Modifiedsierra health and lifePolicy MP.013.24

Orthognathic (Jaw) Surgery

Defines medical necessity criteria, coding, and coverage rationale for orthognathic (upper and/or lower jaw) reconstructive surgery for UnitedHealthcare Commercial and Individual Exchange plans; applies to clinical review and prior authorization decisions.

Policy Summary

Payersierra health and life

PolicyOrthognathic (Jaw) Surgery

Policy CodePolicy MP.013.24

Change TypeUpdated CDT codes and shared policy added for Oxford

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and submit prior authorization with clinical measurements and documentation that demonstrate the numeric thresholds and functional impairment to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated list of applicable CDT codes to reflect annual edits and revised descriptions for D5934 and D5935.

Created shared policy version to support application to Oxford plan membership.

Template update documented in policy history for 01/01/2026.

1policy covered in this brief

dozenscodes listed

multiplenumeric thresholds

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Coverage Criteria

Reconstructive and Medically Necessary Criteria

Orthognathic surgery is considered reconstructive and medically necessary when ALL of the following are met:

Primary skeletal deformity

Anteroposterior discrepancies: Either: maxillary/mandibular incisor relationship horizontal overjet ≥ 5 mm or horizontal overjet of zero to negative value; OR maxillary/mandibular anteroposterior molar relationship discrepancy ≥ 4 mm (norm 0–1 mm).overjet ≥5 mm or molar discrepancy ≥4 mm
Vertical discrepancies: Either: vertical facial skeletal deformity ≥ 2 standard deviations from published norms for accepted skeletal landmarks; OR open bite defined as no vertical overlap of anterior teeth or unilateral/bilateral posterior open bite > 2 mm; also includes deep overbite with soft tissue impingement or supraeruption due to lack of occlusion.>=2 SD or posterior open bite >2 mm
Transverse discrepancies: Either: transverse skeletal discrepancy ≥ 2 standard deviations from published norms; OR total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral discrepancy ≥ 3 mm given normal axial inclination of posterior teeth.>=2 SD or bilateral >=4 mm or unilateral >=3 mm
Asymmetries: Anteroposterior, transverse, or lateral asymmetries > 3 mm with concomitant occlusal asymmetry.>3 mm

Functional impairment: One or more of the following functional impairments must be present: masticatory and swallowing dysfunction due to skeletal malocclusion (examples: inability to bite or chew solid foods, choking on incompletely masticated solids, damage to soft tissue during mastication, malnutrition); OR documentation of speech impairment due to facial skeletal deformity.clinical documentation of dysfunction

AAOMS-specified objective skeletal deformities

Covered when the following verifiable clinical measurements or documented dysfunctions are present:

AAOMS measurable skeletal indications: Anteroposterior discrepancies: maxillary/mandibular incisor relationship horizontal overjet of +5 mm or more, or horizontal overjet of zero to a negative value; OR maxillary/mandibular anteroposterior molar relationship discrepancy of ≥4 mm (norm 0–1 mm). These values represent ≥2 standard deviations from published norms.horizontal overjet >= +5 mm or molar discrepancy >=4 mm

AAOMS vertical indications: Vertical discrepancies: presence of a vertical facial skeletal deformity ≥2 standard deviations from published norms; OR open bite defined as no vertical overlap of anterior teeth, or unilateral/bilateral posterior open bite >2 mm; includes deep overbite with impingement or supraeruption of a dentoalveolar segment due to lack of occlusion.>=2 SD or posterior open bite >2 mm

AAOMS transverse indications: Transverse discrepancies: presence of a transverse skeletal discrepancy ≥2 standard deviations from published norms; OR total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥4 mm, or unilateral discrepancy ≥3 mm given normal axial inclination of posterior teeth.

