ModifiedUnitedHealthcarePolicy CSNC.MP.013.07

Orthognathic (Jaw) Surgery (for North Carolina Only)

Medical policy governing coverage criteria for orthognathic (jaw) surgery for UnitedHealthcare members in North Carolina, specifying when surgery is considered reconstructive and medically necessary versus cosmetic.

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for North Carolina Only)

Policy CodePolicy CSNC.MP.013.07

Change TypeDocumentation requirement added

Effective DateNov 1, 2025

Next Review Date

Key ActionEnsure the patient's medical record contains legible documentation (history, exam, diagnostic test results) that fully supports medical necessity and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

Removed reference link to the guidelines titled 'Medical Records Documentation Used for Reviews'.

AAOMS 2025AAOMS guideline edition

>=5 mmOverjet threshold

4 mmMolar discrepancy

3 mmAsymmetry / unilateral transverse

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8.5%Complication rate (upper)

Coverage Criteria for Orthognathic (Jaw) Surgery

Reconstructive / Medically Necessary Criteria

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

Primary skeletal deformity

Anteroposterior discrepancies: One of: maxillary/mandibular incisor relationship with horizontal overjet >= 5 mm or 0 to a negative value; OR maxillary/mandibular anteroposterior molar relationship discrepancy >= 4 mm (norm 0 to 1 mm)overjet >=5 mm or 0 to negative; molar discrepancy >=4 mm
Vertical discrepancies: One of: presence of vertical facial skeletal deformity >= 2 standard deviations from norms; OR open bite defined as no vertical overlap of anterior teeth OR unilateral/bilateral posterior open bite > 2 mm; OR deep overbite with impingement or supra-eruption due to lack of occlusionvertical deformity >=2 SD; posterior open bite >2 mm
Transverse discrepancies: One of: transverse skeletal discrepancy >= 2 standard deviations from norms; OR total bilateral maxillary palatal cusp to mandibular fossa discrepancy >= 4 mm OR unilateral >= 3 mm given normal axial inclination of posterior teethtransverse >=2 SD; bilateral >=4 mm; unilateral >=3 mm
Asymmetries: Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry>3 mm asymmetry with occlusal asymmetry

Functional impairments (at least one required): One or more documented functional impairments required in addition to skeletal deformity: (1) masticatory and swallowing dysfunction due to skeletal malocclusion (e.g., inability to bite/chew solid foods, choking on incompletely masticated foods, damage to soft tissue during mastication, malnutrition); OR (2) documentation of speech impairment due to facial skeletal deformityN/A

Functional impairment must be documented in the medical record

Medically Necessary Indications (AAOMS criteria)

Covered when documented skeletal deformities meet verifiable clinical measurement thresholds or when specific documented dysfunctions are present.

AAOMS indications (OR logic among categories)

Anteroposterior discrepancies: Presence of maxillary/mandibular incisor relationship abnormality: horizontal overjet of +5 mm or more OR horizontal overjet of zero to a negative value; OR maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm 0 to 1 mm).overjet >= +5 mm or <= 0 mm; molar discrepancy >= 4 mm
These values represent two or more standard deviations from published norms.
Vertical discrepancies: Presence of a vertical facial skeletal deformity two or more standard deviations from norms, open bite (no vertical overlap of anterior teeth or unilateral/bilateral posterior open bite > 2 mm), deep overbite with tissue impingement, or supra-eruption of a dentoalveolar segment due to lack of occlusion.posterior open bite > 2 mm

Orthognathic surgery is not considered Reconstructive and medically necessary when performed for cosmetic purposes only. This policy specifies that procedures done solely to change appearance, without documented functional impairment or verifiable skeletal deformity meeting the stated measurement thresholds, are excluded from coverage.

This policy does not address surgical treatment for obstructive sleep apnea or temporomandibular joint disorders. Refer to the Medical Policy titled Obstructive and Central Sleep Apnea Treatment (for North Carolina Only) or Treatment of Temporomandibular Joint Disorders (for North Carolina Only) for coverage determinations related to those conditions.

For informational purposes only: Orthognathic surgery is a procedure and is not subject to U.S. Food and Drug Administration (FDA) regulation. Accordingly, FDA approval alone is not a basis for coverage under this policy.

Procedures performed for cosmetic purposes only are not considered reconstructive or medically necessary and therefore do not meet the coverage criteria outlined in this policy.

There are no additional explicit "not medically necessary" conditions listed in this portion of the document beyond the exclusion for cosmetic-only procedures; the policy notes that FDA approval is informational and not a coverage determinant.

