Obtain prior authorization; InterQual® applied for Medicare & Community Care

Prior authorization is required for orthognathic surgery. For Medicare and Community Care members, Fallon Health will apply the InterQual® CP Procedures listed in the policy (Orthognathic Surgery and related CP Procedures) when making medical necessity determinations, effective for dates of service on and after September 1, 2025.

• Obtain prior authorization per the member's product rules before scheduling orthognathic procedures.
• For Medicare and Community Care members, ensure the request is reviewed against the InterQual® CP Procedures in effect on the date of service.

Follow product- and program-specific authorization rules

Follow the authorization rules specific to the member's product: Medicare Advantage, MassHealth, NaviCare, PACE and other Fallon products have program-specific requirements and hierarchy for coverage determinations.

• For Medicare Advantage and NaviCare members, comply with applicable CMS NCDs and LCDs first; when those do not establish criteria, follow InterQual® or MassHealth guidance as specified.
• For MassHealth members, Fallon generally follows MassHealth Medical Necessity Guidelines where applicable.
• For PACE members, obtain authorization through the member's Interdisciplinary Team as required.

Attempt and document non-surgical therapies when indicated

Prior to performing orthognathic surgery for TMJ-related symptoms or suspected airway dysfunction, document that appropriate non-surgical therapies were attempted when indicated per AAOMS guidance.

• Document types of non-surgical therapies attempted (e.g., occlusal therapies, conservative TMJ treatments, airway evaluation and non-surgical management).
• Ensure non-surgical treatment attempts are reflected in the clinical record submitted with the authorization request.

Document how the case meets InterQual® criteria and submit supporting records

Include detailed clinical documentation showing how the member's case meets the applicable InterQual® CP Procedure criteria (as in effect on the date of service); submit supporting records and objective measurements referenced by InterQual® and the policy.

• Reference the specific InterQual® CP Procedure used for the decision (e.g., Orthognathic Surgery, Pediatric Orthognathic Surgery, Bone Augmentation modules).
• Provide supporting clinical documentation: history, exam findings, imaging, measured AP/vertical/transverse/asymmetry thresholds, and prior conservative treatments.

Comply with CMS NCDs/LCDs and program statutes; follow MassHealth guidance where applicable

For Medicare Advantage members, follow CMS national and local coverage determinations and applicable statutes/regulations when making medical necessity requests; for MassHealth members, Fallon generally follows MassHealth Medical Necessity Guidelines where applicable.

• When CMS NCDs/LCDs do not fully establish criteria, Fallon may apply InterQual® or create internal criteria as permitted under applicable regulations.
• For NaviCare members, follow CMS NCDs/LCDs first; if criteria are not met or absent, follow MassHealth guidelines per the policy instructions.

Avoid requesting coverage for excluded/cosmetic indications — risk of denial

Do not submit authorization requests for procedures that are primarily cosmetic, intended for dentures or dental implants, or intended to correct malocclusions manageable by standard dental or orthodontic care; such requests are subject to denial.

• If the clinical indication is cosmetic or for isolated mentoplasty/genial procedures, note that these are excluded and will risk denial.
• Ensure the clinical record demonstrates functional impairment and medical necessity rather than cosmetic intent.

Confirm member-specific benefit coverage and EOC — some services may be excluded by plan

Ensure the authorization request and documentation also address product-specific coverage limitations: services noted in this policy may not be covered for all products or employer groups and coverage is determined by the member's benefit plan and Evidence of Coverage.

• Confirm the member's specific plan benefits and Evidence of Coverage for exclusions or benefit limits prior to relying solely on medical necessity determinations.
• If there is any discrepancy between this policy and the member's benefit plan, the benefit plan provisions govern.