CurrentPremera BluecrossPolicy N/A

9.02.501 Orthognathic Surgery

Defines medical necessity criteria, documentation, coding, and exclusions for orthognathic (corrective jaw) surgery, including indications for congenital anomalies, trauma/tumor restoration, masticatory malocclusion, TMJ-related malocclusion, and OSA-related deformities; also addresses splints, investigational procedures, and cosmetic exclusions.

Policy Summary

PayerPremera Bluecross

Policy9.02.501 Orthognathic Surgery

Policy CodePolicy N/A

Change TypeRevised; additions & investigational designations

Effective DateSep 1, 2025

Next Review Date

Key ActionSubmit medical records documenting that the medical necessity criteria are met, including specialist documentation, objective imaging and measurements, and sleep study/PAP documentation when applicable.

SourceLink

POLICY UPDATE CHANGES

Policy revised; changes effective September 4, 2026 (document indicates revision and points to change link).

Added medical necessity criteria for significant transverse maxillary arch deficiency (09/01/23).

Endoscopically assisted nasomaxillary expansion for OSA designated investigational (01/01/24).

Criteria for TMJ-related malocclusion updated (07/01/18 & 07/01/21 history entries): added symptoms and conservative therapy requirements; open bite threshold changed historically.

7Named congenital indications

AHI >=15OSA surgical threshold

Allowed orthognathic splints

InvestigationalEndoscopically-assisted nasomaxillary expansion

Coverage Summary

Defines medical necessity criteria, documentation, coding, and exclusions for orthognathic (corrective jaw) surgery for: congenital craniofacial anomalies (examples: Apert, Cleft deformity, Crouzon, Hemifacial microsomia, Pfeiffer, Pierre Robin, Treacher Collins), restoration of function after traumatic injury or tumor, correction of skeletal deformities causing masticatory malocclusion, treatment of severe malocclusion contributing to TMJ-related symptoms, and correction of mandibular/maxillary deformities contributing to airway dysfunction associated with OSA.

Orthognathic surgery is intended to correct skeletal jaw and craniofacial deformities that cause functional impairment in chewing, speech, or swallowing when orthodontic/dental therapy alone is inadequate. The policy also specifies limits on orthognathic surgical splints, and identifies certain procedures as investigational (e.g., endoscopically-assisted nasomaxillary expansion for OSA, condylar positioning devices) and surgical indications that are cosmetic (not covered).

Key thresholds

Reverse overjet (ROJ)>= 3 mm

Overjet (OJ)>= 6 mm

Open bite (OB) (masticatory)>= 2 mm

Open bite (OB) (TMJ-related)>= 4 mm

Deep bite (DB)>= 7 mm

Unilateral transverse asymmetry> 3 mm

Bilateral transverse deficiency> 7 mm

OSA severityAHI >= 15

PAP trial durationminimum 90 days

Symptom persistenceat least 4 months

Orthognathic surgical splints (note)Use of two splints may be considered medically necessary; >2 not medically necessary

Medical Necessity Criteria (grouped by indication)

Orthognathic surgery for congenital anomalies

Orthognathic surgery for correction of congenital (apparent at birth) deformities may be considered medically necessary for the following diagnoses:

ANY of the following

Apert syndrome
Cleft deformity
Crouzon syndrome
Hemifacial microsomia (HFM)
Pfeiffer syndrome

Not Covered and Investigational Procedures

Investigational / Not medically necessary

Procedures not supported or considered investigational

Endoscopically-assisted nasomaxillary expansion as a treatment for OSA is considered investigational

The use of condylar positioning devices in orthognathic surgery is considered investigational

Orthognathic surgery is considered investigational for all other indications not specified as medically necessary

Cosmetic exclusions

Orthognathic surgery considered cosmetic (not covered)

Correction of unaesthetic facial features, regardless of association with psychological disorders, is considered cosmetic

Coding

Covered / Relevant CPT codes listed for orthognathic procedures and related servicesCPTCovered

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 (e.g., for Long Face Syndrome), 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.
21145	Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts).
21146	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts).
21147	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts).
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).

