CurrentMass General Brigham Health PlanPolicy N/A

Medical Policy Oral and Maxillofacial Surgery and Procedures

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.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Oral and Maxillofacial Surgery and Procedures

Policy CodePolicy N/A

Change TypeClarification / Annual updates (most recent: July 2025)

Effective DateFeb 1, 2011

Next Review DateN/A

Key ActionSubmit required clinical documentation (history, prior interventions, clear photographic/radiographic evidence, Panorex and cephalometric radiographs where indicated) and obtain prior authorization when required (e.g., adult cleft repairs and most OMFS procedures).

SourceLink

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.

POLICY UPDATE CHANGES

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.

1Prior Auth requirement for adult cleft repair

15Years since effective date (approx)

~70+CPT codes listed

Coverage Summary

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.

Policy thresholds and dates

Obstructive Sleep Apnea severityModerate or severe OSA: AHI/RDI >= 15; Mild OSA: AHI/RDI 5-14 with significant O2 desaturations and/or Epworth Sleepiness Scale >9

Effective date2011-02-01

Last review date2025-07-01

StatusCURRENT

Approximate CPT count~70+ CPT codes listed

Medical-Necessity Criteria

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

Required documentation: Specialist and/or primary care provider must submit presenting problems, past medical/surgical interventions and results, clear photographic and/or radiographic evidence, and recommended interventions necessary for determination of coverage
Cleft lip/palate by age
- Pediatric cleft repair: For members under age 18: Primary and secondary cleft lip and cleft palate repair, reconstruction, and excision do not require prior authorization

Not Covered / Exclusions

Denial Risk

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 / InterQual Determinations

TMJ Arthroplasty

Medical necessity for arthroplasty for TMJ is determined using InterQual criteria.

InterQual TMJ arthroplasty: Access InterQual Arthroplasty, TMJ criteria via provider website InterQual Criteria Lookup using CPT code for the procedure

Prior Authorization

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.

Coding

Informational CPT Codes (Commercial and MassHealth)CPT

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

1–10 of 68

1/7

Provider Actions

Prior Authorization

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.

Billing Rule

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.

Background and Evidence Sources

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.

Guideline sourcesAmerican Cleft Palate Association (2024); van der Molen et al. (2021); AAOMS (2023); MassHealth Guidelines (2022); multiple systematic reviews cited

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.

Medicare Determinations

At time of last policy review there was no NCD/LCD for oral and/or maxillofacial surgery procedures.

Revision History

July 2025annual_updateLatest

Annual update: Clarified MassHealth variation.

April 2025content_added

Added Summary of Evidence; references updated. No change to coverage criteria.

October 2024ad_hoc_update

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Oral and Maxillofacial Surgery and Procedures

Policy CodePolicy N/A

Change TypeClarification / Annual updates (most recent: July 2025)

Effective DateFeb 1, 2011

Next Review DateN/A

SourceLink

On This Page

For members 18 years of age and older: Prior authorization is required for cleft lip, palate, and nasolabial repair

Orthognathic surgery for correction of a significant skeletal abnormality when medical necessity is met per InterQual criteria (access via plan provider website using CPT code)

Poor intelligibility indication: Oral/maxillofacial surgery for poor intelligibility when speaking in sentences when all other modalities have failed and documented Speech Language Pathology (SLP) evaluation attests to impairment and expected improvement from surgery

SLP evaluation required

Craniofacial anomalies: Surgical correction of skeletal abnormalities associated with congenital and syndromic craniofacial anomalies requiring repair for nutritional or airway compromise or brain development (e.g., Pierre Robin, Apert, Treacher Collins) with required documentation including history, exam photos, Panorex and cephalometric radiographs, analyses, and other supporting imaging/tracings

Tumor/fracture/osteoradionecrosis: Medically necessary treatment of oral/maxillofacial tumor, facial fractures/dislocations, or osteoradionecrosis of the jaw due to head and neck radiation with required documentation (history, exam, X-rays/CT/photographs demonstrating bone involvement when applicable)

Airway dysfunction due to significant skeletal abnormality (one of following)

Maxillomandibular/mandibular advancement for OSA: Maxillomandibular or mandibular advancement for sleep apnea: document moderate or severe OSA (AHI/RDI >= 15) OR mild apnea (AHI/RDI 5-14) with significant O2 desaturations and/or Epworth Sleepiness Scale >9; failure of PAP titration or adherence despite coaching and adjustments OR failure of an oral appliance due to ineffectiveness or intolerance; if obese, documentation that weight loss was discussed; and requested surgical procedure expected to significantly improve OSA as evidenced by lateral cephalometric radiographs with tracings/measurements/predictions or by 3D CT scan of the upper airwayAHI/RDI thresholds per policy
Other skeletal airway compromise: For other skeletal abnormalities causing airway compromise: documentation of clinical history, photos, Panorex and cephalometric radiographs with analysis and other supporting tracings/imaging

Other covered inpatient/acute surgical oral services (GIC and MassHealth context): Removal of 7 or more permanent teeth, excision of radicular cysts involving roots of 3+ teeth, extraction of impacted teeth, gingivectomies of 2+ gum quadrants when member has serious medical condition requiring acute care hospitalization or surgical care setting for safe performance; MassHealth: medically necessary oral surgery (including extraction of impacted wisdom teeth) performed inpatient or in a surgical care unit/ambulatory surgical facility when member has serious medical condition making hospitalization or surgical day care essential

Refer to Member Handbook for plan-specific circumstances for extractions

Documentation Required

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.

Documentation Required

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.

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.

Added MassHealth variation and clarified Medicare variation language.

July 2024annual_update

Clarified language around coverage of tooth extraction (extraction of impacted teeth coverage varies by plan; refer to Member Handbook).