EmblemHealth Orthognathic Surgery Coverage Update

Coverage Criteria

Medically Necessary Criteria

Orthognathic surgery is medically necessary when ALL of the following groups apply as specified below:

Primary indications

Anteroposterior discrepancies: Either: horizontal overjet ≥ 5 mm OR zero to negative incisor relationship (norm ~2 mm) OR maxillary/mandibular anteroposterior molar relationship discrepancy ≥ 4 mmoverjet ≥5 mm; molar discrepancy ≥4 mm
Numeric values represent ≥2 standard deviations from published norms
Vertical discrepancies: Any of: vertical facial skeletal deformity ≥ 2 SDs from norms for accepted skeletal landmarks; open bite (no vertical overlap of anterior teeth OR unilateral/bilateral posterior open bite > 2 mm); deep overbite with impingement/irritation of buccal, palatal or lingual soft tissues; supraeruption of a dentoalveolar segment causing dysfunction not amenable to conventional prostheticsvaries (≥2 SDs; open bite >2 mm)
Includes functional consequences such as soft tissue impingement
Transverse discrepancies: Either: transverse skeletal discrepancy ≥ 2 SDs from norms OR total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm OR unilateral discrepancy ≥ 3 mm (given normal axial inclination of posterior teeth)≥2 SDs or bilateral ≥4 mm or unilateral ≥3 mm
Measurements assume normal axial inclination of posterior teeth
Asymmetries: Anteroposterior, transverse or lateral facial asymmetries > 3 mm with concomitant occlusal asymmetry (e.g., maxillary cant or cross-bite)>3 mm
Clinically correlated with occlusal asymmetry
Sleep apnea / airway deficiency: Facial skeletal discrepancies (congenital or acquired) that contribute to obstructive sleep apnea or other significant functional airway deficiency as documented; evaluate per referenced MCG criteria
Refer to MCG A-0247, A-0248, or SG-HNS as applicable
Speech impairments secondary to malocclusion: Speech abnormalities secondary to malocclusion (e.g., from cleft deformity) are covered when: impairment is determined by a speech pathologist or therapist; post-surgical improvement is expected (speech pathologist determination); and impairment is refractory to orthodontic management AND at least 6 months of speech therapy6 months speech therapy trial
Speech pathologist determination and documented trial of orthodontic management required

Documentation and preauthorization: Treating physician must submit preauthorization and documentation demonstrating member meets the above clinical criteria, including study models (plaster, printed, or digital), pre-orthodontic photographic and radiographic imaging, cephalometric analysis, and medical record documentation of objective functional impairment (e.g., difficulty with mastication, speech, swallowing, nutrition)

Failure to submit required documentation may result in denial

Orthognathic surgery performed solely to improve facial appearance is considered cosmetic and not medically necessary. This includes procedures where the anatomic variation is within normal limits and the member seeks aesthetic change; psychological motivation (for example, self-esteem) is not a basis for coverage. Additionally, genioplasty is categorized as cosmetic and not medically necessary under these limitations.

Use of three-dimensional virtual treatment planning for orthognathic surgery is classified as investigational and not medically necessary because its effectiveness has not been established in the published literature.

Placement or use of condylar positioning devices in orthognathic surgery is considered experimental/investigational and not medically necessary due to insufficient evidence that these devices improve outcomes for orthognathic procedures.

Within the provided document segment there are no additional explicit exclusions beyond those listed in the Limitations/Exclusions section; applicable diagnosis code guidance and other coding lists are provided elsewhere in the policy.

Orthognathic surgery is listed as investigational for correction of articulation disorders and other speech production impairments when there is insufficient evidence of therapeutic benefit. An exception exists for speech impairment associated with a severe cleft palate, where coverage considerations differ and surgical treatment may be appropriate when supported by the policy and a speech pathologist’s assessment.

No explicit additional entries labeled as 'not medically necessary' are present in this segment beyond the investigational statements and specific limitations already noted in the policy's Limitations/Exclusions section.

Coding

Applicable Procedure CodesCPT

21076	Impression and custom preparation; surgical obturator prosthesis.
21079	Impression and custom preparation; interim obturator prosthesis.
21080	Impression and custom preparation; definitive obturator prosthesis.
21081	Impression and custom preparation; mandibular resection prosthesis.
21082	Impression and custom preparation; palatal augmentation prosthesis.
21083	Impression and custom preparation; palatal lift prosthesis.
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; 2 pieces, segment movement in any direction, without bone graft.

