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ModifiedPremera BluecrossPolicy 9.02.501

Orthognathic Surgery

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Defines when corrective jaw (orthognathic) surgery is considered medically necessary, investigational, or cosmetic for Premera Blue Cross members; intended for providers evaluating coverage and documentation requirements.

Policy Summary

PayerPremera Bluecross

PolicyOrthognathic Surgery

Policy CodePolicy 9.02.501

Change TypeMaterial revisions — investigational statements addedcoding updates

Effective DateSep. 4, 2026

Last ReviewMay 12, 2026

Next Review DateN/A

Key ActionObtain and document prior authorization showing medical necessity criteria are met, including ≥4 months of functional impairment documentation and required specialist evaluations.

SourceLink

POLICY UPDATE CHANGES

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

Policy statement that Virtual Surgical Planning (VSP) is investigational.

Endoscopically assisted nasomaxillary expansion as a treatment for obstructive sleep apnea (OSA) is considered investigational.

Added specific CPT and CDT codes for virtual surgical planning (CDT D0393, CPT 76376, 76377) and removed a list of multiple CDT codes.

Added medical necessity criteria for significant transverse maxillary arch deficiency.

Changed facial skeletal deformity open bite threshold from 4 mm to 2 mm and added specific functional impairment examples and orthodontic trial requirement.

2026-06-01most recent annual review approval date

AHI ≥ 15AHI threshold for OSA

90 daysminimum PAP trial

≤ 2splints considered medically necessary

Added 3VSP codes added

Coverage Criteria for Orthognathic Surgery

Maxillary and/or mandibular facial skeletal deformities associated with masticatory malocclusion

Covered when ALL of the following are met:

Entry criteria: All of the following (1,2,3)

1. Functional impairment: One of the following significant functional impairments is present and persists for at least 4 months: impaired masticatory or incisive function; chewing-induced trauma to the soft tissues of the mouth; impaired swallowing or choking on incompletely chewed solid foods; abnormal tongue thrust; or speech abnormality determined by a speech pathologist/therapist to be due to skeletal malocclusion≥4 months

2. Facial skeletal deformity measurements: One of the following deformities is present: mandibular excess or maxillary deficiency with reverse overjet (ROJ) ≥ 3 mm; maxillary excess or mandibular deficiency with overjet (OJ) ≥ 6 mm; open bite (OB) ≥ 2 mm; deep bite (DB) ≥ 7 mm; or significant transverse maxillary arch deficiency meeting one of the subcriteria (crowded maxillary teeth with first/second bicuspid extracted and no other orthognathic procedures; unilateral maxillary arch expansion asymmetry > 3 mm with concomitant occlusal asymmetry; bilateral transverse arch > 7 mm)ROJ ≥3 mm; OJ ≥6 mm; OB ≥2 mm; DB ≥7 mm; transverse >7 mm or asymmetry >3 mm

3. Orthodontic evaluation: An orthodontic specialist has documented that orthodontia (conservative therapy) is not recommended for the condition (or has been tried and was not adequate)

Treatment of severe malocclusion contributing to TMJ syndrome symptoms

Covered when ALL of the following elements (1,2,3) are met:

Entry criteria: All of the following elements 1-3 must be met

1. Symptoms: One of the following symptoms is present and has persisted for at least 4 months: painful chewing clearly related to the TMJ; frequent and significant headaches clearly related to the TMJ; significant temporomandibular joint and/or muscle tenderness≥4 months

2. Conservative therapy tried: Symptoms persist after at least 4 months of one of the following conservative measures: elimination of aggravating factors (e.g., gum chewing, hard or tough foods); use of anti-inflammatory medications unless contraindicated; or splint therapy unless not tolerated≥4 months of conservative care

3. Malocclusion/dental misalignment measurements: One of the following is present and documented: ROJ ≥ 3 mm; OJ ≥ 6 mm; open bite (OB) ≥ 4 mm; deep bite (DB) ≥ 7 mm; or significant transverse maxillary arch deficiency per listed subcriteria (crowded maxillary teeth with first/second bicuspid extracted and no other orthognathic procedures; unilateral expansion asymmetry >3 mm with occlusal asymmetry)specific measurement thresholds as listed

Mandibular and maxillary deformities contributing to airway dysfunction and associated OSA

Covered when ALL of the following are present and documented:

