CurrentMass General Brigham Health PlanPolicy N/A

Oral and Maxillofacial Surgery Coverage

Governs reimbursement and medical necessity criteria for oral and maxillofacial surgical services for Mass General Brigham Health Plan members, including TMJ, orthognathic surgery, cleft lip/palate, and related procedures. Affects participating providers seeking payment and requiring prior authorization/referral as specified.

Policy Summary

PayerMass General Brigham Health Plan

PolicyOral and Maxillofacial Surgery Coverage

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization for orthognathic procedures and oral surgery for members age 19 and older; verify referral number for non-emergency specialty care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredPA requirement for members 19 and older

No PA <19PA exemption for commercial members <19

15 codesProcedure codes provided

ExcludedOrthodontia excluded

Coverage Criteria for Oral & Maxillofacial Surgery

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Covered indications for oral and maxillofacial surgery

Covered when ANY of the following functional indications are present:

Covered Indications: Significant difficulties with mastication

Covered Indications: Inadequate growth, weight loss, and/or nutritional deficiency due to interference with eating

Covered Indications: Airway dysfunction not amenable to non-surgical treatment (e.g., obstructive sleep apnea, congenital or syndromic craniofacial anomalies such as Pierre Robin, Apert, Treacher-Collins)

Covered Indications: Significant malocclusion of the teeth causing chronic facial or temporomandibular joint (TMJ) pain

Covered Indications: Malocclusion resulting from tumor, infection, or trauma requiring restoration to normal anatomy/function

Covered Indications: Difficulties in phonation when all other treatment modalities have failed and a speech-language evaluation documents the impairment and prior failed interventions

Covered Indications: Removal of impacted teeth

Expenses related to the orthodontic phases of care — including both pre‑surgical and post‑surgical orthodontia — are considered dental in nature and are excluded from the medical benefit. Examples include services associated with development of a surgical treatment plan prior to orthognathic surgery and routine orthodontic care provided before or after surgery. These services are not reimbursed under the medical policy.

Orthodontic and other dental services that are dental in nature and not part of the medical benefit are not reimbursed. Specifically excluded are routine pre/post‑surgical orthodontia and dental procedures such as orthodontic treatment for cleft palate and palatal stiffening/restoration with implants (for example, the Pillar Palatal Implant System). Providers should not bill these services to the medical benefit.

Procedure Codes

Procedure codes listedCPT

21193	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft.
21194	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft).
21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation.
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation.
21198	Osteotomy, mandible, segmental.
21199	Osteotomy, mandible, segmental; with genioglossal advancement.
21206	Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard).
21685	Hyoid myotomy and suspension.
40700	Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral.
40701	Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 stage procedure.

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Authorization, Referral, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for orthognathic procedures and oral surgery. Note: commercial members under age 19 do not require prior authorization for primary and secondary cleft lip and cleft palate repair, reconstruction, and excision; prior authorization is required for all members 19 years of age and older.

Orthognathic procedures — prior authorization required
Oral surgery — prior authorization required
Primary/secondary cleft lip and palate repair: no prior authorization required for commercial members < 19; prior authorization required for members ≥ 19

Note

Verify referral and authorization requirements before rendering non-emergency specialty care. Claims may be denied if prior authorization or referral requirements are not met.

Referral number required for non-emergency specialty care for Mass General Brigham Health Plan members
Check Prior Authorization Guidelines: Prior Authorizations & Referrals

Documentation Required

Required documentation

Providers must supply all necessary clinical information to support medical necessity and benefit determination. Documentation should be included in the medical record and submitted with authorization requests as applicable.

Presenting problems
Past medical and/or surgical interventions and results
Clear photographic evidence when relevant
Recommended interventions and detailed treatment plan
Functional deficit and diagnosis

Denial Risk

Authorization and referral requirements

Claims may be denied if prior authorization or referral requirements are not met; verify member type and age-specific rules prior to scheduling services.

Failure to obtain required prior authorization or referral can result in claim denial
Age-specific rule: commercial members under 19 — no prior authorization for cleft repairs; members 19+ require prior authorization

Background

Oral and maxillofacial surgery addresses structural and functional disorders of the jaws and face, including management of temporomandibular joint (TMJ) conditions, repair of cleft lip and palate, orthognathic (jaw‑corrective) procedures for skeletal abnormalities that impair function, removal of impacted teeth, and airway surgeries related to obstructive sleep apnea. Coverage is focused on services required to restore or preserve function — for example, surgery for significant malocclusion that cannot be corrected with orthodontics alone, interventions for airway dysfunction not amenable to non‑surgical treatment, and procedures necessary to address difficulties with mastication, nutrition, or phonation. Definitions relevant to this scope include Malocclusion (irregular contact of opposing teeth) and Maxillofacial (pertaining to the jaws and face).

Key Definitions

Malocclusion

DefinitionIrregular contact of opposing teeth in the upper and lower jaws.

Clinical relevanceCan cause difficulties with mastication, TMJ pain, and may require surgical correction when not correctable by orthodontics alone.

Related servicesAssessment commonly includes dental/orthodontic evaluation and imaging (e.g., cephalogram, orthopantogram).

Maxillofacial

DefinitionPertaining to the jaws and face, particularly with reference to specialized surgery of this region.

ScopeIncludes surgical treatment of structural and functional disorders of the jaws and face (e.g., orthognathic surgery, TMJ surgery, cleft repair).

Typical providersOral and maxillofacial surgeons and related specialty teams.

Obstructive Sleep Apnea

DefinitionA breathing disorder characterized by brief interruptions of breathing during sleep that occurs when air cannot flow into or out of the person's nose or mouth although efforts to breathe continue; the throat collapses during sleep causing snorting and gasping for breath.

Clinical impactCan cause airway dysfunction not amenable to non-surgical treatment and may be an indication for airway-related maxillofacial surgery.

AssessmentDiagnosis supported by sleep evaluation and documented airway obstruction during sleep.

Orthognathic

DefinitionCorrecting deformities of the jaw and the associated malocclusion.

PurposeRestores normal occlusion and jaw function when skeletal abnormalities impair mastication, speech, or airway.

Typical proceduresOrthognathic procedures include mandibular and maxillary osteotomies and related reconstructive surgeries.