ModifiedCignaPolicy 0209

Orthognathic Surgery

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This policy governs coverage of surgical correction of mandibular, maxillary, or combined jaw abnormalities intended to improve function, subject to the customer’s specific benefit plan, applicable law, and individual clinical circumstances.

Policy Summary

PayerCigna

PolicyOrthognathic Surgery

Policy CodePolicy 0209

Change TypeModified

Effective DateOct 15, 2026

Next Review DateOct 15, 2027

Key ActionSubmit complete clinical and imaging documentation supporting the jaw deformity and functional impairment.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review removed the policy statement addressing services considered integral to orthognathic surgery.

The revision history identifies a prior revision to the policy statement addressing services considered integral to orthognathic surgery.

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.

ModifiedCignaPolicy 0209

Orthognathic Surgery

Customize your policy alerts

Sign up for Cigna Policy 0209 alerts

Get alerted when Policy 0209 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerCigna

PolicyOrthognathic Surgery

Policy CodePolicy 0209

Change TypeModified

Effective DateOct 15, 2026

Next Review DateOct 15, 2027

Key ActionSubmit complete clinical and imaging documentation supporting the jaw deformity and functional impairment.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review removed the policy statement addressing services considered integral to orthognathic surgery.

The revision history identifies a prior revision to the policy statement addressing services considered integral to orthognathic surgery.

ALL 3Required medical-necessity domains

5 mm+Qualifying horizontal overjet

4 mm+Qualifying molar discrepancy

6 monthsMyofascial pain duration

5Cosmetic procedure categories

Orthognathic Surgery Coverage Criteria

Initial orthognathic surgery medical necessity

Orthognathic surgery is considered medically necessary when ALL of the following are met.

Overall medical necessity

Clinical documentation
- Required documentation elements: Medical history and physical examination referencing symptoms related to the orthognathic deformity; description of the specific anatomic deformity; lateral and anterior-posterior cephalometric radiographs; cephalometric analysis; treating-physician records documenting evaluation, diagnosis, and previous management of functional medical impairments; and diagnostic-quality clear photographs fully demonstrating dental occlusion.
Facial skeletal deformity
- Anteroposterior discrepancy
  - Incisor relationship: Horizontal overjet is 5 mm or more, or horizontal overjet is zero to negative.5 mm or more; or zero to negative
  - Molar relationship: Maxillary/mandibular anteroposterior molar relationship discrepancy is present.4 mm or more
- Vertical discrepancy
  - Vertical skeletal deformity: Vertical facial skeletal deformity is two or more standard deviations from published norms for accepted skeletal landmarks.2 or more standard deviations
  - Open bite: There is no vertical overlap of anterior teeth or unilateral/bilateral posterior open bite greater than 2 mm.No anterior overlap or posterior open bite >2 mm
  - Deep overbite causes impingement or irritation of buccal or lingual soft tissues of the opposing arch.
  - Supraeruption of a dentoalveolar segment results from lack of occlusion.
- Transverse discrepancy
  - Transverse skeletal discrepancy is two or more standard deviations from published norms.2 or more standard deviations
  - Palatal cusp-to-fossa discrepancy: Total bilateral discrepancy is 4 mm or greater, or unilateral discrepancy is 3 mm or greater, given normal axial inclination of posterior teeth.4 mm bilateral or 3 mm unilateral
- Asymmetry: Anteroposterior, transverse, or lateral asymmetry is greater than 3 mm and has concomitant occlusal asymmetry.>3 mm
Functional impairment
- Mastication or swallowing difficulty: Persistent difficulty with mastication and swallowing remains after neurological or metabolic causes have been excluded.Persistent
- Nutritional impairment: Malnutrition, significant weight loss, or failure-to-thrive is secondary to facial skeletal deformity.
- Speech dysfunction is directly related to jaw deformity and determined by a speech and language pathologist.
- Myofascial pain is secondary to facial skeletal deformity and persisted despite conservative treatment such as physical therapy and splints.At least 6 months

Adjunctive procedures

The following may be considered medically necessary when used in conjunction with a medically necessary orthognathic procedure.

