ModifiedUnitedHealthcarePolicy CS088NM.C

Orthognathic (Jaw) Surgery (for New Mexico Only)

Defines UnitedHealthcare Community Plan coverage criteria for orthognathic (jaw) surgery in New Mexico, specifying reconstructive/medically necessary indications, required functional impairments, documentation expectations, and lists applicable procedure codes (CPT/CDT). Does not address surgical treatment for obstructive sleep apnea or TMJ disorders and refers to separate sleep apnea policy.

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for New Mexico Only)

Policy CodePolicy CS088NM.C

Change TypeCoverage criteria and documentation updates

Effective DateJun 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record fully supports medical necessity (relevant history, physical exam, and pertinent diagnostic results) and make documentation available upon request.

POLICY UPDATE CHANGES

Coverage Rationale: Removed reference to TMJ Disorders policy and updated to refer to Obstructive and Central Sleep Apnea Treatment (for New Mexico Only).

Medical Records Documentation Used for Reviews: Added detailed language requiring documentation that supports medical necessity and noting federal/state/contractual requirements determine coverage.

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

Supporting Information: Updated Clinical Evidence and References sections to reflect current information.

1State-specific policy (New Mexico)

MultipleReferenced CPT/CDT codes listed

Coverage Summary

This policy defines UnitedHealthcare Community Plan coverage criteria for orthognathic (jaw) surgery in New Mexico and treats the procedure as reconstructive and medically necessary when specified skeletal deformity measurements and associated functional impairments are met. Coverage is governed by policy number CS088NM.C and does not address surgical treatment for obstructive sleep apnea or TMJ disorders (see related sleep apnea policy).

Key thresholds and scope

Horizontal overjet>= 5 mm or 0 to negative value

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

Open bite - posterior> 2 mm (unilateral or bilateral posterior open bite)

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

Asymmetry> 3 mm with concomitant occlusal asymmetry

Skeletal deformity deviation>= 2 standard deviations from published norms

Medically Necessary Criteria (Reconstructive Indications)

Not medically necessary / Exclusions

Orthognathic surgery is not considered reconstructive and medically necessary for:

ANY of the following

All other indications not meeting the above criteria
When performed for cosmetic purposes only
This policy does not address surgical treatment for obstructive sleep apnea or temporomandibular joint disorders (refer to separate policies)
Refer to Obstructive and Central Sleep Apnea Treatment (for New Mexico Only); TMJ disorders covered by separate policy

Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation required

Patient record must fully support the medical necessity for the requested services. Documentation should be legible, maintained in the patient's medical record, and made available upon request. Records must include relevant medical history, a physical examination, and results of pertinent diagnostic tests or procedures to support medical necessity.

Relevant medical history
Physical examination
Results of pertinent diagnostic tests or procedures

Prior Authorization

Prior authorization applicability (check plan)

Benefit coverage may require review of medical records to determine whether the member meets the clinical criteria for coverage. Prior authorization may be required per the applicable benefit plan and by federal, state, or contractual requirements. Check the member's benefit plan for prior authorization rules and coverage determinations.

Applicable Procedure Codes (Reference)

Referenced CPT Codes (applicable procedure codes listed for reference)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

1–10 of 38

1/4

Referenced CDT / Dental Codesmixed

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

Background & Evidence

Orthognathic surgery corrects skeletal abnormalities of the mandible and/or maxilla to improve facial form and function and is often performed with orthodontics for congenital, traumatic, or disease-related deformities; the AAOMS 2025 guidance is referenced for clinical indications. AAOMS provides verifiable measurement thresholds (for example, horizontal overjet, molar discrepancy, vertical and transverse deviation values, and asymmetry thresholds) that are explicitly cited in this policy.

Systematic reviews (2023, 2025) report that orthognathic surgery generally improves oral health–related quality of life and masticatory function, but masticatory performance may not reach that of normal occlusion and long-term stability is variable; reported complication rates vary by procedure and review, and limitations across studies include heterogeneity, retrospective designs, and limited long-term follow-up.

Definitions

Reconstructive ProceduresProcedures where the primary purpose is treatment of a medical condition or improvement/restoration of physiologic function; related to injury, sickness, or congenital anomaly.

Cosmetic ProceduresProcedures that change or improve appearance without significantly improving physiological function.

Functional or Physical Impairment

Revision History

06/01/2026revisedLatest

Coverage Rationale updated: Removed reference to the TMJ Disorders policy and updated instruction to refer to the Obstructive and Central Sleep Apnea Treatment (for New Mexico Only) policy for surgical treatment of obstructive sleep apnea.

06/01/2026addedLatest

Medical Records Documentation Used for Reviews: Added detailed language requiring documentation that fully supports medical necessity, noting benefit coverage is determined by federal/state/contractual requirements and that documentation must be legible, maintained in the medical record, and made available upon request.