CurrentPremera BluecrossPolicy N/A

9.02.501 Orthognathic Surgery

Premera Bluecross medical policy defining medical necessity criteria, documentation, coding, and coverage positions for orthognathic surgery (corrective jaw surgery) including indications related to congenital anomalies, trauma/tumor, masticatory malocclusion, TMJ-related malocclusion, and OSA; also states investigational and cosmetic exclusions and limited coverage for surgical splints and virtual surgery planning.

Policy Summary

PayerPremera Bluecross

Policy9.02.501 Orthognathic Surgery

Policy CodePolicy N/A

Change TypeAnnual review updates; coding and investigational determinations

Effective DateSep 4, 2026

Next Review Date

Key ActionDocument medical necessity criteria and supporting studies (specialist documentation, imaging, study models, and photographs) when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Added Noonan syndrome and revised Pierre Robin syndrome to Pierre Robin sequence to list of congenital anomalies considered medically necessary.

Added policy statement that Virtual Surgery Planning (VSP) is investigational and added VSP codes CDT D0393, CPT 76376, 76377.

Removed multiple CDT codes (D5954, D5955, D5958, D5959, D7283, D7881, D8010, D8020, D8030, D8040, D8070, D8080, D8090, D8210, D8220, D8660, D8670, D8680, D8681, D8999).

Changed OSA severity threshold from prior language 'severe OSA' to 'moderate to severe OSA (AHI ≥ 15)'.

Added significant transverse maxillary arch deficiency criteria and clarified measurements for open bite and asymmetry.

Noonan syndrome added and Pierre Robin syndrome revised to Pierre Robin sequence in list of congenital anomalies that are medically necessary for orthognathic surgery.

Medical necessity criteria for significant transverse maxillary arch deficiency added.

Policy statement that endoscopically assisted nasomaxillary expansion as a treatment for OSA is considered investigational.

Policy statement that Virtual Surgical Planning (VSP) is investigational; CPT codes 76376 and 76377 and CDT D0393 were added.

Multiple CDT codes removed from the policy code list (e.g., D5954, D5955, ... D8999).

MultipleCPT/CDT codes listed

AHI ≥15OSA threshold for coverage

2Allowed orthognathic surgical splints

InvestigationalVSP & nasomaxillary expansion

3VSP codes added

NoonanNew congenital anomaly added

Coverage Summary

Payer: Premera Blue Cross. Policy title: MEDICAL POLICY - 9.02.501 Orthognathic Surgery. Effective date: September 4, 2026; last reviewed May 12, 2026. High-level stance: Orthognathic surgery is considered medically necessary when specific functional and anatomic criteria are met for congenital anomalies, trauma/tumor-related restoration of function, masticatory malocclusion, TMJ-related dysfunction, or deformities contributing to obstructive sleep apnea (OSA). Procedures that are investigational (for example, endoscopically-assisted nasomaxillary expansion for OSA and Virtual Surgical Planning/VSP) or performed primarily for cosmetic purposes are excluded from coverage.

Key thresholds & quick facts

OSA severity threshold (AHI)AHI ≥ 15

Allowed orthognathic surgical splints2 splints allowed; >2 considered not medically necessary

Policy effective dateSept. 4, 2026

Investigational procedures (highlight)Virtual Surgical Planning (VSP) and endoscopically-assisted nasomaxillary expansion are considered investigational

Medical-Necessity Criteria

Orthognathic surgery is considered medically necessary or not medically necessary according to the specific indications and exclusions below.

CONSOLIDATED MEDICALLY NECESSARY INDICATIONS: Orthognathic surgery may be considered medically necessary for: correction of congenital craniofacial anomalies (e.g., Apert, Cleft deformity, Crouzon, Hemifacial microsomia, Noonan, Pfeiffer, Pierre Robin sequence, Treacher Collins) when functional impairment is documented; restoration of function following acute traumatic injury or tumor resection; correction of maxillary and/or mandibular skeletal deformities associated with masticatory malocclusion when criteria below are met; treatment of severe malocclusion contributing to TMJ syndrome when criteria below are met; and correction of mandibular/maxillary deformities contributing to airway dysfunction and obstructive sleep apnea when criteria below are met. Use of up to two orthognathic surgical splints is considered medically necessary.

title":"Medical-Necessity Criteria","type":"criteria_group"},{

nodes":["Orthognathic surgery for congenital anomalies, trauma, or tumor may be considered medically necessary when the procedure is performed to correct congenital deformities apparent at birth (examples include Apert, Cleft deformity, Crouzon, Hemifacial microsomia, Noonan, Pfeiffer, Pierre Robin sequence, Treacher Collins) OR to restore function after acute traumatic injury or tumor resection. Documentation must show the deformity is causing functional impairment and that the procedure is aimed at restoring function."],

Investigational and Not Covered Procedures

Coding

Relevant CPT codes listedCPT

21085	Impression and custom preparation; oral surgical splint.
21088	Impression and custom preparation; facial prosthesis.
21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction (without bone graft).
21142	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft.
21143	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft.
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 (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.