Medically necessary adjuncts

Bone grafting is used in conjunction with a medically necessary orthognathic procedure.
Oral surgical splints: An oral surgical splint is used in conjunction with a medically necessary orthognathic procedure.

Medical necessity and functional indications

Orthognathic surgery is generally considered medically necessary when a significant skeletal abnormality causes considerable functional impairment and cannot be adequately corrected with orthodontic treatment alone.

Overall medical-necessity framework

Skeletal discrepancy or deformity
- Anteroposterior discrepancies: Horizontal overjet is 5 mm or more or zero to negative; or maxillary/mandibular anteroposterior molar relationship discrepancy is 4 mm or more.5 mm or more or zero to negative overjet; 4 mm or more molar discrepancy
  These values are described as two or more standard deviations from published norms.
- Vertical discrepancies: A vertical facial skeletal deformity is two or more standard deviations from published norms; there is no vertical overlap of anterior teeth; posterior open bite is greater than 2 mm; deep overbite impinges on or irritates opposing-arch soft tissue; or a dentoalveolar segment has supraerupted because of absent occlusion.Posterior open bite greater than 2 mm

Correction of contour defects, fat grafting, genioplasty, rhinoplasty, and rhytidectomy are considered cosmetic and not medically necessary when performed with orthognathic surgery solely to improve individual appearance or facial profile.

Rhinoplasty, genioplasty, fat grafting, correction of contour defects, rhytidectomy, and other procedures performed primarily to improve physical appearance or address psychological symptomatology or psychosocial complaints are considered cosmetic in nature.

The cosmetic procedures identified in the policy are not medically necessary when performed in conjunction with orthognathic surgery for the sole purpose of improving appearance and/or facial profile.

Orthognathic surgery performed for cosmetic purposes, without treatment of a significant abnormality causing considerable functional impairment, is not described as medically necessary.

Coverage Coding and Clinical Thresholds

Considered Medically NecessaryCPTCovered

21110	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal.
21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction, 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, including obtaining autografts.
21146	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts, including obtaining autografts.
21147	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts, including obtaining autografts.
21150	Reconstruction midface, LeFort II; anterior intrusion.
21151	Reconstruction midface, LeFort II; any direction, requiring bone grafts, including obtaining autografts.
21159	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts, including obtaining autografts; with LeFort I.

1–10 of 14

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May Be Considered Medically Necessary With a Medically Necessary Orthognathic ProcedureCPTCovered

21085	Impression and custom preparation; oral surgical splint.
21210	Graft, bone; nasal, maxillary or malar areas, includes obtaining graft.
21215	Graft, bone; mandible, includes obtaining graft.

Cosmetic/Not Medically NecessaryCPTNot Covered

11954	Subcutaneous injection of filling material, eg, collagen; over 10.0 cc.
15769	Grafting of autologous soft tissue, other, harvested by direct excision, eg, fat, dermis, fascia.
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate.
15774	Grafting of autologous fat harvested by liposuction technique; each additional 25 cc injectate, or part thereof.
15824	Rhytidectomy; forehead.
15825	Rhytidectomy; neck with platysmal tightening.
15828	Rhytidectomy; cheek, chin, and neck.
15829	Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap.
21120	Genioplasty; augmentation, autograft, allograft, or prosthetic material.
21121	Genioplasty; sliding osteotomy, single piece.

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FDA 510(k) relevant product codesmixed

DYX	FDA 510(k) relevant product code for devices used in orthognathic surgery
DZK	FDA 510(k) relevant product code for devices used in orthognathic surgery
DZL	FDA 510(k) relevant product code for devices used in orthognathic surgery
FWP	FDA 510(k) relevant product code for devices used in orthognathic surgery
HTY	FDA 510(k) relevant product code for devices used in orthognathic surgery
HWC	FDA 510(k) relevant product code for devices used in orthognathic surgery
JAZ	FDA 510(k) relevant product code for devices used in orthognathic surgery
JDP	FDA 510(k) relevant product code for devices used in orthognathic surgery
JEY	FDA 510(k) relevant product code for devices used in orthognathic surgery

