CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Orthognathic Surgery

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These guidelines describe the clinical information MassHealth requires to determine medical necessity and prior authorization for orthognathic surgery. They apply to providers requesting surgery for skeletal deformities, masticatory dysfunction, temporomandibular conditions, airway disorders including obstructive sleep apnea, congenital anomalies, and selected speech impairments.

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 DateOct 4, 2022

Next Review DateN/A

Key ActionSubmit orthognathic surgery prior authorization requests and supporting clinical documentation through POSC, or use the PA-1 Form if an approved electronic claims waiver applies.

SourceLink

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Orthognathic Surgery

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

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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 DateOct 4, 2022

Next Review DateN/A

Key ActionSubmit orthognathic surgery prior authorization requests and supporting clinical documentation through POSC, or use the PA-1 Form if an approved electronic claims waiver applies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredAuthorization status

2+ SDsSkeletal discrepancy reference

≥5 mmHorizontal overjet threshold

Not coveredCosmetic exclusion

Medical Necessity and Coverage Criteria

Skeletal deformities with masticatory dysfunction and malocclusion

Covered when all core requirements are met and at least one qualifying skeletal or functional finding is documented.

Core masticatory dysfunction criteria

Core requirements
- Significant dysfunction and inadequate nonsurgical treatment
  - A skeletal deformity of the maxilla and/or mandible contributes to significant masticatory dysfunction, and the severity of the deformity precludes adequate treatment through dental therapeutics and orthodontics alone.
    Documentation should include imaging, occlusal and skeletal examination findings, and other relevant clinical data.
  - Qualifying skeletal or functional finding
    Anteroposterior discrepancy
    Horizontal overjet of +5 mm or more; reverse overjet greater than 3.5 mm; or maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more.+5 mm; >3.5 mm; or ≥4 mm
    Vertical discrepancy
    Vertical facial skeletal deformity that is two or more standard deviations from published norms; open bite with no anterior vertical overlap; unilateral or bilateral posterior open bite greater than 2 mm; deep overbite causing impingement or irritation of the opposing arch's soft tissues; or supraeruption of a dentoalveolar segment due to lack of opposing occlusion.≥2 SDs or >2 mm for posterior open bite
    Transverse discrepancy
    Bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater; unilateral discrepancy of 3 mm or greater with normal posterior tooth axial inclination; or transverse skeletal discrepancy that is two or more standard deviations from published norms.≥4 mm bilateral; ≥3 mm unilateral; or ≥2 SDs
    Asymmetry
    Anteroposterior, transverse, or lateral asymmetry greater than 3 mm with concomitant occlusal asymmetry.>3 mm
    Functional impairment
    Failure to thrive secondary to facial skeletal deformity, or persistent difficulty with both swallowing and mastication after metabolic and neurologic causes are excluded.

Congenital anomalies

Covered for correction of structural maxillary or mandibular abnormalities secondary to a qualifying congenital anomaly.

Congenital anomaly

Mid-face anomaly involving the nasofrontal region, nasolacrimal apparatus, or a craniofacial syndrome; congenital micrognathia resulting in respiratory obstruction, such as Pierre Robin syndrome; or maxillary deficiency associated with clefts.

Temporomandibular joint pathology

Covered when the TMJ disorder is associated with a specific medical condition and the required treatment and imaging documentation are provided.

TMJ pathology criteria

Medical condition and symptoms
- The TMJ disorder is caused by or results in a specific medical condition, with persistent severe pain, dysfunction, or internal derangement that has not resolved with appropriate nonsurgical treatment, or nonsurgical treatment is documented as unacceptable for the individual case.
  Examples include myofascial pain secondary to skeletal deformity; jaw fracture or dislocation; rheumatoid, degenerative, or infectious arthritis; condylar atrophy, hyperplasia, hypoplasia, or osteolysis; internal derangement; mandibular dislocation; neoplasia; and ankylosis.
Treatment history and plan
- A comprehensive treatment plan documents the member's history; why nonsurgical treatment was unacceptable or, if performed, did not achieve adequate results; and the plan for continued treatment and follow-up.
  Nonsurgical management may include medication, an orthotic or mandibular orthopedic repositioning appliance, and physical therapy.

