CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Orthognathic Surgery Coverage Criteria

This policy governs medical coverage, documentation, and prior authorization requirements for orthognathic (jaw) surgery for Commercial products of Blue Cross Blue Shield - Rhode Island; it excludes BlueCHiP for Medicare members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOrthognathic Surgery Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2015

Next Review DateN/A

Key ActionObtain prior authorization for Phase 3 surgical procedures via the payer's web-based tool before scheduling surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Phase 3Surgical phase coverage

Phases 1–2, post-op >90dNon-covered perioperative phases

BlueCHiP not coveredMedicare exclusion

6 monthsRecency for records

~20Procedure codes

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Medical necessity clinical measurement criteria

Orthognathic surgery is considered medically necessary for Commercial products when ALL of the following are met:

Overall requirement

Anteroposterior criteria: One or more of the following: - Maxillary/mandibular incisor relationship: overjet of 5 mm or more; OR a 0 to negative incisor relationship (norm ~2 mm). - Maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm 0–1 mm).incisor overjet ≥5 mm or 0/negative; molar AP discrepancy ≥4 mm
Values represent ≈2 or more standard deviations from published norms (see source).
Vertical criteria: One or more of the following: - Presence of a vertical facial skeletal deformity ≥2 standard deviations from published norms for accepted skeletal landmarks. - Open bite (no vertical overlap of anterior teeth). - Overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch. - Unilateral or bilateral posterior open bite ≥2 mm greater. - Supraeruption of a dentoalveolar segment due to lack of occlusion.vertical deformity ≥2 SD from norms; posterior open bite ≥2 mm
Vertical criteria include functional problems such as soft-tissue impingement (see source).
Transverse criteria: One or more of the following: - Total bilateral maxillary cusp to mandibular fossa discrepancy ≥4 mm, OR unilateral discrepancy ≥3 mm (with normal axial inclination of posterior teeth). - Anteroposterior, transverse, or lateral asymmetries >3 mm with concomitant occlusal asymmetry.bilateral ≥4 mm or unilateral ≥3 mm; asymmetries >3 mm
Transverse thresholds reflect significant skeletal discrepancy not correctable by orthodontics alone.

Documentation and timing: Comprehensive preoperative planning and documentation must be provided, including the orthodontic work-up/monitoring (which may last 1–3 years) to determine timing for surgery.records within typical monitoring period

See required documentation module for specific films and photos within 6 months of review.

The following procedures, when performed solely to improve appearance in conjunction with orthognathic surgery, are contract exclusions and are not covered benefits: rhinoplasty for nose reshaping; osteoplasty for cosmetic facial bone reduction; genioplasty performed only to improve chin appearance; and rhytidectomy (facelift). These exclusions apply when the procedures are done for cosmetic purposes only and are performed in conjunction with orthognathic surgery.

Augmentation procedures (for example, placement of implants) performed to reshape or enhance facial structures solely for the purpose of improving appearance when done in conjunction with orthognathic surgery are considered not medically necessary and are contract exclusions.

Providers may not bill or charge members for services that have been determined to be not medically necessary or that are non-covered benefits unless the member was informed in advance and provided a written agreement to self-pay. Refer to your participation agreement for applicable provisions.

Orthognathic surgery performed in the absence of significant physical functional impairment is considered cosmetic and therefore not medically necessary. Coverage is limited to cases where the skeletal deformity causes functional impairment that cannot be adequately treated with dental or orthodontic care alone.

Services determined to be not medically necessary are subject to denial and are not billable to members unless the provider has obtained the member's informed written agreement to proceed at their own expense prior to delivering the service.

Coding

Orthognathic surgical CPT codesCPT

21142	Reconstruction midface, LeFort I; Single piece, segment movement in any direction, without bone graft.
21143	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft.
21145	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft.
21146	Reconstruction midface, LeFort I; Single piece, 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 grafts.
21155	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I grafts.
21159	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (monobloc), requiring bone grafts (includes obtaining autografts); without LeFort I grafts.