Horizontal overjet

Qualifying measurementHorizontal overjet of 5 mm or more

Alternative criterionHorizontal overjet of zero to negative value

Relationship assessedMaxillary/mandibular incisor relationship

Anteroposterior molar relationship discrepancy

Qualifying measurement4 mm or more

Relationship assessedMaxillary/mandibular anteroposterior molar relationship

Documentation, Treatment Prerequisites, and Denial Risks

Step Therapy

Conservative Airway Treatment Before Surgery

For airway obstruction, including documented obstructive sleep apnea, document evaluation of the cause and site of the disorder and show that conservative treatment was attempted when indicated. This may include CPAP or an oral appliance; document failure, ineffectiveness, undesirability, or failure of less-invasive surgical procedures when applicable.

Document the sleep study and airway findings.
Document attempted conservative treatment and the reason it was ineffective or undesirable.
Address narrowed posterior airway space, tongue-base obstruction, or relevant craniofacial skeletal abnormalities when applicable.

Step Therapy

Nonsurgical TMJ Treatment Required

For facial skeletal discrepancies associated with documented temporomandibular joint pathology, document attempted nonsurgical treatment before orthognathic surgery, including therapies that mimic the effects of occlusal alteration.

Record the TMJ diagnosis and supporting clinical findings.

Orthognathic Surgery Overview

Orthognathic surgery corrects abnormalities of the mandible, maxilla, or both by repositioning the affected jaw or jaws to improve alignment and function. Dentofacial deformities may be congenital, developmental, acquired, neoplastic, degenerative, or related to deficient or excessive skeletal growth. Functional effects may include impaired occlusion, chewing efficiency, bite forces, mandibular movement, swallowing, speech, nutrition, or myofascial function.

Clinical and Dental Terminology

Cephalometric

MeaningRelates to measurement and analysis of craniofacial skeletal, dental, and soft-tissue relationships

MethodUses standardized radiographic images

Clinical useAssesses dentofacial deformities and helps plan orthognathic treatment

Occlusion

DefinitionAlignment and contact relationship between the upper and lower teeth when the jaws are closed

Functional contextIncludes how the teeth fit together during biting and chewing

Clinical term

Policy Summary

PayerCigna

PolicyOrthognathic Surgery

Policy CodePolicy 0209

Change TypeModified

Effective DateOct 15, 2026

Next Review DateOct 15, 2027

Key ActionSubmit complete clinical and imaging documentation supporting the jaw deformity and functional impairment.

SourceLink

On This Page

Transverse discrepancies: A transverse skeletal discrepancy is two or more standard deviations from published norms; or total bilateral maxillary palatal cusp-to-mandibular fossa discrepancy is 4 mm or greater or unilateral discrepancy is 3 mm or greater with normal posterior-tooth axial inclination.4 mm bilateral or 3 mm unilateral cusp-to-fossa discrepancy

Asymmetry: Anteroposterior, transverse, or lateral asymmetry is greater than 3 mm and is accompanied by occlusal asymmetry.Greater than 3 mm

Documented functional impairment or associated disorder: Qualifying impairment or disorder is documented, such as inability to masticate or swallow adequately, malnutrition or failure to thrive, speech or articulation disorder, persistent myofascial pain, airway obstruction or sleep apnea, temporomandibular joint pathology, congenital or extrinsic craniofacial anomaly, or documented speech impairment.Myofascial pain at least 6 months despite conservative treatment

Specific associated-indication requirements are described elsewhere in the policy.

Functional impairment examples: Persistent inability to masticate and swallow adequately after other neurologic or metabolic causes have been ruled out; malnutrition, significant weight loss, or failure to thrive; speech and articulation disorder directly related to jaw deformity; myofascial pain persisting at least six months despite conservative treatment; or airway obstruction such as obstructive sleep apnea meeting the documented treatment and evaluation conditions.Myofascial pain at least 6 months

For airway obstruction, document sleep-study findings, attempted conservative treatment, and failure of less-invasive surgery when applicable.

