CurrentEmblemHealthPolicy MG.MM.SU.59b

Orthognathic Surgery — Applicable ICD-10 Diagnosis Codes and References

This document section lists applicable ICD-10 diagnosis codes related to cleft lip/palate presentations and provides the reference bibliography supporting the orthognathic surgery policy; it affects providers submitting claims or prior authorization for orthognathic procedures.

Policy Summary

PayerEmblemHealth

PolicyOrthognathic Surgery — Applicable ICD-10 Diagnosis Codes and References

Policy CodePolicy MG.MM.SU.59b

Change TypeNo material change

Effective Date

Next Review DateApr 14, 2023

Key ActionInclude and document the applicable ICD-10 diagnosis from the listed codes when submitting prior authorization for cleft lip/palate–related orthognathic procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9ICD-10 diagnosis codes listed for cleft lip/palate

3+Reference entries (bibliography)

Applicable Diagnosis Codes

Applicable ICD-10 Diagnosis CodesICD-10

Q36.9	Cleft lip, unilateral.
Q37.0	Cleft hard palate with bilateral cleft lip.
Q37.1	Cleft hard palate with unilateral cleft lip.
Q37.2	Cleft soft palate with bilateral cleft lip.
Q37.3	Cleft soft palate with unilateral cleft lip.
Q37.4	Cleft hard and soft palate with bilateral cleft lip.
Q37.5	Cleft hard and soft palate with unilateral cleft lip.
Q37.8	Unspecified cleft palate with bilateral cleft lip.
Q37.9	Unspecified cleft palate with unilateral cleft lip.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. When submitting a prior authorization request and supporting clinical documentation for cleft lip/palate–related procedures, include one of the applicable ICD-10 diagnosis codes from the list below that accurately reflects the member's condition.

Q36.9 — Cleft lip, unilateral
Q37.0 — Cleft hard palate with bilateral cleft lip
Q37.1 — Cleft hard palate with unilateral cleft lip
Q37.2 — Cleft soft palate with bilateral cleft lip

Policy Summary

PayerEmblemHealth

PolicyOrthognathic Surgery — Applicable ICD-10 Diagnosis Codes and References

Policy CodePolicy MG.MM.SU.59b

Change TypeNo material change

Effective Date

Next Review DateApr 14, 2023

Key ActionInclude and document the applicable ICD-10 diagnosis from the listed codes when submitting prior authorization for cleft lip/palate–related orthognathic procedures.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Background

This section lists the specific ICD-10 diagnosis codes for cleft lip and palate variants that are relevant when considering orthognathic surgical procedures. Providers submitting claims or prior authorization requests for orthognathic surgery related to cleft conditions must ensure the member’s record documents one of these diagnoses: Q36.9 (cleft lip, unilateral), Q37.0 (cleft hard palate with bilateral cleft lip), Q37.1 (cleft hard palate with unilateral cleft lip), Q37.2 (cleft soft palate with bilateral cleft lip), Q37.3 (cleft soft palate with unilateral cleft lip), Q37.4 (cleft hard and soft palate with bilateral cleft lip), Q37.5 (cleft hard and soft palate with unilateral cleft lip), Q37.8 (unspecified cleft palate with bilateral cleft lip), and Q37.9 (unspecified cleft palate with unilateral cleft lip).

Definitions (Selected ICD-10 entries)

Q36.9 — Cleft lip, unilateral

ICD-10 codeQ36.9 — Cleft lip, unilateral.

Use in prior authorizationInclude Q36.9 on prior authorization and clinical documentation when billing for related orthognathic procedures.

Denial riskClaims using diagnosis codes outside the listed applicable ICD-10 codes (including Q36.9) may be denied if documentation does not support coverage.

Q37.0 - Q37.9 — Cleft palate with associated cleft lip variants

ICD-10 code rangeQ37.0–Q37.9 — Cleft palate variants with associated unilateral or bilateral cleft lip and unspecified palate codes (see list below).

Specific codesQ37.0: Cleft hard palate with bilateral cleft lip; Q37.1: Cleft hard palate with unilateral cleft lip; Q37.2: Cleft soft palate with bilateral cleft lip; Q37.3: Cleft soft palate with unilateral cleft lip; Q37.4: Cleft hard and soft palate with bilateral cleft lip; Q37.5: Cleft hard and soft palate with unilateral cleft lip; Q37.8: Unspecified cleft palate with bilateral cleft lip; Q37.9: Unspecified cleft palate with unilateral cleft lip.

Documentation requirementClinical documentation must support one of the Q37.x diagnoses when billing for procedures related to orthognathic surgery.