1–10 of 26

1/3

Relevant CPT codes listedCPT

No codes listed

Relevant CDT codes listedmixed

D0330	Panoramic film.
D0340	Cephalometric film.
D0350	Oral/facial photographic images.
D0393	Virtual treatment simulation using 3D image volume or surface scan (Virtual simulation of treatment including orthognathic surgery).
D0470	Diagnostic Casts.
D7940	Osteoplasty - for orthognathic deformities.
D7941	Osteotomy - mandibular rami.
D7943	Osteotomy - mandibular rami with bone graft; includes obtaining the graft.
D7944	Osteotomy - segmented or subapical.
D7945	Osteotomy - body of mandible.

1–10 of 19

1/2

Relevant CDT codes listedmixed

No codes listed

Added CPT codes for Virtual Surgical Planning (VSP)CPTNot Covered

76376	3D image post-processing with interpretation and report
76377	3D rendering with interpretation and report

Added CDT code for Virtual Surgical Planning (VSP)NDC|mixedNot Covered

D0393

Computer-aided 3D planning for orthognathic surgery (CDT code)

Removed CDT codesmixed

D5954
D5955
D5958
D5959
D7283
D7881
D8010
D8020
D8030
D8040

1–10 of 20

1/2

Provider Actions & Prior Authorization

Documentation Required

Document medical necessity and supporting studies

Medical records must document that medical necessity criteria are met, including a written explanation of the clinical course with dates and prior treatments, specialist documentation, detailed description of functional impairment, study models and pre‑orthodontic imaging, cephalometric radiographs/diagrams with measurements, and clear frontal and lateral photographs.

Specialist documentation (e.g., orthodontist, sleep specialist)
Study models and diagnostic casts
Pre-orthodontic imaging: cephalometric radiographs and diagrams with measurements
Clear frontal/full face and lateral view photographs (digital or film)
Documentation of prior treatments with dates and clinical course

Documentation Required

Background & Definitions

Orthognathic surgery involves ostectomy, osteotomy, or osteoplasty of the maxilla and/or mandible to correct skeletal jaw and craniofacial deformities that cause significant functional impairment when orthodontics alone is inadequate. Indications include correction of congenital or developmental anomalies (e.g., cleft deformity, Apert, Crouzon, Hemifacial microsomia, Noonan syndrome, Pierre Robin sequence, Treacher Collins, Pfeiffer), restoration of function after acute traumatic injury or tumor resection, treatment of facial skeletal deformities causing masticatory malocclusion (measurable antero-posterior, vertical, transverse or asymmetry thresholds defined in policy), management of severe malocclusion contributing to TMJ syndrome after conservative therapy, and correction of maxillomandibular deformities contributing to OSA when sleep study and PAP trial criteria are met. Orthognathic procedures performed primarily to reshape or enhance facial appearance (cosmetic indications, including isolated chin procedures) are excluded from benefits.

Definitions (key terms)

AHIApnea-Hypopnea Index (used to classify OSA severity); policy threshold AHI ≥ 15 for OSA indication

ROJReverse overjet (ROJ) — policy threshold ≥ 3 mm

OJOverjet (OJ) — policy threshold ≥ 6 mm

Revision History

2026-05-12policy_revisionLatest

AAOMS 2025 guidance incorporated: added Noonan syndrome and changed 'Pierre Robin syndrome' terminology to 'Pierre Robin sequence' in the list of congenital anomalies considered medically necessary for orthognathic surgery.

2026-05-12policy_revisionLatest

Added policy statement that Virtual Surgical Planning (VSP) is investigational and added VSP codes CDT D0393 and CPT 76376, 76377 to the coding list.

2026-05-12

Policy Summary

PayerPremera Bluecross

Policy9.02.501 Orthognathic Surgery

Policy CodePolicy N/A

Change TypeAnnual review updates; coding and investigational determinations

Effective DateSep 4, 2026

Next Review Date

Key ActionDocument medical necessity criteria and supporting studies (specialist documentation, imaging, study models, and photographs) when requesting coverage.

