OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Currentblue cross blue shield - south dakotaPolicy N/A

Orthognathic (Jaw) Surgery Coverage Criteria

Customize your policy alerts

Sign up for all blue cross blue shield - south dakota policy alerts

Know when blue cross blue shield - south dakota releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs coverage and medical necessity criteria for orthognathic (jaw) surgery for members of Blue Cross Blue Shield - South Dakota, including preoperative planning, orthodontic phases, surgery, and postoperative care.

Policy Summary

Payerblue cross blue shield - south dakota

PolicyOrthognathic (Jaw) Surgery Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual review (no material changes)

Effective DateAug 1, 2022

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting preoperative planning, pre-surgical orthodontic alignment, planned surgical approach, and post-surgical orthodontic plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4clinical treatment phases described

9-18pre-surgical orthodontics (months)

5follow-up period (years)

~20procedure codes listed

~80%TMJ symptom improvement rate

Coverage and Medical Necessity Criteria

Medical necessity criteria (general)

Covered when ALL of the following are met

Core conditions: 1) Documented functional impairment caused by malocclusion (malocclusion must be affecting the patient’s physical health, not just dental health). 2) Deformity is not correctable by dental therapeutics or orthodontics alone; prior appropriate less-invasive treatments (e.g., orthodontics, conservative TMJ therapy, non-surgical sleep apnea measures) were attempted and are documented. 3) Preoperative and surgical planning documented, including photographic analysis, cephalometric and panoramic radiographs, dental impressions/models, and computer-simulated surgical planning; updated dental records after pre-surgical orthodontics as applicable.

Based on AAOMS criteria; presence of malocclusion alone without functional impairment is insufficient.

Medically necessary orthognathic surgery

Covered when ALL of the following are met:

Primary criteria

Documented skeletal discrepancy meeting measurement thresholds:

Policy Summary

Payerblue cross blue shield - south dakota

PolicyOrthognathic (Jaw) Surgery Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual review (no material changes)

Effective DateAug 1, 2022

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting preoperative planning, pre-surgical orthodontic alignment, planned surgical approach, and post-surgical orthodontic plan.

SourceLink

On This Page

Presence of verifiable clinical measurements showing skeletal deformity such as: anteroposterior overjet >= +5 mm or zero/negative overjet; maxillary/mandibular molar AP discrepancy >= 4 mm; transverse discrepancy with total bilateral palatal cusp to mandibular fossa >= 4 mm or unilateral >= 3 mm; vertical facial skeletal deformity >= 2 standard deviations from norms, open bite (no anterior vertical overlap) or unilateral/bilateral posterior open bite > 2 mm; anteroposterior/transverse/lateral asymmetries > 3 mm.

see AAOMS thresholds

Measurements should account for dental compensations and be verifiable in the record (cephalometric/panoramic imaging, models).

Associated functional impairment: Documentation of functional impairment related to the skeletal deformity such as masticatory dysfunction (reduced bite force, abnormal chewing patterns), airway obstruction/obstructive sleep apnea, swallowing difficulty, speech impairment, or temporomandibular joint pathology with symptoms attributable to the deformity.

When airway/OSA present, appropriate evaluation and attempts at non-surgical treatment should be documented prior to surgery.

Conservative management and multidisciplinary evaluation: Evidence that non-surgical therapies and multidisciplinary evaluations (including orthodontic management, conservative TMJ treatments, speech evaluation/therapy, and non-surgical sleep apnea measures when applicable) have been attempted when appropriate and that the deformity cannot be corrected by dental therapeutics or orthodontics alone.

Prior conservative care must be appropriate for the condition and documented in the medical record.

Cosmetic services provided primarily to improve physical appearance are not covered. An intervention that results in only an incidental improvement in appearance may be covered only if it is provided primarily to restore function lost or impaired as the result of illness, accidental injury, or a birth defect. Treatment for complications of a noncovered cosmetic procedure is also not covered.

Procedures performed primarily to accomplish soft-tissue cosmetic changes are not considered primary indications for orthognathic surgery. The policy follows AAOMS guidance that changes in the overlying soft-tissue drape are an expected, consequential effect of skeletal surgery but are not the primary goal; the primary goal must be correction of an underlying skeletal deformity to improve function.

No additional exclusion or coverage language is specified in the provided source text for this item.

Procedures performed solely for cosmetic reasons are considered not medically necessary. Likewise, orthognathic surgery for malocclusion that does not produce demonstrable physical functional impairment (beyond dental concerns) is not medically necessary unless documentation shows the malocclusion impairs physical health and is not correctable with appropriate, less-invasive treatments.

Surgery performed solely for cosmetic improvement of facial appearance is not covered when there is no documented functional impairment or verifiable skeletal deformity that meets the policy’s clinical criteria.

No additional exclusion or not-medically-necessary language is specified in the provided source text for this item.

Procedure and Billing Codes

See codes tablemixed

No codes listed

Covered CPT and Dental/HCPCS Codesmixed

21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), 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 (e.g., Treacher-Collins Syndrome).
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.