Discrepancy typeAnteroposterior molar relationship discrepancy

Vertical skeletal discrepancy

Qualifying deviationTwo or more standard deviations from published norms

Anatomic referenceAccepted skeletal landmarks

Discrepancy typeVertical facial skeletal deformity

Posterior open bite

Qualifying measurementGreater than 2 mm

DistributionUnilateral or bilateral

FindingPosterior open bite

Transverse skeletal discrepancy

Qualifying deviationTwo or more standard deviations from published norms

Discrepancy typeTransverse skeletal discrepancy

Reference standardPublished norms

Maxillary palatal cusp to mandibular fossa discrepancy

Bilateral threshold4 mm or greater

Unilateral threshold3 mm or greater

Required tooth conditionNormal axial inclination of the posterior teeth

Facial asymmetry

Measurement thresholdGreater than 3 mm

Associated findingConcomitant occlusal asymmetry

Asymmetry typesAnteroposterior, transverse, or lateral asymmetry

Myofascial pain duration

Required durationAt least six months

Required treatment historyDespite conservative treatment

Examples of conservative treatmentPhysical therapy and splints

Horizontal overjet

AAOMS-cited thresholdHorizontal overjet of 5 mm or more

Alternative criterionHorizontal overjet of zero to negative value

Reference normThe cited norm is 2 mm

Anteroposterior molar relationship discrepancy

AAOMS-cited threshold4 mm or more

Relationship assessedMaxillary/mandibular anteroposterior molar relationship

Reference normThe cited norm is 0–1 mm

Posterior open bite

Qualifying measurementGreater than 2 mm

DistributionUnilateral or bilateral

FindingPosterior open bite

Transverse palatal cusp-to-fossa discrepancy

Bilateral threshold4 mm or greater

Unilateral threshold3 mm or greater

Required tooth conditionNormal axial inclination of the posterior teeth

Facial skeletal asymmetry

Measurement thresholdGreater than 3 mm

Associated findingConcomitant occlusal asymmetry

Asymmetry typesAnteroposterior, transverse, or lateral asymmetry

Persistent myofascial pain

Required durationAt least 6 months

Required treatment historyDespite conservative treatment

Example treatmentPhysical therapy

List the nonsurgical therapies attempted and the response to each.

Unsupported block type: documentation

Documentation Required

Required Clinical and Imaging Documentation

Submit complete clinical and imaging documentation supporting the need for orthognathic surgery. The record must describe the symptoms and specific anatomic deformity and include the required diagnostic studies and prior functional-impairment management records.

Medical history and physical examination addressing symptoms related to the deformity.
Specific description of the anatomic deformity.
Lateral and anterior-posterior cephalometric radiographs and cephalometric analysis.
Treating-physician records documenting evaluation, diagnosis, and previous management of functional impairment.
Clear, diagnostic-quality photographs demonstrating dental occlusion; molds or dental-model assessment may be requested.

Documentation Required

Substantiate Functional Impairment

Substantiate the qualifying functional impairment and connect it directly to the facial skeletal or jaw deformity. Speech dysfunction must be determined by a speech and language pathologist; other impairments must be documented with appropriate clinical evaluation and exclusion of alternative causes when required.

Document persistent mastication or swallowing difficulty after neurological and metabolic causes have been excluded.
Document malnutrition, significant weight loss, or failure to thrive secondary to the deformity.
For speech dysfunction, include qualified speech-language-pathologist findings linking the dysfunction to the jaw deformity.
For myofascial pain, document persistence for at least six months despite conservative treatment such as physical therapy and splints.

Documentation Required

Preoperative Diagnostic and Planning Records

Before requesting surgery, assemble the complete diagnostic and treatment-planning record for the planned three-dimensional skeletal and dental movements. The preoperative workup should support diagnosis, planning, and intraoperative positioning.

Complete history and physical examination plus skeletal, soft-tissue, and dental analyses.
High-quality standardized photographs, including appropriate intraoral, frontal, lateral, and three-quarter views.
Relevant imaging, such as panorex, posteroanterior and lateral cephalometric radiographs, and, when indicated, cone-beam CT.
Document anatomical landmarks, measurements, cephalometric tracings, dental models or casts, model surgery, and the planned occlusal splint.