SourceLink

On This Page

title":"Orthognathic surgery for congenital anomalies, trauma, tumor","type":"criteria_group"},{

intro":"Orthognathic surgery for correction of skeletal deformities of the maxilla or mandible is considered medically necessary when ALL of the following are met:",

nodes":[{"operator":"all","children":[{"operator":"any","label":"1.","children":[{"text":"Impaired masticatory or incisive function (difficulty chewing)"},{"text":"Chewing-induced trauma to the soft tissues of the mouth"},{"text":"Impaired swallowing or choking on incompletely chewed solid foods"},{"text":"Abnormal tongue thrust"},{"text":"Speech abnormality that impairs communication and is determined by a speech pathologist or therapist to be due to skeletal malocclusion and not resolved by speech therapy"}]},{"operator":"any","label":"2.","children":[{"text":"Mandibular excess or maxillary deficiency with reverse overjet (ROJ)","threshold":"≥ 3 mm"},{"text":"Maxillary excess or mandibular deficiency with overjet (OJ)","threshold":"≥ 6 mm"},{"text":"Open bite (OB)","threshold":"≥ 2 mm"},{"text":"Deep bite (DB)","threshold":"≥ 7 mm"},{"text":"Significant transverse maxillary arch deficiency presenting with ONE of the following:","children":[{"text":"Crowded maxillary teeth with first or second bicuspid extracted and no other orthognathic procedures"},{"text":"Unilateral maxillary arch expansion: asymmetries > 3 mm with concomitant occlusal asymmetry","threshold":"> 3 mm"},{"text":"Bilateral transverse maxillary arch deficiency > 7 mm","threshold":"> 7 mm"}]}]},{"text":"An orthodontic specialist has documented that orthodontia (conservative therapy) is not recommended for the condition."}] }],"title":"Maxillary and/or mandibular facial skeletal deformities associated with masticatory malocclusion","type":"criteria_group"},{

intro":"Treatment of severe malocclusion that contributes to temporomandibular joint (TMJ) syndrome symptoms is considered medically necessary when ALL of the following are met:",

nodes":[{"operator":"all","children":[{"operator":"any","label":"1.","children":[{"text":"Painful chewing clearly related to the TMJ"},{"text":"Frequent and significant headaches clearly related to TMJ"},{"text":"Significant temporomandibular joint and/or muscle tenderness"}]},{"text":"Symptoms persist after ≥ 4 months of treatment with ONE of the following conservative measures: elimination of aggravating factors (e.g., gum chewing, hard/tough foods); use of anti-inflammatory medications unless contraindicated; treatment with splint therapy unless not tolerated."},{"operator":"any","label":"3.","children":[{"text":"Mandibular excess or maxillary deficiency with reverse overjet (ROJ)","threshold":"≥ 3 mm"},{"text":"Maxillary excess or mandibular deficiency with overjet (OJ)","threshold":"≥ 6 mm"},{"text":"Open bite (OB)","threshold":"≥ 4 mm"},{"text":"Deep bite (DB)","threshold":"≥ 7 mm"},{"text":"Significant transverse maxillary arch deficiency presenting with ONE of: crowded maxillary teeth with first or second bicuspid extracted and no other orthognathic procedures; unilateral maxillary arch expansion (asymmetries > 3 mm with concomitant occlusal asymmetry).","threshold":"> 3 mm"}]}],"title":"Treatment of severe malocclusion contributing to TMJ syndrome symptoms","type":"criteria_group"},{

intro":"Maxillofacial surgery for mandibular and maxillary deformities contributing to airway dysfunction and obstructive sleep apnea (OSA) is considered medically necessary when ALL of the following are present and documented:",

nodes":[{"operator":"all","children":[{"text":"Moderate to severe OSA confirmed by a sleep study (AHI)","threshold":"AHI ≥ 15"},{"text":"Individual has trialed and failed a minimum 90-day use of positive airway pressure (PAP)."},{"text":"Individual participated in a PAP compliance program."},{"text":"A qualified sleep specialist has documented that other surgical options are not recommended for OSA OR another surgical option has already been tried and was not adequate."}]}],"title":"Mandibular and maxillary deformities contributing to airway dysfunction and OSA","type":"criteria_group"},{

intro":"Orthognathic surgical splints coverage position:",

nodes":[{"text":"Use of two orthognathic surgical splints may be considered medically necessary."},{"text":"Use of greater than two orthognathic surgical splints is considered not medically necessary."}],"title":"Orthognathic surgical splints","type":"criteria_group"},{

nodes":[{"operator":"any","children":[{"text":"Endoscopically-assisted nasomaxillary expansion as a treatment for OSA is considered investigational."},{"text":"Three-dimensional virtual treatment planning or computer-aided three-dimensional simulation and navigation in orthognathic surgery (e.g., VSP, CASNOS) is considered investigational."},{"text":"Use of condylar positioning devices in orthognathic surgery is considered investigational."},{"text":"Orthognathic surgery for indications not specifically listed as medically necessary in this policy is considered investigational."},{"text":"Orthognathic surgery performed primarily for correction of unaesthetic facial features (cosmetic) is considered cosmetic and not a covered benefit."}]}],"title":"Investigational / Not Medically Necessary Procedures","type":"criteria_group"}],

id":"medical-necessity-criteria","label":"MEDICAL-NECESSITY CRITERIA","title":"Medical-Necessity Criteria"} Cincinnatiopyright 2026 Premera Blue Cross.} PMID:0}Didn't include extra text

Update diagnosis terminology and congenital anomaly documentation

Update diagnostic wording for congenital anomalies per AAOMS 2025: add Noonan syndrome to the list and change “Pierre Robin syndrome” terminology to “Pierre Robin sequence” when applicable; document these diagnoses in the request.