OSA surgery criteria: All of the following must be documented

1. OSA severity: Moderate to severe obstructive sleep apnea (OSA) defined as AHI ≥ 15 confirmed by a sleep studyAHI ≥ 15

2. PAP trial: Individual has trialed and failed a minimum 90-day use of positive airway pressure (PAP)≥90 days

3. PAP compliance: Individual participated in a PAP compliance program

4. Sleep specialist evaluation: A qualified sleep specialist has documented that other surgical options are not recommended for OSA or that another surgical option was tried and found inadequate

Orthognathic surgical splints

Splint coverage: Use of two orthognathic surgical splints may be considered medically necessary; use of greater than two orthognathic surgical splints is considered not medically necessary≤2 splints considered necessary

Investigational and Unproven

Investigational procedures: Endoscopically-assisted nasomaxillary expansion for OSA; Virtual Surgical Planning (VSP) including CDT D0393 and related 3D planning tools; and the use of condylar positioning devices in orthognathic surgery are considered investigational

Orthognathic surgery is investigational for indications not listed as medically necessary

Cosmetic

Cosmetic exclusion: Orthognathic surgery performed primarily to correct unaesthetic facial features (including isolated chin reshaping procedures) is considered cosmetic and not covered

No benefits available when primarily cosmetic

Medical necessity — orthognathic surgery

Covered when ALL of the following are met (per AAOMS indications and policy history):

Orthognathic surgery medical necessity criteria

Measurement examples: Examples include: maxillary/mandibular incisor overjet ≥5 mm; molar AP discrepancy ≥4 mm; vertical or transverse discrepancies ≥2 SDs from norms; total bilateral palatal cusp to mandibular fossa discrepancy ≥4 mm or unilateral ≥3 mm; asymmetries >3 mmAAOMS thresholds

Investigational — endoscopically assisted nasomaxillary expansion for OSA

Not covered / investigational when:

Endoscopically assisted maxillary expansion for OSA: Endoscopically assisted nasomaxillary expansion as a treatment for obstructive sleep apnea

Insufficient evidence for safety and efficacy; considered investigational according to policy.

Investigational — Virtual Surgical Planning (VSP)

Investigational / not medically necessary when:

Virtual Surgical Planning (VSP): Use of Virtual Surgical Planning (VSP) for orthognathic cases (including CDT D0393 and CPT 76376/76377)

Policy statement added that VSP is investigational; corresponding codes were added to the coding list.

Medically Necessary Orthognathic Surgery Criteria (summary)

Covered when ALL of the following are met (summary of revisions noted in history):

Functional impairment: Facial skeletal deformities associated with masticatory malocclusion must demonstrate functional impairment (examples: impaired masticatory or incisive function; chewing-induced trauma to soft tissues; impaired swallowing or choking on incompletely chewed solid foods; abnormal tongue thrust).

An orthodontic specialist must document that orthodontia is not recommended or has been tried and was not adequate.

Open bite magnitude: Open bite must meet the revised threshold criteria (anterior vertical overlap <= 2 mm or posterior open bite > 2 mm / policy summarized as OB ≥ 2 mm).>= 2 mm

OSA contribution: For maxillary and/or mandibular deformities contributing to airway dysfunction and OSA, the condition must be moderate to severe OSA (AHI ≥ 15) and a qualified sleep specialist must document that other surgical options are not recommended or have been tried and were not adequate.AHI ≥ 15

Prior non-surgical options including a PAP trial and compliance program should be attempted when indicated.

Investigational Procedures

Investigational / Not medically necessary statements added:

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

Virtual Surgical Planning (VSP) is considered investigational and therefore not medically necessary for coverage; codes D0393, CPT 76376, 76377 were added to the policy coding list.

Orthognathic surgery performed primarily for cosmetic purposes is excluded from coverage. No benefits are available when the procedure is undertaken mainly to correct unaesthetic facial features or for isolated chin reshaping/augmentation procedures (e.g., mentoplasty, chin implants, genioplasty) performed primarily for cosmetic reasons.

Policy allows up to two orthognathic surgical splints as medically necessary. Any use of greater than two orthognathic surgical splints is considered not medically necessary and is subject to denial.

Endoscopically assisted nasomaxillary expansion for obstructive sleep apnea and Virtual Surgical Planning (VSP) are designated investigational by this policy. The evidence for endoscopically assisted maxillary expansion is limited to small, uncontrolled series without long‑term OSA outcomes, and systematic reviews and expert opinion for VSP do not establish clear efficacy; therefore both interventions are considered investigational and excluded from routine coverage.

Endoscopically assisted nasomaxillary expansion specifically as a treatment for obstructive sleep apnea is considered investigational. The policy states there is insufficient peer‑reviewed evidence of safety and efficacy to support this technique for OSA, and it is explicitly excluded from coverage as a medically necessary intervention for OSA.

