Prior authorization may be required — submit clinical documentation and applicable codes

Submit prior authorization or medical review documentation that demonstrates the member meets the policy's clinical criteria and includes the applicable procedure codes listed in the guideline.

• Provide documentation demonstrating the clinical criteria (objective measurements or documented dysfunction) described in the policy.
• Include applicable procedure and/or diagnosis codes from the policy's code lists for reviewer reference.

Prior authorization recommended — verify plan requirements

Obtain prior authorization per the member-specific benefit plan before surgery; check the member-specific benefit plan and follow this medical policy when determining coverage and obtaining authorization.

• Verify plan-specific prior authorization requirements because the member-specific benefit plan governs coverage.
• Follow the medical policy criteria and instructions when requesting authorization.

Treatment pathway — document orthodontic and multimodality care

Document prior or planned orthodontic care and other non‑surgical therapies when orthognathic surgery is part of a multi-modality treatment plan, since surgery is often performed in combination with orthodontics.

• Include records of prior orthodontic treatment or a plan for pre- or post-surgical orthodontics.
• Note any rehabilitative or non-surgical therapies that are part of the treatment pathway.

Step therapy — not applicable

Step therapy does not apply to this policy; coverage is based on clinical indications and objective measurement thresholds rather than a required sequence of therapies.

• Do not rely on step-therapy sequencing for coverage determinations under this policy.

Medical records requirement — submit records for review

Provide medical records as they may be required to assess whether the member meets the clinical criteria for coverage; records alone do not guarantee coverage.

• Include all relevant medical records referenced in the policy's 'Medical Records Documentation Used for Reviews' section.
• Remember that benefit coverage is determined by the member-specific benefit plan.

Clinical documentation to support medical necessity — include quantified measurements and functional correlation

Include quantified clinical measurements and documentation linking dysfunction to the skeletal deformity to support medical necessity (e.g., measured anteroposterior, vertical, transverse discrepancies, asymmetries, or documented airway/TMJ/speech/psychosocial dysfunction).

• Provide objective measurements cited in the policy (for example, horizontal overjet, molar discrepancy, vertical/transverse thresholds, asymmetry values).
• Document clinical correlation between the skeletal deformity and functional impairment (airway, TMJ, speech, psychosocial, or masticatory dysfunction).

Documentation insufficiency — missing records may lead to denial

Insufficient or missing medical records required to verify the policy criteria may result in denial of the requested service.

• Ensure submitted records include the objective measurements and dysfunction documentation needed to evaluate medical necessity.
• Incomplete documentation does not guarantee coverage and may prompt request for additional information or denial.

Member benefit verification required — confirm plan-specific coverage

Verify the member-specific benefit plan before requesting authorization or scheduling services; the member-specific plan governs coverage and may differ from the standard policy.

• Confirm whether the member's plan has exclusions, different definitions, or additional requirements that affect coverage.
• When in conflict, the member-specific benefit plan document governs the coverage decision.