Obstructive sleep apnea and airway dysfunction

Covered when all OSA criteria are met and craniofacial maxillary and/or mandibular deformity contributes to airway dysfunction.

OSA surgical criteria

Underlying craniofacial mandibular and/or maxillary skeletal deformity contributes to airway dysfunction.
The obstruction may be type I at the soft palate, type II at the oropharynx/hypopharynx and palate, or type III at the hypopharynx and base of the tongue.
A presurgical physical evaluation supports the need for orthognathic surgery.
Clinical evidence shows that the member did not respond to or cannot tolerate nasal continuous positive airway pressure (NCPAP).
A sleep test confirms the diagnosis of OSA and the need for surgical treatment.

Speech and articulation disorders

Covered for speech-production impairments when functional impairment and expected effectiveness are established.

Speech impairment criteria

The member has an articulation disorder or another impairment in speech production associated with a severe cleft deformity or other craniofacial anomaly, with functional impairment documented.
A presurgical speech evaluation documents the nature of the problem and establishes whether improvement can be expected.
Peer-reviewed clinical studies provide evidence that the proposed surgery is effective.

Cosmetic reshaping or enhancement is excluded. Orthognathic surgery performed primarily to improve 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 considered cosmetic; genioplasty performed with other procedures for these purposes is also excluded.

Correction of sibilant sound distortions or other speech-quality distortions, including hypernasal or hyponasal speech, is excluded when there is no evidence of functional impairment. Speech-production requests must therefore demonstrate a functional deficit rather than a speech-quality or articulation concern alone.

TMJ surgery is not medically necessary for patients who are asymptomatic or minimally symptomatic. It is also not indicated as a preventive procedure for patients who have no pain and satisfactory function.

Orthognathic surgery is not medically necessary when the Section II.A criteria are not met. Requests must establish the applicable medical-necessity requirements, including the relevant functional impairment and clinical findings supporting surgery.

Prior Authorization Codes and Clinical Thresholds

Oral and Maxillofacial Surgery Service CPT Codes that require PACPT

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).
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., monobloc), requiring bone grafts (includes obtaining autografts); without LeFort I.

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1/5

Anteroposterior discrepancy

FindingHorizontal overjet

Coverage threshold+5 mm or more

Reference basisThe referenced values represent two or more standard deviations from published norms.

Anteroposterior discrepancy

FindingReverse overjet

Coverage thresholdGreater than 3.5 mm

Reference basisThe referenced values represent two or more standard deviations from published norms.

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required and Reviewed Case by Case

Prior authorization (PA) is required for orthognathic surgery. MassHealth reviews each request case by case for medical necessity under 130 CMR 420.453 and 450.204; approval remains subject to eligibility, other insurance, and program restrictions.

Prior Authorization

Submit PA Through POSC or an Approved Waiver Process

Submit the PA request and all supporting clinical documentation electronically through the Provider Online Service Center (POSC), unless the provider has a currently approved electronic claims waiver.

Direct POSC-access questions to MassHealth at (800) 841-2900 or TDD/TTY 711.
Providers with an approved waiver must use the PA-1 Form process described below.

Prior Authorization

Orthognathic Surgery Overview

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 principal clinical goal is improvement of function rather than facial appearance, including correction of functional skeletal deformity, masticatory dysfunction, selected TMJ disorders, airway dysfunction or obstructive sleep apnea, congenital anomalies, and certain speech impairments.

Key Terms

Orthognathic surgery

Mandibular abnormalitySurgical correction of skeletal abnormalities of the mandible

Maxillary abnormalitySurgical correction of skeletal abnormalities of the maxilla

Combined abnormalitySurgical correction of skeletal abnormalities of the mandible, maxilla, or both

OSA obstruction types

Type I obstructionSoft palate

Type II obstructionOropharynx/hypopharynx and palate

Type III obstructionHypopharynx and base of the tongue

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 DateOct 4, 2022

Next Review DateN/A

Key ActionSubmit orthognathic surgery prior authorization requests and supporting clinical documentation through POSC, or use the PA-1 Form if an approved electronic claims waiver applies.