Virtual Surgical Planning (VSP) (CDT D0393 and CPT 76376/76377) and endoscopically assisted nasomaxillary expansion for OSA are considered investigational and therefore not medically necessary. VSP codes were added to the coding list concurrent with the policy statement that VSP is investigational; use of these planning codes for VSP is subject to the policy’s investigational stance.

Procedures and planning tools identified as investigational in this policy—including endoscopically assisted maxillary expansion for OSA and Virtual Surgical Planning (VSP)—are considered not medically necessary/experimental. Claims for these services may be denied on the basis that they lack sufficient evidence of safety and efficacy per the policy statement.

Virtual Surgical Planning (VSP) is listed as investigational in the policy statement and therefore is considered not medically necessary. The policy history notes the addition of VSP as investigational and the concurrent inclusion of VSP-related codes (D0393, CPT 76376, 76377) in the coding section.

Coding — CPT and CDT

Covered CPT and CDT codesmixed

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)
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
21151	Reconstruction midface, LeFort II; any direction, requiring bone grafts

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Virtual surgical planning codes (added)mixed

D0393	Virtual surgical planning
76376	Computed tomography guidance; surgical planning, image post-processing (added)
76377	3D rendering (added)

Removed CDT codesCDT

D8050-D8999 (range mention removed)

Multiple CDT codes removed from policy list (see history for removed codes)

Covered/Listed CDT codes (added)CDT

D0393

Virtual surgical planning (CDT) - added

Added CPT codes for VSPCPT

76376	3D radiological image post-processing, added
76377	3D radiological image post-processing, added

CDT codes with termination/removed statusCDTNot Covered

D8050	CDT code — termination noted 1/1/2022 (historical)
D8060	CDT code — termination noted 1/1/2022 (historical)
D8690	CDT code — termination noted 1/1/2022 (historical)
D8691	CDT code — termination noted 1/1/2022 (historical)
D8692	CDT code — termination noted 1/1/2022 (historical)
D8693	CDT code — termination noted 1/1/2022 (historical)
D8694	CDT code — termination noted 1/1/2022 (historical)

CDT codes removedCDTNot Covered

D5954	CDT code removed from policy
D5955	CDT code removed from policy
D5958	CDT code removed from policy
D5959	CDT code removed from policy
D7283	CDT code removed from policy
D7881	CDT code removed from policy
D8010	CDT code removed from policy
D8020	CDT code removed from policy
D8030	CDT code removed from policy
D8040	CDT code removed from policy

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1/2

Reverse overjet / Overjet / Open bite / Deep bite / Transverse deficiency — measurement thresholds

Reverse overjet (ROJ)≥ 3 mm

Overjet (OJ)≥ 6 mm

Open bite (OB)≥ 2 mm (policy-wide threshold; note TMJ indication previously cited at ≥4 mm in a specific section)

Deep bite (DB)≥ 7 mm

Transverse maxillary arch deficiencyBilateral transverse arch > 7 mm or unilateral asymmetry > 3 mm (or crowded maxillary teeth with first/second bicuspid extracted and no other orthognathic procedures)

AHI threshold used for OSA

AHI threshold for OSA considered for orthognathic surgeryAHI ≥ 15 (moderate to severe OSA confirmed by sleep study)

Documentation requiredAHI must be confirmed by a sleep study

Associated requirementsPrior PAP trial and sleep specialist evaluation also required per OSA criteria

AAOMS clinical measurement thresholds (overjet, molar, intramaxillary discrepancy)

AAOMS overjet thresholdIncisor overjet of 5 mm or more (≈ ≥2 SDs from published norms)

Molar AP discrepancyAntero-posterior molar relationship discrepancy of ≥ 4 mm (≈ ≥2 SDs)

Vertical discrepancy / Open biteAnterior vertical overlap ≤ 2 mm or unilateral/bilateral posterior open bite > 2 mm; vertical deformity ≥2 SDs from norms

Transverse discrepancyTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral ≥ 3 mm (or transverse deformity ≥2 SDs)

Open bite measurement — revised threshold

Revised open bite surgical threshold>= 2 mm (policy revised open bite criteria from 4 mm to 2 mm)

Open bite in TMJ-specific sectionNote: earlier TMJ-related measurement section lists open bite ≥ 4 mm for that indication (historical distinction)

Documentation requirementClinical photographs, measurements and orthodontic/specialist documentation required to support measurement

Provider Actions, Documentation and Prior Authorization

Denial Risk

Claims Coding and Denial Risk

Claims may be denied if coding uses CDT codes that have been removed or terminated as of their specified dates. Verify current CDT and CPT code sets before submission; billing with deleted CDT codes (for example, D5954, D5955, D5958, D5959, D7283, D7881, D8010, D8020, D8030, D8040, D8070, D8080, D8090, D8210, D8220, D8660, D8670, D8680, D8681, D8999) may result in claim denial.