Functional indications

Covered when specific documented signs of dysfunction accompany skeletal deformity:

Documented dysfunctions: One or more of the following documented and clinically correlated dysfunctions linked to the skeletal deformity: airway dysfunction (e.g., sleep apnea), temporomandibular joint disorders, psychosocial disorders, or speech disorders; OR masticatory/swallowing dysfunctions such as inability to bite/chew solid foods, choking on incompletely masticated solids, damage to soft tissue during mastication, or malnutrition.document clinical correlation

Orthognathic surgery is not considered reconstructive and medically necessary when performed for cosmetic purposes only. Coverage is limited to procedures that meet the policy's reconstructive and functional criteria; operations done solely to change or improve appearance without documented functional impairment are excluded.

This policy does not address surgical treatment for obstructive sleep apnea or temporomandibular joint disorders. For those conditions, refer to the Medical Policies titled “Obstructive and Central Sleep Apnea Treatment” and “Treatment of Temporomandibular Joint Disorders.” Providers should verify and follow the applicable member-specific benefit plan and related policy instructions when seeking coverage for treatments for sleep apnea or TMJ disorders.

Orthognathic surgery is described in this document as a surgical procedure rather than an FDA-regulated device. As noted, FDA approval status is not a basis for coverage determinations; the FDA does not regulate surgical procedures in the same way it regulates medical devices.

Procedures performed solely for cosmetic purposes without accompanying functional impairment are not considered medically necessary. To meet medical necessity, the policy requires documentation of functional deficits (for example, masticatory or swallowing dysfunction or speech impairment) linked to the skeletal deformity in addition to objective skeletal findings.

The clinical evidence section summarizes multiple systematic reviews and observational studies that report variable outcomes and limitations in the literature (including retrospective study designs, small samples, and heterogeneous follow-up). The policy does not add a blanket not medically necessary statement based on evidence; instead, it notes variability in outcomes and that evidence limitations may affect case-by-case determinations of medical necessity.

Coding / Procedure Codes

Applicable CPT/HCPCS Codes (part 1)CPT

21076	Impression and custom preparation; surgical obturator prosthesis.
21079	Impression and custom preparation; interim obturator prosthesis.
21080	Impression and custom preparation; definitive obturator prosthesis.
21081	Impression and custom preparation; mandibular resection prosthesis.
21082	Impression and custom preparation; palatal augmentation prosthesis.
21083	Impression and custom preparation; palatal lift prosthesis.
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material).
21121	Genioplasty; sliding osteotomy, single piece.
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin).
21123	Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts).

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Applicable CPT/HCPCS Codes (part 2)CPT

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) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies).
21150	Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome).
21151	Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts).
21154	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I.
21155	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I.

Applicable CPT/HCPCS Codes (part 3)CPT

21159	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I.
21160	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I.
21188	Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts).
21193	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft.
21194	Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; with bone grafts (includes obtaining graft).
21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation.
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation.
21198	Osteotomy, mandible, segmental.
21199	Osteotomy, mandible, segmental; with genioglossus advancement.
21206	Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard).

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Applicable CPT/CDT Codes (part 4)mixed

21244	Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate).
21245	Reconstruction of mandible or maxilla, subperiosteal implant; partial.
21246	Reconstruction of mandible or maxilla, subperiosteal implant; complete.
21247	Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts).
D5934	Mandibular guidance prosthesis with guide flange.
D5935	Mandibular guidance prosthesis without guide flange.
D5982	Surgical stent.
D5988	Surgical splint.

Applicable CDT Codes (part 5)CDT

D7471	Removal of lateral exostosis (maxilla or mandible).
D7472	Removal of torus palatinus.
D7473	Removal of torus mandibularis.
D7490	Radical resection of maxilla or mandible.
D7610	Maxilla - open reduction (teeth immobilized, if present).
D7630	Mandible - open reduction (teeth immobilized, if present).
D7650	Malar and/or zygomatic arch - open reduction.
D7671	Alveolus - open reduction, may include stabilization of teeth.
D7680	Facial bones - complicated reduction with fixation and multiple surgical approaches.
D7710	Maxilla - open reduction.

