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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Orthognathic Surgery

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This guideline describes the clinical information MassHealth uses to determine medical necessity and prior authorization for orthognathic surgery. It applies to MassHealth members and providers requesting surgery for functional skeletal, airway, temporomandibular joint, speech, or related craniofacial conditions; cosmetic surgery is not covered.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Orthognathic Surgery

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 10, 2025

Next Review DateN/A

Key ActionSubmit the prior authorization request and all supporting documentation electronically through the Provider Online Service Center.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPrior authorization

5Coverage areas

4 mmMolar discrepancy threshold

+5 mm / >3.5 mmOverjet thresholds

3 mmMaximum listed asymmetry

30 daysIncluded follow-up period

Clinical Coverage Criteria

General orthognathic surgery criteria

Covered case by case when all overarching medical-necessity requirements are met.

General medical necessity: The requested surgery corrects a skeletal deformity of the maxilla and/or mandible; the deformity contributes to significant masticatory dysfunction; and the severity precludes adequate treatment through dental therapeutics and orthodontics alone.

Support with imaging, occlusal and skeletal examination, and other clinical information.

Facial skeletal deformities with masticatory dysfunction

Covered when the general medical-necessity requirements are met and at least one qualifying deformity or functional impairment is documented.

Masticatory malocclusion and functional impairment: Qualifying findings include specified anteroposterior, vertical, transverse, or asymmetry discrepancies; deep overbite with impingement or irritation of the opposing arch’s soft tissues; supraeruption of a dentoalveolar segment due to absent opposing occlusion; persistent difficulty with both swallowing and mastication after metabolic and neurologic causes are excluded; or failure to thrive secondary to facial skeletal deformity.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Orthognathic Surgery

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 10, 2025

Next Review DateN/A

Key ActionSubmit the prior authorization request and all supporting documentation electronically through the Provider Online Service Center.

SourceLink

On This Page

See individual thresholds in the coding module.

Documentation must demonstrate significant dysfunction and that dental therapeutics and orthodontics alone are inadequate.

Congenital skeletal deformities

Covered when the general medical-necessity requirements are met and a qualifying congenital or developmental craniofacial abnormality is documented.

Congenital and craniofacial abnormalities: Qualifying examples include mid-face anomalies involving the nasofrontal region, nasolacrimal apparatus, or craniofacial syndromes; congenital micrognathia resulting in respiratory obstruction, such as Pierre Robin syndrome; and maxillary deficiency associated with clefts.

Maxillary osteotomy with or without a graft covers the maxillary surgical procedure for correction of maxillary skeletal malocclusion.

Temporomandibular joint pathology

Covered for TMJ disease, disorder, or dysfunction when all applicable clinical and treatment requirements are documented.

TMJ surgical criteria: The TMJ disorder is caused by or results from a specific medical condition, or additional supporting evidence demonstrates medical necessity; the condition involves internal derangement or severe pain and dysfunction; nonsurgical treatment was not acceptable or failed to achieve adequate results; appropriate diagnostic imaging is submitted; and a continued-treatment plan is provided when needed.

Examples of causative conditions include jaw fractures or dislocations, rheumatoid, degenerative, or infectious arthritis, condylar atrophy, condylar hyperplasia or hypoplasia, condylar osteolysis, internal derangement, mandibular dislocation, neoplasia, and ankylosis. Diagnostic support may include transcranial films in open, closed, and rest positions or MRI with pathology documented by a radiologist.

OSA, airway defects, and soft-tissue discrepancies

Covered when all OSA requirements are met and an underlying craniofacial maxillary and/or mandibular skeletal deformity contributes to airway dysfunction.

Obstructive sleep apnea and airway dysfunction: A presurgical physical evaluation supports surgery; the member did not respond to or cannot tolerate nasal continuous positive airway pressure (NCPAP); a sleep test confirms OSA and the need for surgery; uvulopalatopharyngoplasty (UPPP) was unsuccessful for Type I obstruction when applicable; and imaging confirms clinically significant Type II and/or Type III obstruction.Type I: soft palate; Type II: oropharynx/hypopharynx and palate; Type III: hypopharynx and base of the tongue.

