CurrentProvidence Health PlanPolicy 400

Orthognathic Surgery

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This Medicare Advantage medical policy provides coverage guidance and medical-necessity considerations for orthognathic surgery and related maxillofacial procedures. Member benefit language and applicable CMS guidance take precedence, and the policy does not address orthognathic surgery for obstructive sleep apnea.

Policy Summary

PayerProvidence Health Plan

PolicyOrthognathic Surgery

Policy CodePolicy 400

Change TypeNo material change

Effective DateSep 1, 2026

Last ReviewAug 1, 2026

Next Review DateAug 1, 2027

Key ActionFor an unlisted code submitted for a potentially covered orthognathic-surgery service, obtain prior authorization to help avoid a post-service denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0Specific Medicare coverage criteria identified

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CurrentProvidence Health PlanPolicy 400

Orthognathic Surgery

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Sign up for Providence Health Plan Policy 400 alerts

Get alerted when Policy 400 changes without checking for updates manually.

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Policy Summary

PayerProvidence Health Plan

PolicyOrthognathic Surgery

Policy CodePolicy 400

Change TypeNo material change

Effective DateSep 1, 2026

Last ReviewAug 1, 2026

Next Review DateAug 1, 2027

Key ActionFor an unlisted code submitted for a potentially covered orthognathic-surgery service, obtain prior authorization to help avoid a post-service denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0Specific Medicare coverage criteria identified

Coverage Criteria

Orthognathic surgery for treatment of obstructive sleep apnea (OSA) is outside the scope of this policy. Refer to the applicable cross-referenced policy for other possible coverage guidance.

Corrective facial surgery is considered cosmetic rather than reconstructive when no functional impairment is present. Medical-necessity review considers the member’s diagnoses, conditions, functional status, comorbidities, physician recommendations, and clinical documentation.

Billing and Coding

CPT Codes Listed in PolicyCPT

21070	Coronoidectomy (separate procedure).
21081	Impression and custom preparation; mandibular resection prosthesis.
21082	Impression and custom preparation; palatal augmentation prosthesis.
21083	Impression and custom preparation; palatal lift prosthesis.
21085	Impression and custom preparation; oral surgical splint.
21089	Unlisted maxillofacial prosthetic procedure.
21125	Augmentation, mandibular body or angle; prosthetic material.
21127	Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft).
21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft.
21142	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft.

1–10 of 35

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Provider Guidance

Prior Authorization

Prior Authorization Recommended for Unlisted Codes

For potentially covered orthognathic-surgery services addressed by this policy, prior authorization is recommended to help avoid a post-service denial. All unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing.

Submit prior authorization before services are rendered when an unlisted code is used for a potentially covered orthognathic-surgery service.
See the applicable non-covered and prior authorization lists on the Company Medical Policy, Reimbursement Policy, Pharmacy Policy, and Provider Information website.

Documentation Required

Clinical Documentation for Medical Necessity

Clinical documentation should support the medical-necessity determination and explain why the requested service is reasonable and necessary to treat illness or injury. Determinations may consider coverage and benefit criteria, current standards of care, the member’s medical history, diagnoses, functional status, comorbidities, physician recommendations, and clinical notes.

Policy Background

Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both. These abnormalities may be congenital, develop during growth, or result from trauma. The primary treatment goal is to improve craniofacial function—including speech, swallowing, and chewing—by correcting the underlying skeletal deformity.

Key Definitions

Definitions

TermOrthognathic surgery

DefinitionSurgical correction of abnormalities of the mandible, maxilla, or both.

Definitions

TermMedically reasonable and necessary

DefinitionServices or items that treat illness or injury and satisfy applicable Medicare coverage, benefit, evidence, and individualized clinical requirements.

Documentation Required

Document Functional Impairment and Treatment Rationale

Document the underlying skeletal deformity and the functional impairment or illness/injury being treated, along with the expected benefit of correcting the deformity. Orthognathic surgery is intended to improve craniofacial function, such as speech, swallowing, or chewing; corrective facial surgery may be considered cosmetic when no functional impairment is present.

Describe the congenital, developmental, or traumatic skeletal abnormality of the mandible, maxilla, or both.
Explain the functional impairment or illness/injury, including how it affects speech, swallowing, chewing, or other craniofacial function.
State the treatment rationale and expected functional benefit of the proposed surgery.

Billing Rule

Code Listing Does Not Guarantee Coverage

The code list is provided as a courtesy and may not be all-inclusive. Inclusion or omission of a code does not imply or guarantee reimbursement or coverage; services remain subject to member benefits, eligibility, provider contracts, medical-necessity requirements, and potential utilization audit.

The presence of a payment amount in the Medicare Physician Fee Schedule does not establish that a service is covered or medically reasonable and necessary.
Codes may also be subject to CMS National Correct Coding Initiative procedure-to-procedure bundling edits and medically unlikely edits.