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

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

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 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.

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

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

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

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