Prior Authorization Required

Prior authorization is required for orthognathic surgery services. Verify and obtain any required prior authorization for surgical procedures and for Virtual Surgical Planning (VSP)–related codes before scheduling. Failure to obtain prior authorization when required may result in denial of payment.

• Prior authorization required for orthognathic surgery services.
• Includes VSP-related codes (e.g., CDT D0393; CPT 76376, 76377) where applicable.

Verify Member Benefits and Coverage Limits

Confirm member benefit limitations and coverage specifics prior to treatment. Coverage is subject to the member's benefit plan and contract terms; consult the member benefit booklet or contact customer service for plan-specific limits, exclusions, and preauthorization processes.

• Coverage subject to member benefit plan limits and contract terms.
• Contact member services or review benefit booklet for plan-specific coverage and limits.

Clinical Measurement and Documentation Requirements

Document objective clinical measurements that demonstrate the facial skeletal deformity and functional impairment. Measurements should be clear and measurable and may include overjet, molar discrepancy, vertical measurements, and standardized deviations from norms.

• Document facial skeletal deformities with objective measurements (for example: overjet ≥ 5 mm, molar discrepancy ≥ 4 mm, or vertical deformity ≥ 2 standard deviations from published norms).
• Record evidence of impaired masticatory or incisive function, chewing-induced trauma, impaired swallowing/choking on incompletely chewed solid foods, or abnormal tongue thrust when present.
• Include documentation that an orthodontic specialist has evaluated the condition and that orthodontics alone is not recommended or was tried and found inadequate.

Non‑Surgical Therapy Trial Required Prior to Surgery

For indications related to obstructive sleep apnea (OSA) or temporomandibular joint (TMJ)–related symptoms, document trials of appropriate non‑surgical therapies and their outcomes prior to surgery. Include objective test results and specialist evaluations as applicable.

• For OSA-related indications: include sleep study results (e.g., AHI) and documentation of a trial of positive airway pressure (PAP) therapy, participation in PAP compliance program, and evidence that other surgical options are not recommended or were tried and inadequate.
• For TMJ or severe malocclusion: document conservative dental and orthodontic therapies attempted and their duration/outcomes, and specialist recommendations that surgery is indicated.