CurrentUnitedHealthcarePolicy CS088KY.10

Orthognathic (Jaw) Surgery (for Kentucky Only)

UnitedHealthcare Community Plan medical policy for orthognathic (jaw) surgery applicable only to Kentucky members; references InterQual CP: Procedures for primary medical necessity criteria and provides supplemental objective criteria when InterQual does not apply. Excludes surgical treatment for obstructive sleep apnea and temporomandibular joint disorders (see separate policies).

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for Kentucky Only)

Policy CodePolicy CS088KY.10

Change TypeRevised CDT code descriptions; archived prior version

Effective DateMarch 1, 2026

Next Review Date

Key ActionProviders must document objective verifiable clinical measurements that meet the stated numeric thresholds and at least one functional impairment when InterQual criteria do not apply.

POLICY UPDATE CHANGES

Revised description for CDT codes D5934 and D5935.

YesRequires objective numeric thresholds

InterQualPrimary criteria source

Kentucky-onlyGeographic scope

CS088KY.10Policy version

Coverage Summary

Scope Summary: UnitedHealthcare Community Plan medical policy for Orthognathic (Jaw) Surgery (Kentucky only). Subject: Orthognathic (Jaw) Surgery (Kentucky). Coverage stance: Mixed — Reconstructive and medically necessary when InterQual CP: Orthognathic Surgery (adult) or Orthognathic Surgery (Pediatric) criteria are met; otherwise supplemental objective numeric thresholds apply. Overview: This policy uses InterQual as the primary source for clinical medical necessity determinations. When applicable InterQual criteria do not address a specific orthognathic surgery indication, the policy provides supplemental, verifiable numeric thresholds and documentation requirements (for example, measurements of overjet, molar discrepancy, transverse discrepancy, asymmetry and at least one documented functional impairment) to determine reconstructive medical necessity.

Key thresholds and scope

Horizontal overjet>= 5 mm or 0 to negative value

Anteroposterior molar discrepancy>= 4 mm (norm 0 to 1 mm)

Posterior open bite> 2 mm (unilateral or bilateral)

Transverse discrepancyBilateral maxillary palatal cusp to mandibular fossa >= 4 mm or unilateral >= 3 mm

Asymmetry> 3 mm with concomitant occlusal asymmetry

Skeletal deformity deviation>= 2 standard deviations from published norms (vertical or transverse)

Geographic/scopeKentucky-only; InterQual is primary criteria source; policy provides supplemental objective numeric thresholds

Medical Necessity Criteria

General Coverage Statement

Orthognathic (jaw) surgery may be considered Reconstructive and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to InterQual CP: Orthognathic Surgery or Orthognathic Surgery (Pediatric). Orthognathic surgery not addressed in InterQual may be considered reconstructive when ALL of the following are met:

ALL of the following

Presence of facial skeletal deformity associated with masticatory malocclusion
- Anteroposterior discrepancies (choose one)
  - Incisor relationship: Maxillary/mandibular incisor relationship: Horizontal overjet of 5 mm or more or a 0 to a negative value>= 5 mm or 0 to negative value
  - Molar relationship: Maxillary/mandibular anteroposterior molar relationship: Discrepancy of 4 mm or more (norm 0 to 1 mm)>= 4 mm
- Vertical discrepancies (one of)
  - Vertical facial deformity: Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks>= 2 standard deviations
  - Open bite definitions (one of)
    No vertical overlap of anterior teeth
    Posterior open bite: Unilateral or bilateral posterior open bite greater than 2 mm> 2 mm
  - Deep overbite or supraeruption: Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch, or supraeruption of a dentoalveolar segment due to lack of occlusion
- Transverse discrepancies (one of)
  - Transverse skeletal discrepancy: Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms>= 2 standard deviations
  - Palatal cusp to fossa discrepancy: Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teethbilateral >= 4 mm or unilateral >= 3 mm
- Asymmetries: Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry> 3 mm with concomitant occlusal asymmetry
Functional Impairments
- Masticatory and swallowing dysfunction due to skeletal malocclusion (e.g., inability to bite and/or chew solid foods, choking on incompletely masticated solid foods, damage to soft tissue during mastication, malnutrition)
- Speech impairment: Documentation of speech impairment due to facial skeletal deformity

