ModifiedUnitedHealthcarePolicy CS088NM.C

Orthognathic (Jaw) Surgery (for New Mexico Only)

Defines UnitedHealthcare Community Plan New Mexico medical policy for orthognathic (jaw) surgery, specifying reconstructive/medically necessary indications, required functional impairments, documentation expectations, applicable CPT/CDT codes, exclusions (cosmetic), and references. Does not address surgery for obstructive sleep apnea or temporomandibular joint disorders.

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for New Mexico Only)

Policy CodePolicy CS088NM.C

Change TypeRevised and added documentation & references

Effective DateJun 1, 2026

Next Review Date

Key ActionProvider must maintain legible medical records that fully support medical necessity, including relevant history, physical exam, and pertinent diagnostic test results, and make them available upon request.

POLICY UPDATE CHANGES

Removed reference link to the Medical Policy titled Treatment of Temporomandibular Joint Disorders (for New Mexico Only) and updated instruction to refer to the Medical Policy titled Obstructive and Central Sleep Apnea Treatment (for New Mexico Only) for surgical treatment of obstructive sleep apnea.

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

Updated Clinical Evidence and References sections to reflect recent literature (2023-2025 systematic reviews and AAOMS 2025 guidance).

Archived previous policy version CS088NM.B

7Verified measurement criteria

New MexicoGeographic restriction

Coverage Summary

Defines UnitedHealthcare Community Plan New Mexico medical policy for orthognathic (jaw) surgery, specifying reconstructive/medically necessary indications, required functional impairments, documentation expectations, applicable CPT/CDT codes, exclusions (cosmetic), and references. Orthognathic surgery may be considered Reconstructive and medically necessary with criteria when the specified objective measurement thresholds and functional impairments are met. This policy applies to New Mexico only.

Objective measurement thresholds

Horizontal overjet>= 5 mm or 0 to a negative value (established norm = 2 mm)

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

Vertical facial deformity severity>= 2 standard deviations from published norms

Posterior open bite> 2 mm

Transverse skeletal discrepancy>= 2 standard deviations from published norms

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

Asymmetry> 3 mm with concomitant occlusal asymmetry

Exclusions and limits: Orthognathic surgery is not considered reconstructive and medically necessary when performed for cosmetic purposes only or for any indications that do not meet the reconstructive criteria. This policy does not address surgical treatment for obstructive sleep apnea — refer to the Medical Policy titled Obstructive and Central Sleep Apnea Treatment (for New Mexico Only) — nor does it address surgical treatment for temporomandibular joint disorders (other policies apply). Provider documentation must fully support medical necessity and include relevant medical history, physical exam, and results of pertinent diagnostic tests; documentation must be legible, maintained in the medical record, and made available upon request.

Medical Necessity / Reconstructive Indications

Medically Necessary / Reconstructive Indications

Orthognathic (jaw) surgery may be considered Reconstructive and medically necessary when ALL of the following are met:

ref

Not Medically Necessary / Cosmetic

Orthognathic surgery is not considered Reconstructive and medically necessary for other indications, including:

ANY of the following

When performed for Cosmetic purposes only (procedures that change or improve appearance without significantly improving physiologic function)
All other indications not meeting the reconstructive criteria above

Exclusions / Policy Scope Clarification

Applicable Codes

Applicable CPT Codes (reference list)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
21123	Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

1–10 of 38

1/4

Applicable CDT / Dental Codes (reference list)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)

1–10 of 33

1/4

Provider Actions & Documentation

Documentation Required

Medical record support for medical necessity

Provider must maintain medical records that fully support medical necessity. Required elements include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation must be legible, kept in the patient's medical record, and made available upon request.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Documentation must be legible
Documentation must be maintained in the medical record and available upon request

Documentation Required

Verify applicable federal/state/contractual coverage

Background, Evidence & Definitions

Orthognathic surgery is the surgical correction of skeletal abnormalities of the mandible and/or maxilla to improve facial form and physiologic function. Indications include congenital anomalies, trauma, or disease-related deformities, and treatment is often combined with orthodontics; the primary goal is restoration or improvement of physiologic function.

Citation	Key Finding/Note
Zheng et al. 2025 systematic review	Improvement in oral health-related quality of life across domains after orthognathic surgery; limitations include heterogeneity and limited long-term data
Bunpu et al. 2023 meta-analysis	Masticatory performance improves after orthognathic surgery but may not reach normal occlusion; orthodontic treatment alone can achieve normal levels
Mulier et al. 2021	Variable long-term dental and dentolabial stability; limited evidence quality

Definitions: Cosmetic Procedures — procedures or services that change or improve appearance without significantly improving physiological function. Functional or Physical Impairment — deviation from normal function causing significant limitation in physical or basic life activities. Reconstructive Procedures — procedures whose 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.

Revision History

06/01/2026revisedLatest

06/01/2026added

Added detailed language in Medical Records Documentation Used for Reviews emphasizing that benefit coverage is determined by federal, state, or contractual requirements and that documentation may be required to assess clinical criteria but does not guarantee coverage; specified required documentation items (relevant medical history, physical examination, results of pertinent diagnostic tests or procedures) and that documentation should be legible and available upon request.