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Relevant CDT / Dental codesNDC|mixedCovered

D0330	Panoramic film.
D0340	Cephalometric film.
D0350	Oral/facial photographic images.
D0470	Diagnostic Casts.
D5954	Palatal augmentation prosthesis.
D5955	Palatal lift prosthesis, definitive.
D5958	Palatal lift prosthesis, interim.
D5959	Palatal lift prosthesis, modification.
D7283	Placement of device to facilitate eruption of impacted tooth.
D7881	Occlusal orthotic device adjustment.

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Provider Actions & Documentation Requirements

Documentation Required

Submit medical records demonstrating criteria

Medical records must show that the medical necessity criteria are met; include a written clinical course with dates, specialist clinical documentation (for example, orthodontic and sleep specialists), and a detailed description of the functional impairment attributable to the skeletal abnormality.

Medical records must document that medical necessity criteria are met, including written clinical course with dates, specialist clinical documentation (e.g., orthodontic and sleep specialist), and detailed description of functional impairment due to skeletal abnormality.

Documentation Required

Provide objective imaging and measurements

Provide study models and pre-orthodontic imaging with standard computer-generated measurements, plus clear frontal/full-face and lateral view photographs. Include the listed CDT imaging codes when submitting diagnostic materials.

Background, Evidence, and Definitions

Policy aligns with AAOMS criteria (Criteria for Orthognathic Surgery, 2008, updated 2023) and cites evidence linking orthognathic procedures to measurable improvements in occlusion, nasal/airway resistance, respiration, and functional outcomes (chewing, speech, swallowing) in appropriately selected patients.

Regarding evidence strength: AAOMS criteria are explicitly referenced as guidance for clinical measurements and indications. The policy notes that evidence for certain newer approaches is insufficient — specifically, endoscopically assisted nasomaxillary expansion (EASE) for OSA is designated investigational due to limited uncontrolled data and lack of demonstrated long-term OSA outcome measures (insufficient evidence).

Term	Definition
{"text":"AHI","status":""},{"text":"Apnea-Hypopnea Index, used to define severity of obstructive sleep apnea","status":""}
{"text":"Overjet (OJ)","status":""},{"text":"Horizontal projection of maxillary incisors over mandibular incisors measured in millimeters","status":""}
{"text":"Reverse overjet (ROJ)","status":""},{"text":"Mandibular incisors anterior to maxillary incisors measured in millimeters","status":""}
{"text":"Open bite (OB)","status":""},{"text":"Lack of vertical overlap of anterior teeth measured in millimeters","status":""}
{"text":"Deep bite (DB)","status":""},{"text":"Excessive vertical overlap of anterior teeth measured in millimeters","status":""}

Revision History

04/14/14policy_created

New policy created; orthognathic surgery may be medically necessary for certain skeletal deformities when dental/orthodontic therapy alone is inadequate.

07/01/18criteria_revision

Annual review: treatment of severe malocclusion contributing to TMJ syndrome symptoms added; criteria for TMJ-related indications and conservative therapy requirements introduced (history notes changes effective Oct 5, 2018).

07/01/21criteria_revision

Interim review: facial skeletal deformity criteria updated — open bite threshold changed from 4 mm to 2 mm in the maxillary/mandibular masticatory malocclusion section; added requirement that an orthodontic specialist document orthodontia is not recommended or has been tried and found inadequate; TMJ-related criteria clarified (symptom persistence and conservative therapy).

Policy Summary

PayerPremera Bluecross

Policy9.02.501 Orthognathic Surgery

Policy CodePolicy N/A

Change TypeRevised; additions & investigational designations

Effective DateSep 1, 2025

Next Review Date

SourceLink

On This Page

Pierre Robin syndrome

Treacher Collins syndrome

Orthognathic surgery for traumatic injury or tumor

Orthognathic surgery may be considered medically necessary for restoration of function related to an acute traumatic injury or surgical removal of a tumor.

