CurrentCentenePolicy N/A

Clinical Policy: Orthognathic Surgery

Clinical policy governing medical necessity and coverage considerations for orthognathic surgery for members/enrollees; intended as a guide for providers and health plan administrators.

Policy Summary

PayerCentene

PolicyClinical Policy: Orthognathic Surgery

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRefer to plan-level administrative policies and coverage documents for prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Centenepolicy owner

2018copyright year shown

MedicaidMedicaid precedence

NCD/LCDMedicare advisory

Coverage Criteria

Coverage decisions are subject to the terms, conditions, exclusions and limitations set forth in the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy, or contract of insurance). Where applicable legal or regulatory requirements conflict with this clinical policy, the requirements of law and regulation govern. State Medicaid coverage provisions take precedence when they conflict with this clinical policy.

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Coverage Decisions

Prior authorization and coverage decisions are subject to Health Plan-level administrative policies and the member's benefit documents. Providers must verify eligibility and obtain any required prior authorization from the member's plan before scheduling services. Failure to obtain required prior authorization may result in denial of payment.

Verify member eligibility and benefits prior to service.
Obtain prior authorization when required by the Health Plan's administrative policies.
Contact the Health Plan or use the designated provider portal for prior authorization submission and status.
Ensure services meet applicable coverage criteria and benefit limitations in the member's certificate of coverage/policy.

Policy Summary

PayerCentene

PolicyClinical Policy: Orthognathic Surgery

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRefer to plan-level administrative policies and coverage documents for prior authorization requirements.

SourceLink

On This Page

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Note

Important Reminder to Providers

This clinical policy is a guide to medical necessity and does not replace provider professional judgment. It does not guarantee coverage or payment. Providers remain responsible for clinical decisions and for adhering to all plan, state, and federal requirements.

Documentation Required

Coverage and Benefit Administration

Coverage determinations and benefit administration are governed by the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy) and by applicable exclusions, limitations, and administrative terms. If state Medicaid provisions conflict with this policy, the state Medicaid provisions prevail.

Refer to the member's plan documents for specific exclusions, limitations, and member cost-sharing.
When in doubt, contact the Health Plan's provider services for clarification before rendering services.

Background

This clinical policy was developed by licensed healthcare professionals based on review of accepted standards of medical practice, peer-reviewed literature, evidence-based guidelines, agency approvals, and expert opinion. It is intended as a guide to medical necessity for orthognathic surgery and not as medical advice, a treatment directive, or a substitute for professional medical judgment. Providers are expected to exercise professional judgment in the care of members/enrollees and remain solely responsible for medical advice and treatment decisions.

Definitions

Health Plan — definition

Term'Health Plan'

DefinitionA health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates.

ScopeApplies to the entity that determines effective dates and administers this clinical policy as part of coverage decision and benefit administration.

LimitationsCoverage decisions and benefit administration remain subject to the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance) and applicable state and federal requirements.