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Applicable CDT Codes (part 6)CDT

D7750	Malar and/or zygomatic arch - open reduction; Incision required to reduce fracture.
D7770	Alveolus - open reduction stabilization of teeth.
D7780	Facial bones - complicated reduction with fixation and multiple approaches.
D7940	Osteoplasty - for orthognathic deformities.
D7941	Osteotomy - mandibular rami.
D7943	Osteotomy - mandibular rami with bone graft; includes obtaining the graft.
D7944	Osteotomy - segmented or subapical.
D7945	Osteotomy - body of mandible.
D7946	LeFort I (maxilla - total).
D7947	LeFort I (maxilla - segmented).

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Applicable CDT Codes (updated)CDT

D5934	Description revised (see policy applicable codes list)
D5935	Description revised (see policy applicable codes list)

inv-16: Horizontal overjet — numeric threshold

Horizontal overjet>= 5 mm (horizontal overjet of +5 mm or more per AAOMS)

Alternative overjet findingZero to negative overjet may also indicate anteroposterior discrepancy

Norm referenceEstablished norm = 2 mm (values represent ≥2 SD from published norms)

inv-17: Anteroposterior molar discrepancy — numeric threshold

Molar relationship discrepancy>= 4 mm (maxillary/mandibular anteroposterior molar discrepancy)

Provider Actions and Authorization

Prior Authorization

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

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.

Background & Scope

Orthognathic surgery corrects skeletal abnormalities of the mandible, maxilla, or both to improve facial form and physiologic function. The procedure is typically performed to restore or improve function — such as mastication, swallowing, and speech — and is frequently combined with orthodontic treatment as part of a multi-modality care pathway. Indications include congenital, developmental, traumatic, or disease-related skeletal deformities that cause functional impairment; the policy requires objective measurements and documentation of dysfunction to support medical necessity.

Definitions

inv-35: Reconstructive Procedures — definition and scope

DefinitionReconstructive Procedures: Primary purpose is treatment of a medical condition or improvement/restoration of physiologic function (includes surgery related to injury, sickness, or congenital anomaly)

ScopeIncludes procedures to improve function and/or create normal appearance as part of reconstructive intent (e.g., cleft palate-related dental/orthodontic services)

Exclusion noteProcedures that correct an anatomical congenital anomaly without improving physiologic function may be considered cosmetic

inv-36: Cosmetic Procedures — definition

DefinitionCosmetic Procedures: Procedures or services that change or improve appearance without significantly improving physiological function

California-specific wording

Policy Summary

Payersierra health and life

PolicyOrthognathic (Jaw) Surgery

Policy CodePolicy MP.013.24

Change TypeUpdated CDT codes and shared policy added for Oxford

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and submit prior authorization with clinical measurements and documentation that demonstrate the numeric thresholds and functional impairment to support medical necessity.

SourceLink

On This Page

>=2 SD or bilateral >=4 mm or unilateral >=3 mm

AAOMS asymmetry indications: Asymmetries: anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.>3 mm

Norm referenceNormal molar relationship ~0 to 1 mm (established norm referenced as 2 mm elsewhere)

Clinical contextDiscrepancy of 4 mm represents ≥2 standard deviations from published norms per AAOMS

inv-18: Asymmetry threshold — numeric threshold

Asymmetry magnitude> 3 mm (anteroposterior, transverse, or lateral asymmetries)

Occlusal requirementMust be accompanied by concomitant occlusal asymmetry

Measurement standardValues correspond to verifiable clinical measurements per AAOMS guidance

inv-19: Posterior open bite — numeric threshold

Posterior open bite> 2 mm (unilateral or bilateral posterior open bite >2 mm)

Anterior open biteNo vertical overlap of anterior teeth qualifies as open bite

Associated vertical criteriaCounts toward vertical discrepancy when present with ≥2 SD deviation from norms

inv-20: Vertical/transverse skeletal discrepancy — threshold (SDs)

Vertical/transverse skeletal discrepancy>= 2 standard deviations from published norms for accepted skeletal landmarks

Examples (vertical)Vertical facial skeletal deformity ≥2 SD (includes open bite, deep overbite with soft tissue impingement)

Examples (transverse)Transverse skeletal discrepancy ≥2 SD or palatal cusp to mandibular fossa criteria for transverse assessment

inv-21: Total bilateral palatal cusp to mandibular fossa discrepancy — numeric threshold

