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Defines medical necessity criteria, prior authorization requirements, plan variations (Commercial, MassHealth, Medicare Advantage), covered indications and exclusions for oral and maxillofacial surgery including cleft lip/palate, orthognathic surgery, TMJ arthroplasty, airway procedures, tumor/fracture management, and certain dental-related inpatient procedures.
July 2025: Annual update. Clarified MassHealth variation.
April 2025: Added Summary of Evidence. References updated.
October 2024: Added MassHealth Variation. Clarified Medicare Variation.
July 2024: Clarified language around coverage of tooth extraction.
This policy is issued by Mass General Brigham Health Plan to define medical appropriateness and authorization requirements for a broad range of oral and maxillofacial surgery and related procedures. It applies across plan variations including Commercial, MassHealth, and Medicare Advantage, with plan-specific authorization rules and references to external guidance where noted.
Covered service categories at a high level include repair and reconstruction of cleft lip and cleft palate (with age-based prior authorization rules), orthognathic surgery and TMJ arthroplasty evaluated via InterQual criteria, surgical management of tumors, facial fractures and osteoradionecrosis, airway procedures (including maxillomandibular or mandibular advancement for obstructive sleep apnea when criteria are met), and certain dental-related procedures performed in inpatient or surgical settings when medically necessary.
Medically Necessary Oral and Maxillofacial Surgery
Mass General Brigham Health Plan covers oral and maxillofacial surgery and procedures when medically necessary and covered under the member's benefit package. Coverage requires submission of clinical information, imaging, and documentation as noted.
ALL of the following
Cleft lip/palate by age
SLP evaluation required
Airway dysfunction due to significant skeletal abnormality (one of following)
Refer to Member Handbook for plan-specific circumstances for extractions
Required Clinical Documentation
Submit clinical information to support medical necessity determinations, including the presenting problem(s), past medical/surgical interventions and results, clear photographic and/or radiographic evidence, and the recommended intervention. Where indicated, include Panorex and cephalometric radiographs (lateral and PA orientation) with analyses, plus any other tracings or imaging that support the analysis or treatment plan.
SLP Evaluation for Poor Intelligibility
A Speech Language Pathology (SLP) evaluation is required for cases of poor intelligibility when speaking in sentences. The SLP report must substantiate the degree of impairment, document failed non‑surgical treatments, and attest to the expected improvement from surgery.
Cosmetic Exclusion
Procedures performed solely to enhance appearance without signs or symptoms of functional abnormality or associated medical complication are considered cosmetic and are not covered; claims for cosmetic‑only surgery risk denial.
TMJ Arthroplasty
Medical necessity for arthroplasty for TMJ is determined using InterQual criteria.
Authorization Required for Most OMFS Procedures
Authorization is required for most oral and maxillofacial procedures. Medical necessity for orthognathic surgery and for TMJ arthroplasty is determined using InterQual criteria accessible via the plan’s provider website; look up the applicable InterQual subset using the procedure CPT code.
| 21010 | Arthrotomy temporomandibular joint |
| 21029 | Removal by contouring of benign tumor of facial bone |
| 21060 | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) |
| 21100 | Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) |
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement |
| 21142 | Reconstruction midface, LeFort I; 2 pieces, segment movement; requiring bone grafts (includes obtaining autografts) |
| 21145 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement |
| 21146 | Reconstruction midface, LeFort I; 2 pieces, segment movement, requiring bone grafts |
| 21147 | Reconstruction midface, LeFort I; 3 or more pieces, requiring bone grafts |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion |
Prior Authorization for Cleft Repair in Adults
Prior authorization is required for cleft lip, palate, and nasolabial repair for members 18 years of age and older.
Inpatient/Surgical Setting Requirement for Certain Dental Procedures
Removal of 7 or more permanent teeth, excision of radicular cysts involving roots of three or more teeth, extraction of impacted teeth, and gingivectomies of two or more gum quadrants are covered only when the member has a serious medical condition that makes admission to an acute care hospital or a surgical care setting essential for safe performance. Coverage nuances for extraction of impacted teeth vary by plan; MassHealth specifies inpatient or surgical care unit/ambulatory surgical facility when medically necessary.
Scope: The policy describes Mass General Brigham Health Plan’s criteria for determining medical necessity for oral and maxillofacial surgery and procedures and sets documentation and prior authorization requirements. Providers must submit presenting problems, prior interventions and results, clear photographic and/or radiographic evidence, and recommended interventions to support coverage determinations.
InterQual references: Medical necessity determinations for orthognathic surgery and for temporomandibular joint (TMJ) arthroplasty are made using InterQual criteria; providers are directed to the plan’s provider website InterQual Criteria Lookup and to search by CPT code to access the applicable InterQual subset.
Plan variations: Authorization is required for most procedures for Commercial and Qualified Health Plans and for MassHealth as indicated; cleft lip and palate repair for members under 18 years old is exempt from prior authorization for Commercial members (MassHealth may differ); Medicare Advantage coverage decisions follow CMS guidance (NCDs/LCDs/LCAs) when available and otherwise use this medical policy. Specific coverage of extractions and other dental procedures varies by plan and may require inpatient or surgical care setting documentation for coverage.
Primary surgery for cleft lip and palate: Surgery undertaken to repair the cleft lip deformity, repair the cleft palate, or replace bone in the alveolar cleft (graft); the repair is often completed in stages.
Significant malocclusion: A malocclusion that cannot be corrected by orthodontic treatment alone.
Temporomandibular joint (TMJ): A syndrome evident by severe aching pain in and around the temporomandibular joint, often worsened by chewing, and frequently accompanied by clicking and limited joint movement.
At time of last policy review there was no NCD/LCD for oral and/or maxillofacial surgery procedures.
Annual update: Clarified MassHealth variation.
Added Summary of Evidence; references updated. No change to coverage criteria.
Added MassHealth variation and clarified Medicare variation language.
Clarified language around coverage of tooth extraction (extraction of impacted teeth coverage varies by plan; refer to Member Handbook).