ModifiedCentenePolicy CP.MP.202

Orthognathic Surgery

Defines medical necessity criteria and coding implications for orthognathic surgery for members/enrollees of Centene-affiliated health plans; applies to coverage determinations for corrective jaw surgery to address functional impairment from skeletal deformities.

Policy Summary

PayerCentene

PolicyOrthognathic Surgery

Policy CodePolicy CP.MP.202

Change TypeThreshold and coding revisions

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed orthognathic CPT codes and document specific skeletal measurements and functional impairment to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated measurement thresholds in criteria I.A.1.a and I.A.1.b to ≥5 mm and ≥4 mm respectively, and clarified language in several criteria (e.g., I.A.2.c and I.A.3.b).

Added multiple CPT codes (e.g., 21120, 21121, 21122, 21123, 21159, 21160) and removed others (e.g., 21248, 21249).

IPolicy section

4Deformity categories

≥5/≥4/≥2SDNumeric thresholds

21110–21249CPT range (selected)

Medicaid/Medicare

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Coverage Criteria

Initial Medical Necessity Criteria

Covered when ALL of the following are met:

Top-level: All major conditions A and B must be satisfied.

Policy I.

A. Skeletal deformity (one required): Member has one of the specified skeletal deformities associated with masticatory malocclusion.See children

I.A

I.A.1 Anteroposterior discrepancy: Either (a) maxillary/mandibular incisor overjet ≥5 mm or zero to negative value (norm = 2 mm) OR (b) maxillary/mandibular anteroposterior molar relationship discrepancy ≥4 mm (norm = 0 to 1 mm).≥5 mm; ≥4 mm

I.A.1.a/b

I.A.2 Vertical discrepancy: One of: (a) vertical facial skeletal deformity ≥2 standard deviations from published norms; (b) open bite with no vertical overlap of anterior teeth or unilateral or bilateral posterior open bite >2 mm; (c) deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch; (d) supraeruption of a dentoalveolar segment resulting from lack of occlusion when the dentition in the segment is intact.≥2 SD; >2 mm

I.A.2

I.A.3 Transverse discrepancy: One of: (a) transverse skeletal discrepancy ≥2 standard deviations from published norms; (b) total bilateral palatal cusp to mandibular fossa discrepancy ≥4 mm, or unilateral ≥3 mm, given normal axial inclination of the posterior teeth.≥2 SD; ≥4 mm bilateral; ≥3 mm unilateral

I.A.3

I.A.4 Asymmetry: Anteroposterior, transverse or lateral asymmetries >3 mm with concomitant occlusal asymmetry.>3 mm

I.A.4

B. Functional impairment (at least one): At least one documented functional impairment is present: (1) persistent difficulties with mastication and swallowing after exclusion of neurologic or metabolic causes; (2) malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity; (3) speech dysfunction directly related to jaw deformity as determined by a speech and language pathologist; (4) myofascial pain secondary to facial skeletal deformity persisting ≥6 months despite compliant conservative treatment (e.g., physical therapy, splints); (5) airway obstruction such as obstructive sleep apnea documented by polysomnogram when (a) intolerant to or failed a trial of PAP and (b) has failed or is not a candidate for less invasive surgical procedures.myofascial pain ≥6 months

I.B

Orthognathic procedures performed solely to improve appearance are considered cosmetic and are excluded from coverage. The policy explicitly states that surgery whose only purpose is aesthetic enhancement — even when associated with psychological concerns — is not medically necessary and may be denied.

Members who are still skeletally developing are similarly excluded when the deformity can be corrected with less intrusive, conservative measures (for example, orthodontic expanders or head gear). In these cases, the plan expects consideration of age and growth status and the use of non‑surgical alternatives before approving definitive orthognathic surgery.

Orthognathic surgery is not medically necessary when performed solely for cosmetic reasons. Requests that have no functional indication and are intended only to improve appearance do not meet the policy’s medical necessity requirements and may be denied.