Total bilateral discrepancy>= 4 mm (total bilateral maxillary palatal cusp to mandibular fossa discrepancy)

Unilateral thresholdUnilateral discrepancy >= 3 mm given normal axial inclination of posterior teeth

ContextUsed to define transverse skeletal discrepancy per AAOMS guidance

inv-22: Anteroposterior and molar relationship thresholds — restates overjet and molar discrepancy thresholds

Restated horizontal overjet>= 5 mm (horizontal overjet of +5 mm or more)

Restated molar discrepancy>= 4 mm (maxillary/mandibular anteroposterior molar discrepancy)

Norms noteValues represent ≥2 standard deviations from published norms (established norm = 2 mm)

inv-23: Transverse discrepancy thresholds — palatal cusp to mandibular fossa thresholds

Bilateral transverse threshold>= 4 mm (total bilateral palatal cusp to mandibular fossa discrepancy)

Unilateral transverse threshold>= 3 mm (unilateral discrepancy, given normal posterior tooth axial inclination)

Alternative criterionPresence of transverse skeletal discrepancy defined as ≥2 SD from norms

inv-24: Asymmetry threshold — anteroposterior/transverse/lateral asymmetries >3 mm with occlusal asymmetry

Asymmetry magnitude> 3 mm (anteroposterior, transverse, or lateral asymmetries)

Occlusal requirementMust be accompanied by concomitant occlusal asymmetry to meet threshold

Clinical useDefines when facial asymmetry is considered a reconstructive indication

inv-25: Vertical discrepancy threshold — 6gt;=2 SD from norms; posterior open bite >2 mm

Vertical deformity threshold>= 2 SD from published norms for accepted skeletal landmarks

Posterior open bite specificPosterior open bite >2 mm qualifies as vertical discrepancy

Other vertical findingsIncludes open bite (no anterior vertical overlap) and deep overbite with soft tissue impingement

Note

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

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.

Documentation Required

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.

Documentation Required

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).

Denial Risk

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.

Billing Rule

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.

Performed to alter or reshape normal structures to improve appearance (Cosmetic Procedures - California only)

Coverage implicationCosmetic purpose alone does not meet reconstructive/medically necessary criteria

inv-37: Functional or Physical Impairment — definition

DefinitionFunctional or Physical Impairment: Deviation from normal function causing significantly limited or impaired capacity to perform physical activities or basic life functions

ManifestationsExhibited by difficulties in physical/motor tasks, independent movement, or performing basic life functions

RelevancePresence of functional impairment linked to skeletal deformity supports medical necessity for reconstructive surgery

inv-38: Anteroposterior discrepancy — definition and example thresholds

DefinitionAnteroposterior discrepancy: Measured differences in maxillary/mandibular incisor or molar relationship (e.g., horizontal overjet >= +5 mm or zero/negative overjet; molar discrepancy >=4 mm)

Numeric thresholdsHorizontal overjet >=5 mm; molar discrepancy >=4 mm (norm 0-1 mm); established norm referenced as 2 mm

Clinical noteThese values represent two or more standard deviations from published norms per AAOMS guidelines

inv-39: Vertical discrepancy — definition and thresholds

DefinitionVertical discrepancy: Vertical facial skeletal deformity defined as >= 2 standard deviations from published norms

Specific findingsIncludes open bite (no anterior vertical overlap), unilateral or bilateral posterior open bite >2 mm, and deep overbite with soft tissue impingement

Clinical implicationMeets reconstructive indication when documented as >=2 SD or when posterior open bite >2 mm

inv-40: Transverse discrepancy — definition and thresholds

DefinitionTransverse discrepancy: Presence of a transverse skeletal discrepancy >= 2 standard deviations from published norms

Palatal cusp to fossa thresholdsTotal bilateral palatal cusp to mandibular fossa discrepancy >=4 mm, or unilateral >=3 mm given normal axial inclination of posterior teeth

Clinical useUsed to verify transverse skeletal deformity for reconstructive/medical necessity determinations per AAOMS