Documentation Required

Document Associated Functional Impairments

For associated functional impairments, provide objective documentation of the condition, its cause and anatomic site, and the treatment history supporting surgery. The record should show that appropriate nonoperative measures were attempted when indicated.

For airway or sleep-related impairment, include a sleep study and airway evaluation identifying the cause and site of obstruction.
Document CPAP, oral appliance, or other conservative treatment attempts and outcomes when applicable.
Link the impairment to the facial skeletal discrepancy and document relevant causation.
Include qualified speech evaluation for speech impairment and prior nonsurgical management for TMJ, psychological, or other applicable conditions.

Denial Risk

Verify Coverage, Diagnosis, and Coding

Claims may be denied when the diagnosis or procedure is not covered, required covered codes are absent, or the customer's benefit plan excludes the service. The applicable benefit plan document controls when it differs from the policy.

Verify the diagnosis and procedure codes are covered under the applicable policy and benefit plan.
Submit the most appropriate codes in effect on the date of service.
Confirm plan-specific exclusions and coverage terms before rendering services.

Denial Risk

Meet All Medical-Necessity Domains

Orthognathic surgery is subject to all applicable medical-necessity domains, not merely one qualifying finding. Incomplete clinical documentation, failure to demonstrate a qualifying skeletal deformity, or failure to substantiate a qualifying functional impairment creates denial risk.

Meet the complete documentation requirements.
Document at least one qualifying facial skeletal deformity using the applicable measurements or findings.
Document at least one qualifying functional impairment and its relationship to the deformity.
Include requested diagnostic studies, photographs, and prior management records.

Denial Risk

Cosmetic Adjunctive Procedures

Contour correction, fat grafting, genioplasty, rhinoplasty, and rhytidectomy are cosmetic and not medically necessary when performed with orthognathic surgery solely to improve appearance or profile.

Do not represent these adjunctive procedures as medically necessary solely because they accompany covered orthognathic surgery.
Document a separate covered functional indication if one exists and is applicable under the benefit plan.

Denial Risk

Cosmetic-Purpose Procedures

Procedures performed primarily to improve physical appearance or to treat psychological symptomatology or psychosocial complaints are considered cosmetic in nature and may be denied.

Establish and document the functional abnormality being corrected.
Do not rely on appearance-related, psychological, or psychosocial goals as the primary medical-necessity rationale.

Supraeruption

DefinitionExcessive eruption or extrusion of a tooth beyond its normal position in the jaw

Common circumstanceMay occur when an opposing tooth is missing

Anatomic descriptionA tooth extends beyond its normal jaw position

Class I occlusion

ClassificationClass I, or neutro-occlusion

Maxillary landmarkMesiobuccal cusp of the maxillary first molar

Mandibular landmarkArticulates within the mesiobuccal groove of the mandibular first molar

Class II occlusion

ClassificationClass II, or disto-occlusion

Molar relationshipThe mandibular first molar articulates distal to the mesiobuccal cusp of the maxillary first molar

Associated patternsIncludes Division I and Division II patterns and may reflect lower-jaw deficiency or upper-jaw excess

Class III occlusion

ClassificationClass III, or mesio-occlusion

Molar relationshipThe mesiobuccal groove of the mandibular first molar is mesial to the mesiobuccal cusp of the maxillary first molar

Common presentationMay produce a protruding chin or underbite due to mandibular excess or maxillary deficiency

Distraction osteogenesis

DefinitionA distraction device is applied to bone

Surgical processA controlled fracture is created and the bone segments are gradually separated

ResultNew bone formation allows lengthening of facial bone and adjacent soft tissue

Orthognathic surgery

Primary techniqueAn osteotomy is made in the affected jaw

PurposeJaw bones are repositioned into a more normal alignment

StabilizationPlates, screws, and/or wires hold the bones in position; intermaxillary fixation may provide added stability