Removed/terminated CDT codes include: D5954, D5955, D5958, D5959, D7283, D7881, D8010, D8020, D8030, D8040, D8070, D8080, D8090, D8210, D8220, D8660, D8670, D8680, D8681, D8999
Policy added VSP codes (CDT D0393; CPT 76376, 76377) — verify coverage status and prior authorization requirements before billing

Documentation Required

Conservative Therapy Requirement

Orthognathic surgery requires documentation that conservative/orthodontic therapies were attempted and found inadequate prior to approval when indicated by the medical necessity criteria. Conservative measures must be trialed for at least 4 months where specified and may include elimination of aggravating factors, anti-inflammatory medication when appropriate, and splint therapy unless not tolerated. An orthodontic specialist’s documentation is required when the criteria call for orthodontia to be tried or deemed not recommended.

Conservative therapies: elimination of aggravating factors, anti-inflammatory medications (unless contraindicated), splint therapy (unless not tolerated)
Duration: symptoms should persist after 4 months of conservative treatment when required by criteria
Orthodontic documentation: a specialist must document that orthodontia has been tried and found inadequate or is not recommended

Background

Orthognathic surgery involves revision of the maxilla and/or mandible by ostectomy, osteotomy, or osteoplasty to correct skeletal jaw and craniofacial relationships that impair function. Indications generally include congenital anomalies, trauma, tumors, or skeletal deformities that cause malocclusion, temporomandibular joint symptoms, or airway dysfunction contributing to obstructive sleep apnea—particularly when orthodontic treatment alone is inadequate to restore functional occlusion.

Definitions and Measurement Thresholds

Orthognathic surgery — definition

DefinitionRevision by ostectomy, osteotomy or osteoplasty of the maxilla and/or mandible intended to alter the relationship of the jaws and teeth to correct skeletal deformities and improve function.

Purpose examplesTo correct skeletal jaw and craniofacial deformities associated with impaired chewing, speaking or swallowing

When usedWhen conventional orthodontic therapy alone is unable to provide a satisfactory, functional dental occlusion

AHI — Apnea/Hypopnea Index

AHI definition in policyApnea/Hypopnea Index (AHI) used to categorize OSA severity; policy uses AHI ≥ 15 to define moderate to severe OSA for orthognathic surgery consideration.

Confirmatory testingAHI must be confirmed by a sleep study as part of documentation

Associated requirementsPAP trial and sleep specialist documentation required when AHI ≥ 15 is present

AAOMS measurement thresholds — Overjet / Molar / Intramaxillary discrepancy

Overjet / incisor relationshipIncisor overjet ≥ 5 mm (≈ 2+ SDs from norms)

Molar AP discrepancyAntero-posterior molar discrepancy ≥ 4 mm

Vertical/transverse thresholdsVertical or transverse deformity ≥ 2 SDs from published norms; specific transverse values include bilateral discrepancy ≥ 4 mm or unilateral ≥ 3 mm

Asymmetry thresholdAntero-posterior, transverse or lateral asymmetries > 3 mm with occlusal asymmetry

Functional impairment — examples

Examples of functional impairmentImpaired masticatory or incisive function

Chewing-related injuryChewing-induced trauma to oral soft tissues

Swallowing/speech impactImpaired swallowing or choking on incompletely chewed solid foods, or speech abnormality attributable to skeletal malocclusion

Open bite — surgical criteria threshold

Open bite surgical criteria>= 2 mm (policy revised open bite threshold to 2 mm)

DocumentationMeasurements must be supported by clinical photos, models, cephalometric imaging and specialist documentation

Historical noteOpen bite threshold was previously 4 mm in TMJ-specific measurement section (historical distinction prior to revision)

Policy Summary

PayerPremera Bluecross

PolicyOrthognathic Surgery

Policy CodePolicy 9.02.501

Change TypeMaterial revisions — investigational statements addedcoding updates

Effective DateSep. 4, 2026

Last ReviewMay 12, 2026

Next Review DateN/A

Key ActionObtain and document prior authorization showing medical necessity criteria are met, including ≥4 months of functional impairment documentation and required specialist evaluations.

SourceLink

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