1–10 of 29

1/3

Covered CPT CodesCPTCovered

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 graft (includes obtaining graft).
21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation.
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation.
21198	Osteotomy, mandible, segmental.
21199	Osteotomy, mandible, segmental; with genioglossus advancement.
21206	Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard).

Dental Procedure Codes (D-codes)HCPCSCovered

D7940	Osteoplasty - for orthognathic deformities.
D7941	Osteotomy - mandibular rami.
D7943	Osteotomy - mandibular rami with bone graft; includes obtaining the graft.
D7944	Osteotomy - segmented or subapical.
D7945	Osteotomy - body of mandible.
D7946	LeFort I (maxilla - total).
D7947	LeFort I (maxilla - segmented).
D7948	LeFort II or LeFort III (osteoplasty of facial bones of midface hypoplasia or retrusion) without bone graft.
D7949	LeFort II or LeFort III - with bone graft.

Service and Place of Servicemixed

Surgery	Type of Service
Inpatient/Outpatient	Place of Service

Anteroposterior / transverse / vertical discrepancy thresholds

Anteroposterior — overjetHorizontal overjet of +5 mm or more (normal 2-3 mm); zero to negative overjet also indicates deformity

Anteroposterior — molar relationshipMaxillary/mandibular anteroposterior molar discrepancy of 4 mm or more (norm 0–1 mm)

Transverse — bilateralTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm (with normal posterior tooth inclination)

Transverse — unilateralUnilateral palatal cusp to mandibular fossa discrepancy ≥ 3 mm (with normal posterior tooth inclination)

Vertical / asymmetry thresholdsVertical deformity ≥ 2 standard deviations from published norms; open bite = no anterior vertical overlap or posterior open bite > 2 mm; asymmetries > 3 mm

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for orthognathic surgical procedures. Providers must obtain prior authorization before scheduling surgery and document completion of preoperative treatment planning, completion of pre-surgical orthodontic alignment when applicable, and a clear surgical plan (including planned surgical approach and anticipated procedures).

Prior authorization required prior to orthognathic procedures
Document preoperative treatment planning and simulated surgical planning
Document completion or planned timeline for pre-surgical orthodontics when indicated

Prior Authorization

Prior Authorization May Be Required for Listed Procedure Codes

Prior authorization may be required for the orthognathic procedure codes listed in the coding section. Providers should verify payer-specific requirements and place-of-service implications when submitting claims.

Verify prior authorization requirements for listed CPT and dental (D) codes
Confirm inpatient vs outpatient place of service requirements

Denial Risk

Denial Risk — Lack of Documentation Showing Deformity or Prior Conservative Therapy

Claims may be denied if documentation does not demonstrate that the malocclusion or facial skeletal deformity causes a physical functional impairment (not solely dental/alignment concerns), or if documentation fails to show that appropriate non-surgical or less invasive treatments were attempted and were ineffective.

Denial risk when only cosmetic or dental malocclusion is documented
Denial risk when conservative therapy or prior appropriate treatments are not documented

Documentation Required

Required Preoperative and Supporting Documentation

Providers must include comprehensive preoperative and supporting documentation with authorization requests and the medical record. This includes photographic analysis, cephalometric and panoramic radiographs, dental impressions/models (or digital equivalents), computer-simulated surgical planning, and updated dental records after pre-surgical orthodontics.

Photographic analysis and full orthognathic work-up
Cephalometric and panorex (panoramic) radiographs; cone beam CT when obtained
Dental impressions/models or digital scans and new records after pre-surgical orthodontics
Computer-simulated surgery and surgeons pre-surgical planning notes

Documentation Required

Documentation Should Include Verifiable Clinical Measurements

Documentation should include verifiable clinical measurements of skeletal discrepancies per accepted criteria (for example AAOMS): measurable overjet/overbite values, molar relationship discrepancies, transverse measurements, and quantified asymmetries. When applicable, include objective measures or test results for airway dysfunction (e.g., sleep study results), TMJ evaluation, or speech assessments.

Overjet measurements (e.g., +5 mm or more, or zero to negative values)
Anteroposterior molar discrepancy (e.g., 4 mm or more)
Vertical discrepancies (open bite >2 mm, deep overbite with soft tissue impingement)
Transverse discrepancies (bilateral palatal cusp to fossa >=4 mm, unilateral >=3 mm)
Asymmetry >3 mm with occlusal asymmetry
Objective airway, TMJ, or speech testing when cited as indications

Billing Rule

Procedure Code Descriptions Provided — Use on Claims and Authorizations

Procedure code descriptions for orthognathic surgery (CPT and dental D-codes) are provided in the coding section and should be used on claims to describe the performed procedure(s). Include applicable CPT/HCPCS and dental codes on the prior authorization request and claim.

