Application and removal of interdental fixation (CPT 21110) is covered only when performed as an adjunct to surgical repositioning tied to a medically necessary orthognathic procedure. Authorization decisions are made based on medical necessity at the time the authorization is issued and do not guarantee payment; payment depends on the member having active coverage and applicable benefits at the time of service.

Prior authorization is required for orthognathic surgery and associated procedures, and requests are reviewed according to surgical prior authorization procedures using case-specific information. To support a request for an oral surgical splint (CPT 21085) or interdental fixation (CPT 21110), submit a fully completed authorization request via the online web portal, include clinical documentation from the requesting physician/APRN/PA that demonstrates the medical necessity per the Clinical Guideline, and provide any additional information requested. Failure to provide required documentation or to obtain prior authorization may result in denial of the request.

Orthognathic surgery involves surgical correction of skeletal abnormalities of the mandible and maxilla to improve functional impairments such as speech and chewing. Underlying deformities may be congenital, developmental, or post-traumatic; the primary goal of these procedures is functional improvement through correction of the skeletal deformity. When available, HUSKY Health uses InterQual criteria to review prior authorization requests and applies the Department of Social Services definition of Medical Necessity to coverage determinations.