Acute traumatic injury to facial skeleton or surgical removal of tumor resulting in functional impairment requiring restoration

Treatment of severe malocclusion contributing to TMJ syndrome symptoms

May be considered medically necessary when ONE of each of the following elements (1, 2 and 3) are met:

ALL of the following

1. Symptoms (ONE of) persisting >= 4 months
- Painful chewing clearly related to the TMJ
- Frequent and significant headaches clearly related to TMJ
- Significant temporomandibular joint and/or muscle tenderness
2. Symptoms persist after 4 months of conservative treatment with ONE of
- Elimination of aggravating factors such as gum chewing or chewing hard/tough foods
- Use of anti-inflammatory medications, unless contraindicated
- Treatment with splint therapy, unless not tolerated
3. Malocclusion/dental misalignment supported by ONE of
- Mandibular excess or maxillary deficiency with a reverse overjet (ROJ) of at least 3 mm>= 3 mm
- Maxillary excess or mandibular deficiency with an overjet (OJ) of at least 6 mm>= 6 mm
- Open bite (OB) of at least 4 mm>= 4 mm
- Deep bite (DB) of at least 7 mm>= 7 mm
- Significant transverse maxillary arch deficiency presenting with ONE of

Mandibular and maxillary deformities contributing to airway dysfunction and associated OSA

Maxillofacial surgery for treatment of mandibular and maxillary deformities contributing to airway dysfunction and associated obstructive sleep apnea (OSA) may be considered medically necessary when ALL of the following are present and documented:

ALL of the following

Moderate to severe OSA (AHI ≥ 15), confirmed by a sleep studyAHI >= 15
Individual has trialed and failed a minimum 90-day use of positive airway pressure (PAP)minimum 90 days
Individual participated in a PAP compliance program
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

Orthognathic surgical splints

Splints used in orthognathic surgery

The use of two orthognathic surgical splints may be considered medically necessary

Any use of greater than two orthognathic surgical splints is considered not medically necessary

Orthognathic surgery to reshape or enhance size of the chin (mentoplasty, chin augmentation, chin implants, genioplasty, or mandibular osteotomies/ostectomies) when performed as an isolated procedure or with other procedures is considered cosmetic

No benefits are available when orthognathic surgery is performed primarily for cosmetic purposes

D0340
D0330
D0350
D0470
Include study models, pre-orthodontic imaging such as cephalometric radiographs and diagrams with standard computer-generated measurements, and clear frontal/full face and lateral view photographs.

Documentation Required

Sleep study and PAP documentation for OSA-related surgery

For OSA-related orthognathic surgery, submit a sleep study showing AHI ≥ 15 and documentation that the patient trialed and failed PAP for a minimum of 90 days, participated in a PAP compliance program, and received a sleep specialist's rationale that other surgical options are not recommended or were inadequate.

AHI >= 15
Minimum 90-day PAP trial
Participation in a PAP compliance program
Sleep specialist documentation that other surgical options are not recommended or another surgical option was tried and was not adequate

Billing Rule

Orthognathic surgical splints limit

Two orthognathic surgical splints may be considered medically necessary; use of more than two splints is considered not medically necessary.

Affected code: 21085
Rule: max 2 splints

09/01/23added_criteria

Annual review: added medical necessity criteria for significant transverse maxillary arch deficiency (including crowded maxillary teeth with bicuspid extraction, unilateral asymmetry >3 mm, or bilateral transverse deficiency >7 mm).

01/01/24added_investigational

Interim review: endoscopically assisted nasomaxillary expansion (EASE) for obstructive sleep apnea designated investigational due to insufficient evidence.

09/01/25substantive_review

Annual review performed; references added and updated; policy statements unchanged. History records this as the most recent substantive review date.

09/04/26revision_effectiveLatest

Header notes policy revised with changes effective September 4, 2026 (document indicates revision and points to change link).

Crowded maxillary teeth with first or second bicuspid extracted and no other orthognathic procedures

Unilateral maxillary arch expansion (asymmetries greater than 3 mm with concomitant occlusal asymmetry)> 3 mm