CurrentTexas Children's Health PlanPolicy 6192

Oral Surgery Authorization and Coverage Guidelines

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This guideline governs Texas Children's Health Plan authorization and coverage of oral surgery procedures, including medically necessary oral surgery and orthognathic surgery. It applies to providers requesting services for TCHP members, except surgical procedures to correct cleft lip and palate.

Policy Summary

PayerTexas Children's Health Plan

PolicyOral Surgery Authorization and Coverage Guidelines

Policy CodePolicy 6192

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit authorization requests for all oral surgery procedures, except cleft lip and palate repair, with medical-necessity documentation and the service location or facility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysInitial treatment window after accidental injury

4 monthsRequired symptom duration for masticatory dysfunction

5 mmQualifying horizontal overjet

4 mmQualifying molar discrepancy

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CurrentTexas Children's Health PlanPolicy 6192

Oral Surgery Authorization and Coverage Guidelines

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 6192 alerts

Get alerted when Policy 6192 changes without checking for updates manually.

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Policy Summary

PayerTexas Children's Health Plan

PolicyOral Surgery Authorization and Coverage Guidelines

Policy CodePolicy 6192

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit authorization requests for all oral surgery procedures, except cleft lip and palate repair, with medical-necessity documentation and the service location or facility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysInitial treatment window after accidental injury

4 monthsRequired symptom duration for masticatory dysfunction

5 mmQualifying horizontal overjet

4 mmQualifying molar discrepancy

Significant occlusal asymmetry threshold

Covered Oral Surgery and Orthognathic Surgery

Covered oral surgery

Covered when medically necessary and one of the following clinical situations applies:

Covered oral surgery situations

Developmental cyst: The procedure treats a developmental cyst of epithelial remnants, such as a globulomaxillary, median alveolar, median palatine, or nasopalatine cyst; the cyst is not tooth-related.
Removal is considered medically appropriate.
Biopsy of oral soft tissue: The procedure is a biopsy of the buccal mucosa, tongue, or palate.
Biopsy of gingiva or supporting tooth structures: The procedure is a biopsy of the gingiva or supporting structures of the teeth, other than tissue obtained as part of a routine tooth extraction or routine periodontal procedure.
Subsequent care or treatment of dental conditions is ineligible under medical or surgical contracts.
Accidental injury to sound natural teeth
- The procedure treats an accidental injury caused by a force outside the body or oral cavity to sound and natural teeth.
- Initial treatment is rendered within 90 days of the injury.Within 90 days of injury
- The affected tooth had no restorative treatment or disease before the injury.
Congenital anomaly or disease
- The procedure treats an underlying congenital anomaly or disease that was present at birth.
- Medical documentation of the anomaly is provided.
  Documentation may include provider documentation, genetic testing records, or birth records.

Orthognathic surgery indications

Orthognathic surgery may be covered when medically necessary or when necessary as part of an approved Texas Medicaid Dental Program plan of care.

The surgery is necessary as part of an approved plan of care in the Texas Medicaid Dental Program.
The surgery produces signs or symptoms of masticatory dysfunction.
The surgery addresses facial skeletal discrepancies associated with documented sleep apnea, airway defects, or soft tissue discrepancies.
Speech impairment due to malocclusion
- A speech pathologist or therapist determines that the documented speech impairment is due to a malocclusion.
- The speech impairment was not helped by orthodontia or at least six months of speech therapy.

Masticatory dysfunction or dysphagia

Orthognathic surgery for masticatory dysfunction or dysphagia is medically necessary only when ALL of the following criteria are met.

Masticatory dysfunction or dysphagia criteria

The patient has symptoms related to difficulty chewing, including choking due to incomplete mastication, difficulty swallowing chewed solid food, ability to chew only soft food, reliance on liquid food, or intra-oral trauma while chewing related to malocclusion.
Intra-oral trauma may include loss of food through the lips during mastication causing recurrent damage to oral soft tissues.
Symptoms are documented in the medical record, are significant, and persist for at least four months.At least 4 months
Other causes of swallowing or choking problems have been ruled out by history, physical examination, and appropriate diagnostic studies.

Orthognathic malocclusion criteria

Orthognathic surgery for masticatory dysfunction or malocclusion is medically necessary when either the Section 7 criteria are met OR the following skeletal growth, imaging, and discrepancy criteria are satisfied.

Qualifying pathway

The patient meets all masticatory dysfunction or dysphagia criteria in Section 7.
Skeletal growth, imaging, and discrepancy pathway
- Skeletal growth is complete, documented by a long-bone x-ray or serial cephalometrics showing no change in facial bone relationships over the prior 3- to 6-month period.No change over 3-6 months
  Class II malocclusions and individuals age 18 or older do not require this documentation.
- Malocclusion is documented by applicable intra-oral casts, bilateral lateral x-rays, a cephalometric radiograph with measurements, a panoramic radiograph, or tomograms.
- At least one qualifying discrepancy

The following services are not covered under this guideline: single-arch comprehensive orthodontic services; orthodontic services performed solely for cosmetic purposes; routine dental extractions; biopsies for dental-related cysts or tissue of dental origin; and removal of tooth-related cysts.