The requested surgery must be expected to decrease airway resistance and improve breathing, and the airway dysfunction must not be amenable to nonsurgical treatment.

Speech impairments associated with skeletal discrepancies

Covered for articulation disorders or other speech-production impairments when the required clinical evidence is present.

Speech impairment: The speech impairment accompanies a severe cleft deformity or other craniofacial anomaly; a presurgical speech evaluation documents the nature of the problem and whether improvement can be expected; and peer-reviewed clinical studies demonstrate the effectiveness of correction.

Speech-quality distortions without evidence of functional impairment are not covered.

Orthodontic treatment before surgery

Orthodontic treatment may precede orthognathic surgery when needed to establish adequate postoperative occlusion.

Preoperative orthodontics: Orthodontic treatment positions the teeth in a manner that will provide adequate occlusion following surgical repositioning of the jaws.

For members under 21 years of age, orthodontic treatment is subject to prior authorization, service descriptions, and limitations in 130 CMR 420.431. Dental anomaly and malocclusion evaluation is covered under the MassHealth dental program and requires prior authorization.

Cosmetic procedures are not covered. Orthognathic surgery performed primarily to reshape or enhance unaesthetic facial features is excluded, including isolated mentoplasty or genial osteotomy/ostectomy for genial hypoplasia, hypertrophy, or asymmetry.

Correction of sibilant sound-class distortions or speech-quality distortions such as hypernasal or hyponasal speech is excluded when there is no evidence of functional impairment.

A genioplasty is included with a mandibular osteotomy only when it is performed as part of a larger orthognathic surgical procedure. Genioplasty is covered only when performed for functional reasons.

TMJ surgery is not medically necessary for patients who are asymptomatic or minimally symptomatic, or when surgery is proposed for preventive purposes in patients without pain and with satisfactory function.

Orthognathic surgery for TMJ disease, disorder, or dysfunction is medically necessary only when the condition is caused by or results from a specific medical condition. If no such condition is present, additional supporting evidence must establish medical necessity.

Orthognathic surgery is not medically necessary when the applicable clinical coverage criteria are not met.

Covered Procedures and Clinical Thresholds

Maxillofacial reconstruction and midface proceduresCPT

21137	Reduction forehead, Contouring only.
21138	Reduction forehead; Contouring and application of prosthetic material or bone graft (includes obtaining autograft).
21139	Reduction forehead; Contouring and setback of anterior frontal sinus wall.
21146	Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft).
21147	Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies).
21150	Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome).
21151	Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts).
21154	Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I.
21155	Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I.
21159	Reconstruction midface forehead advance; LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I.

1–10 of 14

1/2

Mandibular and maxillary osteotomy proceduresCPT

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	Reconstruction of mandibular rami and/or body, osteotomy, mandible.
21199	Osteotomy, mandible, segmental.
21206	Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard).

Facial bone and cartilage graft proceduresCPT

21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant).
21209	Osteoplasty, facial bones; reduction.
21210	Graft, bone; nasal, maxillary, or malar areas (include obtaining graft).
21215	Graft, bone; mandible (includes obtaining graft).
21230	Graft, rib cartilage autogenous to face, chin, nose, or ear (includes obtaining graft).
21235	Graft; ear cartilage autogenous to nose or ear (includes obtaining graft).

TMJ, mandibular, and craniofacial reconstruction proceduresCPT

21240	Arthroplasty temporomandibular joint (TMJ) with or without autograft (includes obtaining autograft).
21242	Arthroplasty temporomandibular joint TMJ with allograft.
21243	Arthroplasty temporomandibular joint TMJ with prosthetic joint replacement.
21244	Reconstruction of mandible, extra oral, with transosteal bone plate (e.g., mandibular staple bone plate).
21247	Reconstruction of mandible condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial macrosomia).
21255	Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts).
21299	Unlisted craniofacial and maxillofacial procedure.