The policy also specifies that orthognathic surgery is not medically necessary for members who are still developing if the deformity could be managed with less intrusive treatments (for example, an expander or head gear). Providers should document growth status and whether conservative alternatives were tried or sufficient before pursuing coverage.

Coding and Measurement Thresholds

Listed CPT CodesCPT

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 (eg, wedge excision or bone wedge reversal for asymmetrical chin).
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 (eg, for Long Face Syndrome), 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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1/4

Overjet / Molar discrepancy / Transverse and vertical thresholds

Maxillary/mandibular incisor overjet≥5 mm (policy updated from >5 mm to ≥5 mm)

Molar anteroposterior discrepancy≥4 mm (maxillary/mandibular molar relationship; norm = 0 to 1 mm)

Vertical skeletal discrepancy≥2 standard deviations from published norms for accepted skeletal landmarks

Open bite / posterior open biteNo vertical overlap of anterior teeth OR unilateral/bilateral posterior open bite >2 mm

Transverse palatal cusp to mandibular fossa discrepancyTotal bilateral ≥4 mm or unilateral ≥3 mm (with normal axial inclination of posterior teeth)

Asymmetry threshold>3 mm for anteroposterior, transverse or lateral asymmetries with concomitant occlusal asymmetry

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Expected

Prior authorization is expected for orthognathic procedures listed in the coding section. Providers should obtain prior authorization before scheduling or performing any of the referenced CPT codes to avoid claim denials or delays.

Affected codes: see Coding Implications CPT list (e.g., 21110, 21120–21199, 21206–21249).
Prior authorization helps confirm medical necessity and coverage under the member's benefit contract.

Note

Medicare Consistency Review Required

For Medicare members/enrollees, providers must review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles prior to applying this clinical policy. Medicare requirements and determinations supersede or inform application of the policy when applicable.

Refer to CMS website: http://www.cms.gov for current NCDs, LCDs, and Coverage Articles.

Background

Orthognathic surgery is performed to correct skeletal abnormalities of the maxilla, mandible, or both when those deformities produce clinically significant functional impairments. Typical functional indications include impaired mastication or swallowing, speech dysfunction attributable to jaw deformity, persistent myofascial pain related to the skeletal abnormality, malnutrition or failure to thrive secondary to jaw dysfunction, and airway obstruction such as obstructive sleep apnea.

For obstructive sleep apnea specifically, the policy requires objective documentation (polysomnography) and that the member be intolerant to or have failed a trial of PAP and have failed or be ineligible for less invasive surgical procedures before orthognathic surgery will be considered medically necessary.

Definitions

Occlusion classification (AAOMS)

Class ITeeth in a normal relationship: mesial-buccal cusp of the maxillary first permanent molar coincides with the buccal groove of the mandibular first molar.

Class IIMandibular teeth positioned behind the normal relationship to the maxillary teeth; may be due to mandibular deficiency (Type 1) or maxillary excess (Type 2).

Class IIILower dental arch is mesial to (in front of) the upper dental arch (underbite); often due to horizontal mandibular excess or horizontal maxillary deficiency, producing a protrusive chin.

Additional definitions and policy items

Documentation requirementsRecords must demonstrate specific skeletal measurements (e.g., overjet, molar discrepancy, transverse measurements, asymmetry) and associated functional impairment such as persistent mastication/swallowing difficulty, malnutrition, speech dysfunction, myofascial pain ≥6 months despite conservative therapy, or OSA with prior PAP failure or ineligibility for less invasive surgery.

Revision History

2011-03-11policy_developed

Policy developed and approved; initial adoption of member terminology and template transfer noted.

2020-10-20annual_review_and_revision

Annual review: updated measurement thresholds (I.A.1.a to ≥5 mm and I.A.1.b to ≥4 mm), added wording to I.A.2.c, specified 'maxillary' palatal cusp in I.A.3.b, added CPT codes 21120, 21121, 21122, 21123, 21159, 21160 and removed CPTs 21248 and 21249; ICD-10 table removed.

2021-10-21annual_review_and_approval

Annual review completed with same clinical edits as 10/20 (threshold and wording updates) and CPT code changes confirmed; reviewed by specialist and approved.