This guideline does not apply to the diagnosis or treatment of temporomandibular joint disorders (TMJ).

Surgical procedures to correct cleft lip and palate are excepted from TCHP oral surgery authorization requirements.

Orthodontic services performed solely for cosmetic purposes are not covered.

Clinical Thresholds and Diagnostic Definitions

Horizontal overjet

Qualifying thresholdHorizontal overjet of 5 mm or more

Alternative qualifying findingHorizontal overjet of zero to a negative value

Established incisor relationship norm2 mm

Maxillary/mandibular molar relationship discrepancy

Qualifying discrepancyMaxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more

Normal range0 to 1 mm

Relationship measuredMaxillary/mandibular anteroposterior molar relationship

Authorization, Documentation, and Denial Rules

Prior Authorization

Prior Authorization Required for Oral Surgery

TCHP requires prior authorization for all oral surgery procedures except surgery to correct cleft lip and palate. Submit requests to the Utilization Management Department through online submission, fax, phone, or mail during normal business hours; TCHP also follows the Texas Medicaid Provider Procedures Manual.

Exception: surgical procedures to correct cleft lip and palate do not require authorization under this guideline.
Submission pathway: online, fax, phone, or mail.

Documentation Required

Utilization Management Review

A Utilization Management professional reviews the submitted information to determine whether the documentation supports the requested oral surgery as an eligible service. TCHP applies the criteria and requirements of the Texas Medicaid Provider Procedures Manual.

Guideline Scope

This guideline addresses medically necessary oral surgery, including biopsies, treatment of selected cysts, traumatic injury to sound natural teeth, congenital anomalies, and orthognathic surgery. Orthognathic surgery may be considered for functional problems such as masticatory dysfunction, dysphagia, airway or sleep apnea-related skeletal discrepancies, speech impairment due to malocclusion, and structural jaw abnormalities. The guideline excludes diagnosis and treatment of temporomandibular joint disorders.

Key Terms

Sound tooth

Natural supportSufficiently supported by its natural structure, including bone and gum tissue

FormationFormed by the human body

Condition at injury siteNot decayed or weakened by previous dental work; for example, no crowns, root canals, periodontal condition, or fractures, and no treatment need unrelated to the accidental injury

Congenital anomaly or disease

DefinitionAn abnormality of structure or function that was present at birth

ExamplesCleft palate and ectodermal dysplasia

Not considered congenital

Policy Summary

PayerTexas Children's Health Plan

PolicyOral Surgery Authorization and Coverage Guidelines

Policy CodePolicy 6192

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit authorization requests for all oral surgery procedures, except cleft lip and palate repair, with medical-necessity documentation and the service location or facility.

SourceLink

On This Page

At least 6 months of speech therapy

The surgery treats structural abnormalities of the jaws secondary to infection, trauma, neoplasia, or congenital anomalies.

Anteroposterior discrepancy
- Horizontal overjet is 5 mm or more.≥ 5 mm
- Horizontal overjet is zero to a negative value.≤ 0
  Overjet up to 5 mm may be treatable with routine orthodontic therapy.
- Maxillary/mandibular anteroposterior molar relationship discrepancy is 4 mm or more.≥ 4 mm; norm is 0 to 1 mm
Vertical discrepancy
- A vertical facial skeletal deformity is two or more standard deviations from published norms for accepted skeletal landmarks.≥ 2 standard deviations
- There is no vertical overlap of the anterior teeth.
- There is a unilateral or bilateral posterior open bite greater than 2 mm.> 2 mm
- A deep overbite impinges on or irritates the buccal or lingual soft tissues of the opposing arch.
- A dentoalveolar segment has supra-erupted due to lack of occlusion.
Transverse discrepancy
- A transverse skeletal discrepancy is two or more standard deviations from published norms.≥ 2 standard deviations
- The total bilateral maxillary palatal cusp to mandibular fossa discrepancy is 4 mm or greater, or the unilateral discrepancy is 3 mm or greater, with normal axial inclination of the posterior teeth.Bilateral ≥ 4 mm or unilateral ≥ 3 mm
Asymmetry
- Anteroposterior, transverse, or lateral asymmetry is greater than 3 mm.> 3 mm
- The asymmetry is accompanied by concomitant occlusal asymmetry.

Vertical facial skeletal deformity

Qualifying deviationTwo or more standard deviations from published norms

Applicable reference pointsAccepted skeletal landmarks

Discrepancy categoryVertical facial skeletal deformity

Posterior open bite

Qualifying thresholdGreater than 2 mm

Permitted distributionUnilateral or bilateral

FindingPosterior open bite

Transverse maxillary discrepancy

Bilateral thresholdTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater

Unilateral thresholdUnilateral maxillary palatal cusp to mandibular fossa discrepancy of 3 mm or greater

Occlusal conditionNormal axial inclination of the posterior teeth

Occlusal asymmetry

Asymmetry thresholdAnteroposterior, transverse, or lateral asymmetry greater than 3 mm

Additional requirementConcomitant occlusal asymmetry

Qualifying categoriesAnteroposterior, transverse, or lateral asymmetries

Submit sufficient clinical information and medical-necessity documentation for review.

