, osteoplasty, rhytidectomy) are not paid by BCBSRI.
Background
Orthognathic surgery corrects abnormalities of the maxilla and/or mandible that produce dentoskeletal deformities and resultant functional impairment. It is indicated when the severity of the skeletal deformity results in significant functional impairment that cannot be adequately treated by dental or orthodontic services alone. Indications include anteroposterior, vertical, transverse discrepancies and asymmetries that meet established objective thresholds, and the procedure aims to normalize occlusion and improve function such as chewing, swallowing, speech, and relief of pain. Because of the complexity of planning and execution, orthognathic surgery typically requires comprehensive preoperative coordination with dental specialists and is performed by oral and maxillofacial or plastic and reconstructive surgeons.
Definitions and Published Norms
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