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Applicable ICD-10 Diagnosis CodesICD-10

G47.33	Obstructive sleep apnea (adult) (pediatric).
M26.00	Unspecified anomaly of jaw size.
M26.01	Maxillary hyperplasia.
M26.02	Maxillary hypoplasia.
M26.03	Mandibular hyperplasia.
M26.04	Mandibular hypoplasia.
M26.05	Macrogenia.
M26.06	Microgenia.
M26.07	Excessive tuberosity of jaw.
M26.09	Other specified anomalies of jaw size.

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Applicable ICD-10: Dentofacial anomaly codesICD-10Covered

M26.55	Insufficient anterior guidance = Centric occlusion maximum intercuspation discrepancy
M26.56	Insufficient anterior guidance = Non-working side interference
M26.57	Insufficient anterior guidance = Lack of posterior occlusal support
M26.59	Insufficient anterior guidance = Other dentofacial functional abnormalities
M26.70	Insufficient anterior guidance = Unspecified alveolar anomaly
M26.71	Insufficient anterior guidance = Alveolar maxillary hyperplasia
M26.72	Insufficient anterior guidance = Alveolar mandibular hyperplasia
M26.73	Insufficient anterior guidance = Alveolar maxillary hypoplasia
M26.74	Insufficient anterior guidance = Alveolar mandibular hypoplasia
M26.79	Insufficient anterior guidance = Other specified alveolar anomalies

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Applicable ICD-10: Cleft lip/palate codesICD-10Covered

Q35.1	Cleft hard palate
Q35.3	Cleft soft palate
Q35.5	Cleft hard palate with cleft soft palate
Q35.7	Cleft uvula
Q35.9	Cleft palate, unspecified
Q36.0	Cleft lip, bilateral
Q36.1	Cleft lip, median
Q36.9	Cleft lip, unilateral
Q37.0	Cleft hard palate with bilateral cleft lip
Q37.1	Cleft hard palate with unilateral cleft lip

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Anatomic measurement thresholds

Horizontal overjet≥ 5 mm (≥2 SDs from norms)

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

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

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

Transverse discrepancyTransverse skeletal discrepancy ≥ 2 SDs OR total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm (or unilateral ≥ 3 mm)

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

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Preauthorization is required. The treating physician or primary care provider must submit clinical evidence that the member meets the medical necessity criteria prior to the procedure. EmblemHealth will not be able to properly review the request without this documentation for preauthorization or post-payment review.

Prior authorization required before scheduling orthognathic surgery

Documentation Required

Diagnosis Codes Required for Prior Authorization

Documentation must include appropriate ICD-10 diagnosis codes from the M26 and Q35–Q37 series to substantiate medical necessity. Use one of the applicable diagnosis codes when requesting prior authorization and when billing orthognathic procedures.

Use appropriate ICD-10 codes from M26 and Q35–Q37 series (see policy ICD-10 list)

Background

Orthognathic surgery comprises procedures that realign the maxillofacial skeleton—principally the maxilla and mandible—to correct malocclusion and related functional impairments. Typical operations include LeFort osteotomies of the maxilla and sagittal split or other osteotomies of the mandible, often performed with rigid fixation to restore occlusion. Indications focus on functional benefit when orthodontic treatment alone is insufficient, addressing problems such as impaired mastication, speech or swallowing, and craniofacial contributions to airway compromise (including selected cases of obstructive sleep apnea).

Definitions

Malocclusion / Class II / Class III

Malocclusion (definition)Imperfect contact between mandibular and maxillary teeth.

Class II (brief)Mandibular teeth are distal/posterior to normal relation with maxillary teeth (overbite); may reflect mandibular deficiency or maxillary excess; includes Division I and II presentations.

Class III (brief)Mandibular dental arch positioned anterior to the maxillary arch (underbite).

Genioplasty

Genioplasty (definition)Plastic surgery of the chin; noted in the policy Limitations/Exclusions as considered cosmetic and not medically necessary.

ContextMay be performed as a cosmetic adjunct to orthognathic procedures but is separately classified as plastic/chin surgery in exclusions.