1–10 of 21

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Covered CPT CodesCPTCovered

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 grafts
21155	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I grafts
21159	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (monobloc), requiring bone grafts (includes obtaining autografts); without LeFort I grafts
21160	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (monobloc), requiring bone grafts (includes obtaining autografts); with LeFort I grafts
21188	Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)
21193	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
21194	Reconstruction of mandibular rami; horizontal, vertical, C; Or L osteotomy; with bone (includes obtaining graft) graft

1–10 of 14

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Additional CPT CodesCPTCovered

21206	Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21208	Osteoplasty, facial bones; augmentation (autograft allograft; or prosthetic implant)
21209	Osteoplasty, facial bones; reduction

Deformity measurement thresholds

Incisor overjetMaxillary/mandibular incisor relationship: overjet of 5 mm or more, or a 0 to negative incisor relationship (norm ~2 mm)

Molar AP discrepancyMaxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm 0–1 mm)

Bilateral transverse discrepancyTotal bilateral maxillary cusp to mandibular fossa discrepancy of 4 mm or greater (with normal axial inclination of posterior teeth)

Unilateral transverse discrepancyUnilateral maxillary cusp to mandibular fossa discrepancy of 3 mm or greater (with normal axial inclination of posterior teeth)

Asymmetry thresholdAP, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry

Vertical deformity standardVertical facial skeletal deformity defined as two or more standard deviations from published norms

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is recommended for Commercial products and must be obtained via the payer's web-based tool for participating providers before scheduling Phase 3 (surgery).

Phase 3 (surgery) is covered only with prior authorization
Use the payer's online preauthorization tool for submission

Note

Medicare Coverage Exclusion

Orthognathic surgery is not covered for BlueCHiP for Medicare members because CMS classifies these procedures as dental services, which are excluded from Medicare coverage.

Do not bill Medicare for orthognathic surgery as a covered medical service

Denial Risk

Nonmedical Necessity Billing Risk

If services are determined not to be medically necessary or are non-covered benefits, the provider may not charge the member for those services unless the member was informed in advance and agreed in writing to assume financial responsibility.

Contact the provider call center for member-specific benefit determinations
Obtain written member agreement before providing noncovered services to avoid billing disputes

Documentation Required

Required Documentation & Timing

The following clinical documentation is required to determine medical necessity for orthognathic surgery and must be completed within six months of submitting the case for review.

Presurgical frontal and lateral cephalograms (with prediction tracing)
Panoramic film
Frontal and profile smiling photos
Consultation letter documenting diagnosis and treatment plan
All required documentation must be dated within 6 months of case submission

Note

Preoperative Work-up

Preoperative monitoring and orthodontic work-up is an essential phase of care. This monitoring/work-up phase may last 1–3 years depending on case complexity while the oral surgeon and orthodontist determine optimal timing for surgery.

Phase is monitoring and orthodontic preparation prior to surgery
Timing determined by complexity and growth — typically 1–3 years

Definitions

Orthognathic surgery — definition

DefinitionSurgical correction of abnormalities of the maxilla, mandible, or both to correct dentoskeletal deformities and improve function.

Primary goalsNormalize occlusion; improve chewing, swallowing, speech, and relieve pain when deformity causes functional impairment.

IndicationsPerformed when severity of skeletal deformity results in significant functional impairment not correctable by dental or orthodontic treatment alone.

LeFort osteotomy types referenced

LeFort types referencedLeFort I, LeFort II, and LeFort III osteotomies are referenced in the midface reconstruction codes (e.g., CPT 21142–21160 series).

Examples in codingCodes include reconstruction midface, LeFort I (single/multiple pieces), LeFort II (anterior intrusion/with bone grafts), and LeFort III (extracranial/intracranial, with or without LeFort I grafts).

Related proceduresAlso listed: midface osteotomies other than LeFort type (CPT 21188) and forehead advancement (monobloc) with LeFort III (CPT 21159, 21160).

OpenPayer

Orthognathic Surgery Coverage Criteria

Coverage Criteria

Coding

Provider Actions & Requirements

Background

Definitions