TMJ arthroscopy and related oral proceduresCPT

29800	Arthroscopy, temporomandibular joint TMJ, diagnostic, with or without synovial biopsy (separate procedure).
29804	Arthroscopy, temporomandibular joint TMJ.
40840	Vestibuloplasty; anterior unilateral.
40842	Vestibuloplasty; posterior unilateral.
40843	Vestibuloplasty; posterior bilateral.
40844	Vestibuloplasty; entire arch.
40845	Vestibuloplasty; complex (including ridge extension, muscle repositioning).
41820	Gingivectomy, excision gingiva each quadrant.
42280	Maxillary impression for palatal prosthesis.
42281	Insertion of pin-retained palatal prosthesis.

Anteroposterior molar relationship discrepancy

FindingMaxillary/mandibular anteroposterior molar relationship discrepancy

Qualifying threshold4 mm or more

Normal range0–1 mm

Horizontal overjet

FindingMaxillary/mandibular incisor relationship with horizontal overjet

Qualifying threshold+5 mm or more

Coverage contextDocumentation must demonstrate significant dysfunction and that dental therapeutics and orthodontics alone are inadequate

Reverse overjet

FindingMaxillary/mandibular incisor relationship with reverse overjet

Qualifying thresholdGreater than 3.5 mm

Coverage contextDocumentation must demonstrate significant dysfunction and that dental therapeutics and orthodontics alone are inadequate

Vertical skeletal deformity

FindingVertical facial skeletal deformity

Qualifying thresholdTwo or more standard deviations from published norms

Reference standardAccepted skeletal landmarks

Anterior or posterior open bite

Anterior open biteNo vertical overlap of the anterior teeth

Posterior open biteUnilateral or bilateral posterior open bite greater than 2 mm

FindingAnterior or posterior open bite associated with facial skeletal deformity and masticatory malocclusion

Transverse skeletal discrepancy

FindingTransverse skeletal discrepancy

Qualifying thresholdTwo or more standard deviations from published norms

Clinical contextThe discrepancy is evaluated as part of facial skeletal deformity associated with masticatory malocclusion

Maxillary palatal cusp to mandibular fossa discrepancy

Bilateral discrepancyTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater

Unilateral discrepancyUnilateral discrepancy of 3 mm or greater

Posterior tooth requirementNormal axial inclination of the posterior teeth

Facial asymmetry

Affected dimensionsAnteroposterior, transverse, or lateral asymmetry

Qualifying thresholdGreater than 3 mm

Additional requirementConcomitant occlusal asymmetry

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for orthognathic surgery services. MassHealth reviews each request case by case for medical necessity under applicable MassHealth regulations; approval is based on the clinical criteria and documentation requirements in the policy.

Prior Authorization

Submit the PA Electronically

Providers must electronically submit the PA request and all supporting documentation through the Provider Online Service Center (POSC). Providers with a currently approved electronic claims waiver may use the alternative submission process.

POSC questions: contact MassHealth at (800) 841-2900; TDD/TTY: 711.
Waiver holders must submit the MassHealth PA-1 Form and all supporting documentation by mail, as directed by MassHealth.

Prior Authorization

PA-Required Oral and Maxillofacial Services

The following oral and maxillofacial surgery service codes require PA and may be used only by dental providers who are specialists in oral surgery, consistent with 130 CMR 420.405(A)(7).

21137 — Reduction forehead; contouring only.
21138 — Reduction forehead; contouring and application of prosthetic material or bone graft, including obtaining autograft.
21139 — Reduction forehead; contouring and setback of anterior frontal sinus wall.
21146 — Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts, including obtaining autografts.
21147 — Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts, including obtaining autografts.
21150 — Reconstruction midface, LeFort II; anterior intrusion.
21151 — Reconstruction midface, LeFort II; any direction, requiring bone grafts, including obtaining autografts.
21154 — Reconstruction midface, LeFort III, extracranial, requiring bone grafts, without LeFort I.
21155 — Reconstruction midface, LeFort III, extracranial, requiring bone grafts, with LeFort I.
21159 — Reconstruction midface forehead advance; LeFort III, extra- and intracranial, with forehead advancement, requiring bone grafts, without LeFort I.
21160 — Reconstruction midface forehead advance with LeFort I.
21172 — Reconstruction superior-lateral orbit rim and lower forehead, advancement or alteration, with or without grafts.
21175 — Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration, with or without grafts.
21188 — Reconstruction midface, osteotomies other than LeFort type, and bone grafts.
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.