Use CPT codes 21141 21199 and related codes as appropriate
Use dental D-codes (D7940D7949) where applicable
Indicate Type of Service: Surgery and Place of Service: Inpatient/Outpatient as appropriate

Documentation Required

Non-surgical Therapies When Applicable

When applicable, providers must document attempts at non-surgical therapies (for example orthodontic treatment, TMJ conservative management, speech therapy, or non-surgical OSA treatments) and document that these were inadequate to correct the functional impairment prior to consideration of orthognathic surgery.

Document pre-surgical orthodontic therapy and outcomes
Document non-surgical airway or OSA treatments attempted when airway dysfunction is cited
Document conservative TMJ therapies attempted prior to surgery
Provide speech therapy evaluation and trial when speech impairment is an indication

Note

Provider Operational Note

Providers: ensure all required elements are in the medical record and attached to prior authorization requests. Failure to supply requested documentation may delay review or result in denial. Contact the payer for any uncertainty regarding authorization or documentation requirements.

Key Terms and Measurements

Malocclusion (Class I, II, III)

Class I occlusionTeeth in normal relationship: mesial-buccal cusp of maxillary first permanent molar coincides with buccal groove of mandibular first molar.

Class II malocclusionMandibular teeth are distal (behind) the normal relationship to maxillary teeth; includes Division I (upper incisor protrusion) and Division II (maxillary incisor retrusion); often associated with deep bite (overbite).

Class III malocclusionLower dental arch is mesial (in front of) the upper dental arch (underbite), often due to horizontal mandibular excess or maxillary deficiency, may present with a protrusive chin.

Functional Impairment

DefinitionA deviation from normal function of a tissue or organ causing significantly limited, impaired, or delayed capacity to perform physical activities (e.g., eating); used to establish medical necessity when malocclusion produces demonstrable physical functional impairment.

Examples of functional impactMasticatory dysfunction, swallowing difficulty, speech impairment, airway obstruction/OSA, or TMJ pathology documented to be caused by the skeletal deformity.

Documentation requirementMedical records must document the functional deficit and link it to the skeletal malocclusion (clinical measurements and supporting studies).

Reconstructive Surgery

DefinitionSurgery primarily intended to restore function lost or impaired as a result of illness, injury, or birth defect; incidental improvement in appearance may occur but is not the primary goal.

Relevance to coverageProcedures performed primarily for cosmetic reasons are not covered; reconstructive intent must be documented when claiming medical necessity.

Authoritative framingAligned with the American Society of Plastic Surgeons definition: reconstructive procedures treat structures affected aesthetically or functionally by congenital defects, trauma, infection, tumors, or disease to improve function and ability.

Overjet

MeasurementOverjet = horizontal overlap of maxillary central incisors over mandibular central incisors; normal 2–3 mm.

Indication thresholdAn overjet of +5 mm or more is an indication for orthognathic surgery per AAOMS criteria.

Additional noteZero to negative overjet (edge-to-edge or reverse) is also cited as an anteroposterior indication.

Overbite

DefinitionOverbite = vertical overlap of the maxillary central incisors over the mandibular central incisors; normally ~2–3 mm or ~20–30% of mandibular incisor height.

Pathologic vertical findingsOpen bite defined as no anterior vertical overlap; posterior open bite > 2 mm is significant; deep overbite with soft-tissue impingement is also addressed in indications.

Clinical relevanceVertical discrepancies that are ≥ 2 standard deviations from norms constitute indications when associated with functional impairment.

LeFort I / II / III (midface osteotomies and associated D-codes)

LeFort IMidface osteotomy of the maxilla (LeFort I) — D7946 (LeFort I total), D7947 (LeFort I segmented); CPT descriptions include single- to multi-piece LeFort I reconstructions (21141–21147).

LeFort IIMidface osteotomy for LeFort II-level advancement/osteoplasty — D7948 (LeFort II/III without bone graft), D7949 (LeFort II/III with bone graft); CPT codes include 21150–21151 describing LeFort II reconstructions.

LeFort IIIMore extensive midface (LeFort III) osteotomy/advancement (extracranial/intracranial variants) described in CPT (21154–21160) and D-code group for LeFort II/III procedures.

Clinical Background and Scope

Orthognathic surgery corrects skeletal abnormalities of the mandible, maxilla, or both to restore anatomic and functional relationships in dentofacial skeletal anomalies. The primary goal is to improve function by correcting the underlying skeletal deformity; soft-tissue changes are consequential and not the primary objective. Orthodontic therapy is commonly required preoperatively and postoperatively — pre-surgical orthodontics aligns teeth to the underlying jaws and post-surgical orthodontics typically begins 4–6 weeks after surgery to finalize occlusion. The presence of malocclusion alone does not qualify a patient for surgery without documentation that the malocclusion is affecting the patient’s physical health (not just dental health) and that appropriate less-invasive treatments have been attempted and documented.

Policy Revision History

2025-01policy_revisionLatest

Policy revised during annual review, reflecting updates to coverage and prior authorization requirements for orthognathic procedure codes.

2024-05annual_review

Annual review conducted; policy content and code listings evaluated (May 2024 entry in policy history).