CurrentUnitedHealthcarePolicy CS088KS.04

Orthognathic (Jaw) Surgery (for Kansas Only)

UnitedHealthcare Community Plan medical policy for orthognathic (jaw) surgery applicable only to the state of Kansas; describes reconstructive/medical necessity criteria, references InterQual CP criteria, lists applicable CPT/HCPCS/CDT codes, documentation requirements, exclusions, and references.

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for Kansas Only)

Policy CodePolicy CS088KS.04

Change TypeDocumentation requirements added; evidence updated

Effective DateJun 1, 2026

Next Review Date

Key ActionEnsure the patient medical record includes legible documentation (history, physical exam, and pertinent diagnostic results) that fully supports medical necessity and make it available upon request.

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews language added specifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria and must fully support medical necessity.

Updated Clinical Evidence and References sections to reflect most current information.

Archived previous policy version CS088KS.03.

InterQualPrimary criteria source

Numerical thresholdsVerifiable clinical measurements

ExcludedCosmetic-only indications

Coverage Summary

Background: Orthognathic surgery is the surgical correction of skeletal abnormalities of the mandible and/or maxilla to improve facial form and physiologic function; these abnormalities may be congenital, developmental, traumatic, or disease-related and are often treated in combination with orthodontics. (Policy Number: CS088KS.04, Subject: Orthognathic (Jaw) Surgery (Kansas Only); Effective/Last Review Date: June 1, 2026)

Scope summary: This UnitedHealthcare Community Plan medical policy applies only to the state of Kansas and describes reconstructive/medical necessity criteria for orthognathic (jaw) surgery, references InterQual CP criteria as the primary source, lists applicable procedure codes, documents required medical-record elements, and specifies exclusions for cosmetic-only indications.

Coverage stance: Orthognathic surgery is covered with criteria (reconstructive and medically necessary) when InterQual CP criteria are met or, if InterQual does not address the case, when the policy-specific clinical criteria and functional impairment requirements are documented and supported in the medical record.

Medical-Necessity Criteria

General coverage / Reconstructive and medically necessary

Orthognathic (jaw) surgery may be considered reconstructive and medically necessary when InterQual CP criteria are met or when the following criteria are met:

Either InterQual criteria or policy-specific criteria

If not addressed by InterQual, must have both A and B
- A. Presence of one or more facial skeletal deformities associated with masticatory malocclusion
  - Anteroposterior discrepancies (established norm = 2 mm) - ONE of
    Maxillary/mandibular incisor relationship: Horizontal overjet of 5 mm or more or a 0 to a negative value>= 5 mm or 0 to negative
    Maxillary/mandibular anteroposterior molar relationship: Discrepancy of 4 mm or more (norm = 0 to 1 mm)>= 4 mm
  - Vertical discrepancies - ONE of
    Presence of a vertical facial skeletal deformity which is 2 or more standard deviations from published norms for accepted skeletal landmarks
InterQual reference: Meets InterQual CP: Procedures - Orthognathic Surgery or Orthognathic Surgery (Pediatric)
Click link to view InterQual criteria

Not Medically Necessary / Cosmetic exclusions

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

All indications not meeting the criteria above
Includes procedures performed for cosmetic purposes only
Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered Cosmetic and not reconstructive
Policy does not address surgical treatment for obstructive sleep apnea or temporomandibular joint disorders; refer to respective policies

Applicable Codes (reference only)

Applicable CPT / Procedure Codes (reference only)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 CDT / Dental Codes (reference only)mixed

D5934	Mandibular guidance prosthesis with guide flange.
D5935	Mandibular guidance prosthesis without guide flange.
D5982	Surgical stent.
D5988	Surgical splint.
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).

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Provider Actions & Prior Authorization

Documentation Required

Medical records documentation required

Patient medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation should be legible, maintained in the patient's record, and made available upon request. Benefit coverage is determined by federal, state, or contractual requirements; medical record documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Prior Authorization

InterQual-based prior authorization / criteria use

Coverage decisions use InterQual CP criteria for orthognathic surgery. Providers should reference applicable InterQual criteria (Orthognathic Surgery or Orthognathic Surgery [Pediatric]) when submitting prior authorization requests.

Reference InterQual criteria in prior authorization submissions.

Background and Evidence

Background: Orthognathic surgery corrects skeletal abnormalities of the mandible and/or maxilla to improve facial form and physiologic function; abnormalities may be congenital, developmental, traumatic, or disease-related and are often combined with orthodontic treatment.

Definitions: Cosmetic Procedures — Procedures or services that change or improve appearance without significantly improving physiological function. Functional or Physical Impairment — Deviation from normal function of a tissue or organ resulting in significantly limited capacity to perform physical activities or basic life functions. Reconstructive Procedures — Procedures where the primary purpose is treatment of a medical condition or improvement/restoration of physiologic function related to injury, sickness, or congenital anomaly; the primary result is not a changed or improved physical appearance.

Evidence

Revision History

2026-06-01policy_revision_addedLatest

Added Medical Records Documentation Used for Reviews language: benefit coverage is determined by federal, state, or contractual requirements; medical records may be required to assess clinical criteria but do not guarantee coverage; patient record must fully support medical necessity including relevant medical history, physical exam, and pertinent diagnostic test/procedure results; documentation must be legible, maintained, and made available upon request. (Material change—clarified required documentation elements.)

2026-06-01supporting_information_updatedLatest

Updated Clinical Evidence and References sections to reflect most current information, including systematic reviews and AAOMS 2025 guidance.