SourceLink

On This Page

Required imaging

Transcranial films are submitted in open, closed, and rest positions, or MRI studies are submitted with pathology documented by a radiologist.

For type I obstruction at the soft palate, documentation shows that uvulopalatopharyngoplasty (UPPP) was unsuccessful.

For clinically significant type II and/or type III obstruction, imaging confirms the obstruction.

Acceptable imaging includes cone-beam CT, fiber optic pharyngoscopy, or cephalometric radiographs with tracing.

Anteroposterior discrepancy

FindingMaxillary/mandibular anteroposterior molar relationship discrepancy

Coverage threshold4 mm or more

Published norm0–1 mm

Vertical discrepancy

FindingPosterior open bite

Coverage thresholdGreater than 2 mm

DistributionUnilateral or bilateral

Transverse discrepancy

FindingTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy

Coverage threshold4 mm or greater

Associated conditionNormal axial inclination of the posterior teeth

Transverse discrepancy

FindingUnilateral maxillary palatal cusp to mandibular fossa discrepancy

Coverage threshold3 mm or greater

Associated conditionNormal axial inclination of the posterior teeth

Asymmetry

FindingAnteroposterior, transverse, or lateral facial skeletal asymmetry

Coverage thresholdGreater than 3 mm

Required associated findingConcomitant occlusal asymmetry

Skeletal discrepancy reference

Vertical skeletal discrepancyTwo or more standard deviations from published norms for accepted skeletal landmarks

Transverse skeletal discrepancyTwo or more standard deviations from published norms

Clinical categoryVertical or transverse skeletal discrepancy

Use POSC or Submit the PA-1 Form

Use POSC for electronic submission. If an approved electronic claims waiver applies, submit the MassHealth Prior Authorization Request (PA-1 Form) with all supporting documentation.

The PA-1 Form is available through mass.gov/prior-authorization-for-masshealthproviders by selecting “Request prior authorization for nonpharmacy services” and then “By mail.”

Billing Rule

PA Required for Listed Surgery Codes

PA is required for the listed orthognathic and oral and maxillofacial surgery service codes. These codes may be used only by dental providers who are specialists in oral surgery.

Apply the provider restriction in 130 CMR 420.405(A)(7).
See 130 CMR 420.453 and 420.455 for service codes requiring PA.

Step Therapy

Conservative Dental, Orthodontic, and TMJ Treatment First

Document that the skeletal deformity causes significant masticatory dysfunction and is too severe for adequate treatment through dental therapeutics and orthodontics alone. Conservative dental, orthodontic, and other nonsurgical treatment should precede surgery when clinically appropriate.

Document clinical examination of occlusion and skeletal discrepancies, imaging findings, and other relevant clinical data.
For TMJ disorders, nonsurgical management may include medication, physical therapy, or mandibular orthopedic repositioning appliances.

Step Therapy

Document OSA Nonsurgical Treatment Failure

For OSA-related surgery, document failure of or inability to tolerate nasal continuous positive airway pressure (NCPAP). For type I obstruction, also document unsuccessful uvulopalatopharyngoplasty (UPPP) treatment.

Identify the applicable OSA obstruction type and the nonsurgical treatment history.

Unsupported block type: documentation

Documentation Required

Provide Dental Evaluation and Imaging

Include a comprehensive dental evaluation and diagnostic-quality imaging. Required or relevant studies include lateral and anteroposterior cephalometric radiographs with tracings, tomograms, submental vertex radiographs, and photographs.

Include pre-orthodontic imaging and clinical imaging showing dental malocclusion.
For TMJ surgical consideration, provide specialized imaging such as cephalometric x-rays, tomograms, submental vertex radiographs, transcranial films, or MRI when applicable.

Documentation Required

Include Provider Evaluation Records

Include treating physician or oral surgeon progress notes and evaluations with dates of service, social history, current and past medical and physical examinations, diagnoses, medical and surgical history, and prior management of the functional impairment.

Records must support the requested surgery and describe relevant treatment history and findings.

