ModifiedPremera BluecrossPolicy N/A

Orthognathic Surgery

Defines medical necessity, documentation, and coding for orthognathic (corrective jaw) surgery for members covered by Premera Blue Cross; intended for providers evaluating coverage for functional jaw and facial skeletal deformities, trauma, tumors, congenital anomalies, TMJ-related indications, and OSA-related deformities.

Policy Summary

PayerPremera Bluecross

PolicyOrthognathic Surgery

Policy CodePolicy N/A

Change TypeRevised (effective Sep 4, 2026)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit documentation demonstrating coverage criteria and required imaging/measurements before scheduling orthognathic procedures.

SourceLink

POLICY UPDATE CHANGES

This policy has been revised with changes effective September 4, 2026.

≥ 4 monthsminimum symptom persistence required

AHI ≥ 15OSA severity threshold

90 daysminimum PAP trial

2 splintsmax splints allowed

AAOMS 2023guideline referenced

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