ModifiedCentenePolicy CP MP.202

Clinical Policy: Orthognathic Surgery

Defines medical necessity criteria for orthognathic (jaw) surgery for members/enrollees of Centene-affiliated health plans, including required skeletal deformities, functional impairments, exclusions, and applicable CPT codes for billing guidance.

Policy Summary

PayerCentene

PolicyClinical Policy: Orthognathic Surgery

Policy CodePolicy CP MP.202

Change TypeCriteria revisions and clarifying language updates

Effective Date

Next Review Date

Key ActionProvide objective measurements demonstrating specified skeletal discrepancies and document at least one related functional impairment and obtain prior authorization per Health Plan procedures before scheduling orthognathic surgery.

POLICY UPDATE CHANGES

Updated Criteria I.A.1.b from greater than 4 mm to 4 mm or greater and updated multiple clarifying language points (I.A.2.c, I.A.3.b).

Added CPT codes 21120, 21121, 21122, 21123, 21159, and 21160 in prior revisions; later added 21248 and 21249 then removed them in another revision reflected in coding list.

Added language to include 'irritation of buccal or lingual soft tissues of the opposing arch' in criteria I.A.2.c and clarified impingement of palatal soft tissue wording.

Minor verbiage updates throughout policy with no impact to criteria in some review cycles.

≥1Required skeletal deformities (categories)

≥1Required functional impairments

Coverage Summary

Scope: This policy defines medical necessity criteria for orthognathic (jaw) surgery for Centene-affiliated health plan members/enrollees, specifying required objective skeletal findings and related functional impairments for coverage decisions. Status: Covered with criteria; coverage requires documentation of at least one (≥1) qualifying skeletal deformity category (anteroposterior, vertical, transverse, or asymmetry) AND at least one (≥1) related functional impairment directly attributable to the jaw deformity.

Molar relationship discrepancy≥ 5 mm

Incisor overjet≥ 5 mm or zero to negative value

Vertical facial deformity (SD)≥ 2 standard deviations from published norms

Posterior open bite> 2 mm

Total bilateral palatal cusp to mandibular fossa discrepancy≥ 4 mm

Unilateral palatal cusp to mandibular fossa discrepancy≥ 3 mm

Asymmetry threshold≥ 3 mm

Myofascial pain conservative treatment duration≥ 6 months

Medical-Necessity Criteria

Not Medically Necessary (Exclusions)

Orthognathic surgery is not medically necessary when ANY of the following are present:

ANY of the following

When the sole purpose is to improve individual appearance (cosmetic), regardless of associated psychological disorders
When the member/enrollee is still developing and the deformity could be corrected with less intrusive treatment (e.g., expander or headgear)

Coding

Relevant CPT codes (informational; included in policy coding implications)CPT

21110	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material)
21121	Genioplasty; sliding osteotomy, single piece
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies
21123	Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
21125	Augmentation, mandibular body or angle; prosthetic material
21127	Augmentation, mandibular body or angle; with bone graft; onlay or interpositional (includes obtaining autograft)
21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction without bone graft
21142	Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft
21143	Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft

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Provider Actions

Prior Authorization

Prior authorization likely required

Policy is the medical necessity guideline for coverage decisions; providers should obtain prior authorization per Health Plan procedures to confirm coverage before scheduling orthognathic surgery.

Documentation Required

Document skeletal measurements and functional impairment

Provide objective measurements (mm or SD from norms) demonstrating the specified skeletal discrepancies and documentation of at least one related functional impairment tied to the deformity (e.g., speech evaluation, polysomnogram for OSA, evidence of malnutrition).

Polysomnogram for OSA
Speech evaluation (by a speech and language pathologist)
Objective millimeter (mm) measurements or standard deviation (SD) from published norms

Background

Background: Orthognathic surgery corrects developmental or acquired skeletal abnormalities of the mandible and/or maxilla that cause functional impairments not correctable with dental treatment alone. Typical procedures include osteotomies with repositioning of bony segments, internal fixation with plates/screws and/or intermaxillary fixation, and grafting (autograft or alloplastic) when bone is deficient. These operations are generally performed under general anesthesia and are often done in the inpatient setting.

Evidence and guidance: The policy references the American Association of Oral and Maxillofacial Surgeons (AAOMS) classification of occlusion and related indications; AAOMS guidance is cited as the guideline source informing the coverage criteria.

Definitions: Overjet — horizontal distance between upper and lower incisors; policy threshold defined as ≥ 5 mm or a zero to negative value. Open bite — lack of vertical overlap of anterior teeth; policy considers a posterior open bite of greater than 2 mm or no anterior vertical overlap as clinically significant.

Revision History

revised

Updated Criteria I.A.1.b from greater than 4 mm to 4 mm or greater and updated multiple clarifying language points (I.A.2.c, I.A.3.b).

added

Added CPT codes 21120, 21121, 21122, 21123, 21159, and 21160 in prior revisions; later added 21248 and 21249 then removed them in another revision reflected in coding list.

clarified

Added language to include 'irritation of buccal or lingual soft tissues of the opposing arch' in criteria I.A.2.c and clarified impingement of palatal soft tissue wording.