Unsupported block type: documentation

Unsupported block type: step_therapy

Documentation Required

Document Clinical Course and Functional Impairment

Submit a written explanation of the member’s clinical course, including dates of service and the nature of previous treatment, physical evidence of the skeletal, facial, or craniofacial deformity, pre-orthodontic imaging, and a detailed description of the functional impairment directly resulting from the skeletal abnormality.

Documentation Required

Include Dental Evaluation and Imaging

Include a comprehensive dental evaluation and clinical imaging demonstrating dental malocclusion.

Lateral and anterior-posterior cephalometric radiographs and tracings.
Tomograms and submental vertex radiographs.
Diagnostic-quality photographs.

Documentation Required

Include Provider Evaluations and Treatment History

Include treating physician or oral surgeon progress notes and other evaluations with dates of service and the member’s relevant history and examination findings.

Social history.
Present and past medical and physical examinations.
Diagnosis; summary of medical and surgical history; and prior management of the functional impairment.

Documentation Required

Specify Diagnosis and Anatomic Detail

Describe the anatomic deformity and identify the diagnoses and coding information supporting medical necessity.

Detailed narrative of the anatomic deformity.
Primary diagnosis name, CPT code, ICD code, and date of diagnosis.
Secondary diagnosis names and ICD codes pertinent to comorbid conditions.
Any other clinical information MassHealth requests.

Documentation Required

Submitting Specialist

Clinical information for the PA request must be submitted by an oral and maxillofacial surgeon.

Documentation Required

OSA-Specific Documentation

For orthognathic surgery proposed for obstructive sleep apnea, document the presurgical evaluation, objective sleep findings, prior treatment response or intolerance, and the airway abnormality supporting surgery.

Presurgical physical evaluation supporting the need for surgery.
Clinical evidence that the member did not respond to or cannot tolerate nasal continuous positive airway pressure (NCPAP).
Sleep-test results confirming OSA and the need for surgical treatment.
For type I obstruction, documentation that uvulopalatopharyngoplasty (UPPP) was unsuccessful.
For type II or III obstruction, cone-beam CT, fiber-optic pharyngoscopy, or cephalometric radiographs with tracing confirming clinically significant obstruction.

Documentation Required

Speech-Related Documentation

For articulation disorders or other speech-production impairments, obtain a presurgical speech evaluation showing the nature of the problem and whether improvement can be expected from surgery.

Clinical-study evidence from peer-reviewed published medical literature must support the effectiveness of orthognathic surgery for the speech impairment.

Documentation Required

TMJ Imaging

When evaluating TMD for surgical consideration, submit specialized radiological studies documenting the relevant pathology.

Cephalometric x-rays, tomograms, and submental vertex radiographs may be medically necessary for surgical evaluation.

Documentation Required

Document TMJ Conservative-Treatment History

Provide the member’s history of prior nonsurgical TMJ treatment and explain why it was not an acceptable option or, if performed, why it failed to achieve adequate results.

Address the type and degree of the disorder and management, including medication such as NSAIDs, an orthotic appliance, and/or physical therapy.

Documentation Required

Provide a Continued-Care Plan

Submit a plan for continued TMJ care when treatment beyond the included 30 days is required.

Specify the follow-up treatment plan and the number of visits needed after the included 30-day period.

Denial Risk

Criteria Not Met

Requests are at risk of denial when the applicable orthognathic surgery criteria are not met. Documentation must establish the qualifying deformity, associated functional impairment, and the applicable clinical basis for surgery.