References / Bibliography

Aghabeigi B, Hiranaka D, Keith DA, et al. Effect of orthognathic surgery on the temporomandibular joint in patients with anterior open bite. Int J Adult Orthodon Orthognath Surg. 2001;16(2):153-160.

Ahn SJ, Kim JT, Nahm DS. Cephalometric markers to consider in the treatment of Class II Division 1 malocclusion with the bionator. Am J Orthod Dentofacial Orthop. 2001;119(6):578-586.

American Association of Oral and Maxillofacial Surgeons. Criteria for Orthognathic Surgery. 2013. https://www.aaoms.org/docs/practice_resources/clinical_resources/ortho_criteria.pdf. Accessed April 28, 2023.

American Association of Oral and Maxillofacial Surgeons. Guidelines to the evaluation of impairment of the oral and maxillofacial region. 2008. https://www.aaoms.org/docs/practice_resources/clinical_resources/impairment_guidelines.pdf. Accessed April 28, 2023.

American Association of Oral and Maxillofacial Surgeons. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery. Sixth ed. 2017. http://www.aaoms.org/images/uploads/pdfs/parcare_assessment.pdf. Accessed April 28, 2023.

Cheung LK, Lo J. The long-term clinical morbidity of mandibular step osteotomy. Int J Adult Orthod Orthognath Surg. 2002;17(4):283-290.

Han H, Davidson WM. A useful insight into 2 occlusal indexes: HLD(Md) and HLD(CalMod). Am J Orthod Dentofacial Orthop. 2001;120(3):247-253.

Huang CS, Hsu SS, Chen YR. Systematic review of the surgery-first approach in orthognathic surgery. Biomed J. 2014;37(4):184-190.

Incisivo V, Silvestri A. The reliability and variability of SN and PFH reference planes in cephalometric diagnosis and therapeutic planning of dentomaxillofacial malformations. J Craniofacial Surg. 2000;11(1):31-38.

Kim JC, Mascarenhas AK, Joo BH, et al. Cephalometric variables as predictors of Class II treatment outcome. Am J Orthod Dentofacial Orthop. 2000;118(6):636-640.

Mihalik CA, Profitt WR, Phillips C. Long-term follow-up of Class II adults treated with orthodontic camouflage: a comparison with orthognathic surgery outcomes. Am J Orthod Dentofacial Orthop. 2003;123(3):266-278.

Nickel JC, Yao P, Spalding PM, Iwasaki LR. Validated numerical modeling of the effects of combined orthodontic and orthognathic surgical treatment on TMJ loads and muscle forces. Am J Orthod Dentofacial Orthop. 2002;121(1):73-83.

Oguri Y, Yamada K, Fukui T, et al. Mandibular movement and frontal craniofacial morphology in orthognathic surgery patients with mandibular deviation and protrusion. J Oral Rehabil. 2003;30(4):392-400.

Oomens MA, Verlinden CR, Goey Y, Forouzanfar T. Prescribing antibiotic prophylaxis in orthognathic surgery: a systematic review. Int J Oral Maxillofac Surg. 2014;43(6):725-731.

Park JE, Baik SH. Classification of angle Class III malocclusion and its treatment modalities. Int J Adult Orthod Orthognath Surg. 2001;16(1):19-29.

Ruf S, Pancherz H. Orthognathic surgery and dentofacial orthopedics in adult Class II Division 1 treatment: mandibular sagittal split osteotomy versus Herbst appliance. Am J Orthod Dentofacial Orthop. 2004;126(2):140-152.

Stellzig-Eisenhauser A, Lux CJ, Schuster G. Treatment decision in adult patients with Class III malocclusion: orthodontic therapy or orthognathic surgery? Am J Orthod Dentofacial Orthop. 2002;122(1):27-38.

Wolford LM, Karras S, Mehra P. Concomitant temporomandibular joint and orthognathic surgery: a preliminary report. J Oral Maxillofac Surg. 2002;60(4):356-362.

Wolford LM, Karras SC, Mehra P. Consideration for orthognathic surgery during growth, part 1: mandibular deformities. Am J Orthod Dentofacial Orthop. 2001;119(2):95-101.

Wolford LM, Karras SC, Mehra P. Consideration for orthognathic surgery during growth, part 2: maxillary deformities. Am J Orthod Dentofacial Orthop. 2001;119(2):102-105.

Yamada K, Hanada K, Hayashi T, Ito J. Condylar bony change, disk displacement, and signs and symptoms of TMJ disorders in orthognathic surgery patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(5):603-610.