Include AAOMS‑aligned diagnosis labels (e.g., Noonan syndrome; Pierre Robin sequence)
Document that the congenital diagnosis is apparent at birth and relates to the surgical request

Prior Authorization

Benefit and contract verification

Verify member contract and benefits prior to submission — some health plan contracts may not include coverage for orthognathic surgery. Confirm plan-specific coverage, prior authorization requirements, and any contract limitations.

Prior Authorization

Prior authorization and coverage determination timing

Policy revisions are effective September 4, 2026. Obtain prior authorization per the member’s plan requirements for services on or after that date and follow plan-specific timing and submission procedures.

Documentation Required

Orthodontic specialist statement

An orthodontic specialist must document that orthodontia (conservative therapy) is not recommended or has been tried and found inadequate before coverage for masticatory malocclusion indications will be approved.

Formal statement from orthodontic specialist that orthodontic treatment is not recommended or was inadequate
Supportive records of prior orthodontic treatment and results, if tried

Documentation Required

Sleep specialist documentation for OSA cases

For OSA‑related indications, include sleep specialist documentation of AHI from a sleep study, evidence of a minimum 90‑day PAP trial with participation in a PAP compliance program, and a qualified sleep specialist’s statement that other surgical options are not recommended or were tried and were inadequate.

Apnea‑Hypopnea Index (AHI) from a sleep study (AHI ≥ 15 required)
Documentation of ≥90‑day PAP trial
Evidence of participation in a PAP compliance program
Sleep specialist justification that other surgical options are not recommended or were tried and inadequate

Billing Rule

Orthognathic surgical splints limit

Coverage for orthognathic surgical splints is limited to two splints; any use of greater than two is considered not medically necessary. Example CPT affected: 21085 (impression and custom preparation; oral surgical splint).

Limit: up to 2 orthognathic surgical splints covered
Code example: CPT 21085

Denial Risk

Investigational procedures not covered

Procedures and services identified as investigational may be denied. This includes Virtual Surgical Planning (VSP) and related codes and endoscopically assisted nasomaxillary expansion for OSA. Claims using CPT 76376, CPT 76377, or CDT D0393 for VSP, or for endoscopically assisted nasomaxillary expansion, may be considered investigational and denied.

CPT 76376
CPT 76377
CDT D0393

Open bite (OB) — policy thresholds: ≥ 2 mm for masticatory malocclusion; ≥ 4 mm for TMJ-related criteria

DBDeep bite (DB) — policy threshold ≥ 7 mm

VSPVirtual Surgical Planning (computer-assisted 3D planning; CDT D0393, CPT 76376/76377); policy states VSP is investigational

Evidence & guideline notes

Literature review cutoffApril 14, 2026

AAOMS guidance referencedAAOMS Indications for Orthognathic Surgery (2025)

Policy approval dateMay 12, 2026 (policy approval) — revisions effective Sept. 4, 2026

Clarified and added medical necessity criteria for significant transverse maxillary arch deficiency and explicit measurements for open bite and asymmetry (e.g., open bite ≥2 mm for masticatory malocclusion; open bite ≥4 mm for TMJ-related indications; asymmetry >3 mm; bilateral transverse >7 mm).

2026-05-12policy_revisionLatest

Changed OSA coverage threshold language to 'Moderate to severe OSA (AHI ≥ 15)' and specified requirement for a minimum 90-day PAP trial and participation in a PAP compliance program.

2026-06-01coding_updateLatest

Coding cleanup/removals: removed multiple CDT codes (including D5954, D5955, D5958, D5959, D7283, D7881, D8010, D8020, D8030, D8040, D8070, D8080, D8090, D8210, D8220, D8660, D8670, D8680, D8681, D8999) as part of the 2026 update.

2026-09-04effective_dateLatest

Policy revisions (including AAOMS updates, VSP investigational designation and codes, OSA threshold and PAP requirements, transverse maxillary criteria, and coding cleanup) effective for dates of service on or after September 4, 2026.

2024-01-01policy_statementLatest

Statement added (01/01/24) that endoscopically assisted nasomaxillary expansion as a treatment for OSA is considered investigational.