Documentation Required

Prior Orthodontic or Speech Therapy

For speech-impairment indications related to a facial skeletal discrepancy, documentation must show that a speech pathologist or therapist determined the impairment is due to malocclusion and that the condition was not helped by orthodontia or by at least six months of speech therapy.

Document the speech professional’s determination that the impairment is related to malocclusion.
Document prior orthodontic treatment or at least 6 months of speech therapy and lack of improvement.

Documentation Required

Core Submission Requirements

The requesting provider must submit documentation supporting the medical necessity of the requested procedure and identify the location or facility where services will be provided.

Medical-necessity documentation is required.
Include the service location or facility.

Documentation Required

Congenital Condition Documentation

When services treat an underlying congenital anomaly or disease present at birth, provide medical documentation of the condition.

Acceptable documentation includes provider documentation, genetic testing records, or birth records.

Documentation Required

Orthognathic Surgery Records

Requests for medically necessary mandibular or maxillary orthognathic surgery must include records supporting the relevant symptoms, diagnostic findings, skeletal maturity, and malocclusion criteria.

Document masticatory dysfunction or dysphagia symptoms, such as choking from incomplete mastication, difficulty swallowing chewed solid food, inability to eat anything beyond soft food, reliance on liquid food, or intra-oral trauma during chewing related to malocclusion.
For masticatory dysfunction or dysphagia, document that symptoms are significant, persist for at least 4 months, and are recorded in the medical record; document that other causes have been ruled out through history, physical examination, and appropriate diagnostic studies.
Document completion of skeletal growth with long-bone x-ray or serial cephalometrics showing no change in facial bone relationships during the prior 3–6 months. Class II malocclusions and individuals age 18 or older do not require this documentation.
Document malocclusion using applicable intra-oral casts, bilateral lateral x-rays, cephalometric radiographs with measurements, panoramic radiographs, or tomograms.
Include applicable anteroposterior, vertical, transverse, or asymmetry findings, including the guideline thresholds.

Documentation Required

Speech Impairment Documentation

For speech-impairment indications, submit documentation from a speech pathologist or therapist establishing that the impairment is associated with a facial skeletal discrepancy and malocclusion.

The documentation must identify the speech impairment and attribute it to malocclusion.
Include evidence that orthodontia or at least 6 months of speech therapy did not help.

Documentation Required

Masticatory Dysfunction Documentation

For masticatory dysfunction or dysphagia, submit medical-record documentation showing significant symptoms related to chewing or swallowing that have persisted for at least 4 months, along with evaluation excluding other causes.

Examples include choking from incomplete mastication, difficulty swallowing chewed solid food, ability to chew only soft food, reliance on liquid food, or intra-oral trauma during chewing related to malocclusion.
Support the symptoms with history, physical examination, and appropriate diagnostic studies ruling out other causes.

Denial Risk

Non-Covered Dental and Cosmetic Procedures

Unless otherwise stated in this guideline or the Texas Medicaid Provider Procedures Manual, TCHP does not cover oral surgical procedures. Routine dental and cosmetic services are among the non-covered services.

Single-arch comprehensive orthodontic services.
Orthodontic services performed solely for cosmetic purposes.
Routine dental extractions.
Biopsies for dental-related cysts or tissue of dental origin, including amalgam tattoo, fibroma, or hyperkeratoses.
Removal of tooth-related cysts, including follicular-dentigerous, primordial, multilocular, cysts of Malassez, radicular, residual cysts, and odontomas.

Denial Risk

Accidental Injury Eligibility Requirements

Treatment for accidental injury is eligible only when the initial treatment is rendered within 90 days of the injury and the affected tooth was sound and natural, with no restorative treatment or disease before the injury.

The injury must be caused by a force from outside the body or oral cavity.
Both the 90-day initial-treatment requirement and the sound-natural-tooth requirement must be met.

Denial Risk

Dental-Related Biopsy or Follow-Up

Biopsy of the gingiva or supporting structures of the teeth is not covered when tissue is obtained as part of a routine tooth extraction or routine periodontal procedure. Subsequent care or treatment of dental conditions is also ineligible under medical/surgical contracts.

Routine extraction-related and routine periodontal-procedure-related tissue collection is excluded.
Dental-condition follow-up care remains ineligible under medical/surgical coverage.

Denial Risk

Failure to Meet Guideline Criteria

Requests for oral surgery procedures that do not meet the applicable guideline criteria are referred to a TCHP Medical Director or Physician Reviewer, and the Denial Policy is followed.

Ensure the request addresses the guideline criteria and includes supporting documentation before submission.

Billing Rule

Authorization Is Not a Guarantee of Payment

Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility. Approval applies only to the medical necessity of the authorized treatment or service; all benefit limitations, exclusions, and payment conditions remain applicable.

Providers remain subject to state and federal regulatory requirements.
Failure to comply may result in retrospective audit and potential financial recoupment.

A clinical condition that develops after birth but is based on inherited factors, such as diabetes