Denial Risk

Cosmetic Indication Is Not Covered

Orthognathic surgery performed primarily to reshape or enhance unaesthetic facial features is not medically necessary, regardless of whether the features are associated with psychological disorders. Isolated mentoplasty or genial osteotomy/ostectomy for genial hypoplasia, hypertrophy, or asymmetry is cosmetic, as is such surgery performed with other procedures.

Denial Risk

Speech Distortion Without Functional Impairment

Correction of sibilant-sound distortions or other speech-quality distortions, including hypernasal or hyponasal speech, is not medically necessary without evidence of functional impairment.

Denial Risk

Asymptomatic or Preventive TMJ Surgery

TMJ surgery is not indicated for asymptomatic or minimally symptomatic patients, or for preventive purposes in patients without pain and with satisfactory function.

Billing Rule

General Payment Conditions Still Apply

PA approval does not guarantee payment. Payment remains subject to all general MassHealth conditions, including member eligibility, other insurance, program restrictions, applicable regulations, service limitations, and the requirements of the member’s managed-care plan when applicable.

Providers should consult applicable MassHealth regulations, the Dental Manual, and the member’s ACPP, MCO, One Care, SCO, or PACE medical policy, as applicable.

Policy Background

Orthognathic surgery surgically corrects skeletal abnormalities of the mandible, maxilla, or both. These abnormalities may be congenital, developmental, traumatic, or secondary to systemic disease. The procedure is intended primarily to improve function by correcting the underlying skeletal deformity, including functional masticatory, airway, temporomandibular joint, speech, and related craniofacial conditions; it is not intended for cosmetic enhancement.

Key Definitions

Orthognathic surgery

DefinitionSurgical correction of skeletal abnormalities of the mandible, maxilla, or both

Structures correctedMandible and/or maxilla

Primary purposeImprove function through correction of the underlying skeletal deformity

OSA obstruction types

Type I obstructionSoft palate

Type II obstructionOropharynx/hypopharynx and palate

Type III obstructionHypopharynx and base of the tongue

Medically significant skeletal deformity

Affected structuresMaxilla and/or mandible

Functional effectContributes to significant masticatory dysfunction

Treatment severityToo severe for adequate treatment through dental therapeutics and orthodontics alone

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 — Reconstruction of mandibular rami and/or body, segmental osteotomy.

21199 — Osteotomy, mandible, segmental.

21206 — Osteotomy, maxilla, segmental.

21208 — Osteoplasty, facial bones; augmentation with autograft, allograft, or prosthetic implant.

21209 — Osteoplasty, facial bones; reduction.

21210 — Bone graft for nasal, maxillary, or malar areas, including obtaining graft.

21215 — Bone graft for mandible, including obtaining graft.

21230 — Autogenous rib cartilage graft to face, chin, nose, or ear, including obtaining graft.

21235 — Autogenous ear cartilage graft to nose or ear, including obtaining graft.

21240 — TMJ arthroplasty with or without autograft, including obtaining autograft.

21242 — TMJ arthroplasty with allograft.

21243 — TMJ arthroplasty with prosthetic joint replacement.

21244 — Extraoral mandibular reconstruction with transosteal bone plate.

21247 — Reconstruction of mandibular condyle with bone and cartilage autografts, including obtaining grafts.

21255 — Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage, including obtaining autografts.

21299 — Unlisted craniofacial and maxillofacial procedure.

29800 — Diagnostic TMJ arthroscopy, with or without synovial biopsy.

29804 — TMJ arthroscopy.

40840 — Vestibuloplasty; anterior unilateral.

40842 — Vestibuloplasty; posterior unilateral.

40843 — Vestibuloplasty; posterior bilateral.

40844 — Vestibuloplasty; entire arch.

40845 — Complex vestibuloplasty, including ridge extension and muscle repositioning.

41820 — Gingivectomy, excision of gingiva, each quadrant.

42280 — Maxillary impression for palatal prosthesis.

42281 — Insertion of pin-retained palatal prosthesis.