Documentation Required

Document Diagnosis and Anatomy

Document the anatomic deformity and identify the primary diagnosis, CPT code, ICD code, and diagnosis date. Include secondary diagnoses and ICD codes for pertinent comorbid conditions, plus any other clinical information MassHealth requests.

Use a detailed narrative to connect the deformity and diagnoses to the functional impairment.

Prior Authorization

Meet Submission and Provider Qualification Requirements

The clinical information must be submitted by an oral and maxillofacial surgeon, using the required electronic process or an approved waiver-based process.

Submit through POSC unless a currently approved electronic claims waiver applies.
For an approved waiver, include the PA-1 Form and all supporting documentation.

Documentation Required

Document the TMJ Treatment Plan

For TMJ surgery, submit a comprehensive treatment plan documenting the member’s history, why nonsurgical treatment was unacceptable or failed to achieve adequate results, and the proposed continuing care.

Address appropriate nonsurgical options, such as NSAIDs, an orthotic appliance, or physical therapy.
Include transcranial films in open, closed, and rest positions or MRI with pathology documented by a radiologist.
Specify follow-up care, including the number of visits if care beyond the included 30 days is needed.

Documentation Required

Document OSA Medical Necessity

For OSA, provide a presurgical physical evaluation, a sleep test with documented results confirming OSA and the need for surgery, and evidence that NCPAP was ineffective or intolerable. Document UPPP failure for type I obstruction and airway imaging for type II or III obstruction.

Use cone-beam CT, fiber optic pharyngoscopy, or cephalometric radiographs with tracing to confirm clinically significant type II or type III obstruction.
Document the underlying maxillary or mandibular skeletal deformity contributing to airway dysfunction.

Prior Authorization

Submit the PA-1 Form and Supporting Documentation

When submitting through an approved electronic claims waiver, include the MassHealth PA-1 Form and every supporting clinical document required to establish medical necessity.

Obtain the PA-1 Form through the MassHealth prior-authorization webpage and select the nonpharmacy-services and mail options.
Include the clinical course, examinations, imaging, diagnoses, treatment history, and functional-impairment documentation.

Denial Risk

Cosmetic Purpose Is Not Covered

Do not request coverage when orthognathic surgery is performed primarily for cosmetic purposes. Isolated mentoplasty or genial osteotomy/osteoplasty to address genial hypoplasia, hypertrophy, or asymmetry is considered cosmetic, including when performed with other surgical procedures.

Cosmetic intent remains a noncoverage risk even when facial features are associated with psychological disorders.

Denial Risk

Criteria or Functional Impairment Not Established

A request is at risk of denial when the Section II.A criteria are not met or when the submission does not establish a qualifying skeletal deformity causing significant functional impairment.

Show that the deformity contributes to significant masticatory dysfunction, speech impairment, or airway dysfunction, as applicable.
Show why dental therapeutics, orthodontics, or other nonsurgical treatment cannot adequately address the problem.

Denial Risk

TMJ Symptoms or Conservative Treatment Requirement Not Met

TMJ surgery is not indicated for asymptomatic or minimally symptomatic members, for preventive purposes when pain is absent and function is satisfactory, or when required nonsurgical treatment has not been attempted or adequately addressed.

Document severe pain and dysfunction or internal derangement and the response to appropriate nonsurgical management.

Denial Risk

Speech Request Lacks Functional Impairment

Speech-related surgery is at risk of denial when the request concerns only sibilant distortions or speech-quality changes such as hypernasal or hyponasal speech without evidence of functional impairment.

Obtain a presurgical speech evaluation and provide peer-reviewed clinical evidence showing that surgery is effective for the documented impairment.

Denial Risk

OSA Prerequisites Must Be Satisfied

An OSA-related request is at risk of denial unless all required prerequisites are documented, including presurgical evaluation, NCPAP nonresponse or intolerance, diagnostic sleep testing, and obstruction-specific treatment and imaging evidence.

For type I obstruction, document unsuccessful UPPP treatment.
For type II or III obstruction, provide imaging confirming clinically significant obstruction and document the contributing craniofacial skeletal deformity.