Exclusions / Not Medically Necessary

Orthognathic surgery is not considered Reconstructive and medically necessary for the following:

Exclusions

Does not meet objective criteria: Indications not meeting the stated objective skeletal deformity and functional impairment criteria
Cosmetic only: Procedures performed for cosmetic purposes only
OSAS/TMJ exclusions: Surgical treatment for obstructive sleep apnea or temporomandibular joint disorders (these are addressed in separate UnitedHealthcare Kentucky policies)

Provider Actions & Billing Guidance

Documentation Required

Objective measurements and functional impairment documentation required

When InterQual criteria do not apply, document objective, verifiable clinical measurements that meet the numeric thresholds in the policy and also document at least one functional impairment (masticatory/swallowing dysfunction or speech impairment).

Horizontal overjet: >= 5 mm or 0 to negative value
Anteroposterior molar discrepancy: >= 4 mm
Transverse discrepancy: bilateral palatal cusp to mandibular fossa >= 4 mm or unilateral >= 3 mm
Asymmetry: > 3 mm with concomitant occlusal asymmetry
Posterior open bite: > 2 mm

Documentation Required

Reference InterQual for primary criteria

Apply InterQual CP: Orthognathic Surgery (adult) or InterQual CP: Orthognathic Surgery (Pediatric) as the primary medical necessity determination. This policy supplements InterQual when InterQual lacks applicable criteria.

Use InterQual criteria first for primary determination; this policy provides supplemental objective criteria when InterQual does not have applicable criteria.

Billing Rule

Use applicable procedure codes for claim submission

Report the applicable CPT and CDT procedure codes listed in the policy when submitting claims. The list of codes is provided for reference only and does not guarantee coverage; benefit coverage and reimbursement are determined by federal, state, or contractual requirements and applicable laws.

21076
21079
21080
21081
21082
21083
21120
21121
21122
21123
21125
21127
21141
21142
21143
21145
21146
21147

Background & Evidence

Background: Orthognathic surgery corrects skeletal abnormalities of the mandible, maxilla, or both to improve facial form and physiologic function and is often performed in combination with orthodontics. The policy references InterQual criteria and AAOMS guidance for objective indications and numerically aligned thresholds. Clinical evidence summarized from systematic reviews indicates that orthognathic surgery improves masticatory performance but may not restore it fully to levels seen in normal occlusion (Bunpu et al. 2023), long-term dental/dentolabial stability is variable with limited evidence (Mulier et al. 2021), some surgery-first approaches may have poorer postoperative stability than orthodontics-first approaches (Wei et al. 2018; Yang et al. 2017), and complication rates for segmental Le Fort I osteotomy have been estimated at less than < 8.5% in available observational studies (Haas Junior et al. 2017).

Citation	Key finding
Bunpu et al. 2023	Systematic review/meta-analysis: masticatory performance improves after orthognathic surgery but may not reach normal occlusion; orthodontic treatment alone may reach normal occlusion.
Mulier et al. 2021	Systematic review: variable long-term dental/dentolabial stability; evidence limited and further prospective studies recommended.
Wei et al. 2018	Systematic review: surgery‑first approach may yield poorer postoperative stability than conventional orthodontics‑first (mandibular counterclockwise rotation noted).
Haas Junior et al. 2017	Systematic review: complications after segmental Le Fort I osteotomy estimated to be less than 8.5%; evidence limited by retrospective designs.
AAOMS 2025 guidance	Provides verifiable numeric indications aligned with policy thresholds for anteroposterior, vertical, transverse discrepancies and asymmetries.

Definitions: Reconstructive Procedures — procedures primarily intended to treat a medical condition or improve/restore physiologic function (related to injury, sickness, or congenital anomaly) where the primary result is not improved appearance. Functional or Physical Impairment — a deviation from normal function causing significantly limited capacity to perform physical activities or basic life functions (e.g., difficulty with physical/motor tasks, independent movement, or basic life functions). Cosmetic Procedures — procedures or services that change or improve appearance without significantly improving physiological function.

OpenPayer

Orthognathic (Jaw) Surgery (for Kentucky Only)

Coverage Summary

Medical Necessity Criteria

Provider Actions & Billing Guidance

Procedure Codes (Reference)

Background & Evidence

Revision History