Relevant Codes and Thresholds

Referenced CPT Codes (partial list shown)CPT

21076

Impression and custom preparation; surgical obturator prosthesis

Referenced CPT Codes (extended list)CPT

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
21125	Augmentation, mandibular body or angle; prosthetic material

1–10 of 37

1/4

Referenced CDT/Dental CodesCDT

D5934	Mandibular resection prosthesis with guide flange
D5935	Mandibular resection 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

Procedure regulation noteneutral

No codes listed

inv-12: Anteroposterior overjet threshold

Anteroposterior overjet thresholdHorizontal overjet of +5 mm or more, or horizontal overjet of zero to a negative value

Established normEstablished norm = 2 mm (values represent two or more standard deviations from published norms)

Context for necessityMeasured as part of maxillary/mandibular incisor relationship when associated with masticatory malocclusion

inv-13: Molar anteroposterior discrepancy

Molar anteroposterior discrepancy thresholdDiscrepancy of 4 mm or more (norm 0 to 1 mm)

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for the procedures and CPT codes listed in this policy. Providers should obtain prior authorization before scheduling services when applicable under the member's benefit plan.

Prior authorization is implied for listed CPT codes and related CDT codes referenced for orthognathic and reconstructive procedures.

Note

Verify Benefits and Provide Supporting Documentation

Providers must verify the member's federal, state, and contractual benefit requirements and confirm coverage prior to delivering services. Documentation supporting medical necessity is required at time of review and should be submitted with any prior authorization or claims.

Verify benefits and applicable coverage rules before using this policy.
Submit supporting clinical documentation with authorization requests or claims (see Medical Records Documentation Used for Reviews).

Background

Orthognathic surgery is performed to correct skeletal abnormalities of the mandible and/or maxilla that may be congenital, developmental, traumatic, or disease-related. The primary goals include improving facial form and physiologic function—often in combination with orthodontic treatment—and addressing masticatory malocclusion when documented by verifiable clinical measurements or associated functional impairments.

Definitions

inv-29: Reconstructive Procedures — definition of reconstructive procedures

DefinitionProcedures where the primary purpose is treatment of a medical condition or improvement/restoration of physiologic function

IncludesSurgery or other procedures related to an injury, sickness, or congenital anomaly where the primary result is not improved appearance

Exclusion noteProcedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered Cosmetic

inv-30: Cosmetic Procedures — definition

DefinitionProcedures or services that change or improve appearance without significantly improving physiological function

Contrast to reconstructive

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for North Carolina Only)

Policy CodePolicy CSNC.MP.013.07

Change TypeDocumentation requirement added

Effective DateNov 1, 2025

Next Review Date

Key ActionEnsure the patient's medical record contains legible documentation (history, exam, diagnostic test results) that fully supports medical necessity and make it available upon request.

SourceLink

On This Page

Transverse discrepancies: Transverse skeletal discrepancy two or more standard deviations from norms: total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth.bilateral >= 4 mm; unilateral >= 3 mm

Asymmetries: Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.> 3 mm

Dysfunction indications: Orthognathic surgery may also be indicated when specific documented signs of dysfunction are present, including airway dysfunction (e.g., sleep apnea), temporomandibular joint disorders, psychosocial disorders, and speech disorders.N/A

Values represent two or more standard deviations from published norms

Clinical contextPart of maxillary/mandibular anteroposterior molar relationship assessment associated with masticatory malocclusion

inv-14: Vertical/transverse/asymmetry thresholds

Vertical deformity thresholdVertical facial skeletal deformity two or more standard deviations from published norms

Open bite thresholdNo vertical overlap of anterior teeth OR unilateral/bilateral posterior open bite greater than 2 mm

Transverse threshold (general)Transverse skeletal discrepancy two or more standard deviations from published norms

Asymmetry threshold (summary)Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry

inv-15: Horizontal overjet — specific threshold detail

Horizontal overjet specific thresholdHorizontal overjet of +5 mm or more OR horizontal overjet of zero to a negative value

Established norm noteEstablished norm = 2 mm; thresholds represent ≥2 standard deviations from published norms

Associated requirementMeasured within maxillary/mandibular incisor relationship and associated with masticatory malocclusion

inv-16: Anteroposterior molar relationship discrepancy — specific threshold

Anteroposterior molar relationship discrepancyDiscrepancy of 4 mm or more (norm 0 to 1 mm)

Normative contextNorm 0 to 1 mm; values cited represent two or more standard deviations from published norms

Clinical associationMeasured as part of maxillary/mandibular anteroposterior molar relationship when linked to masticatory malocclusion

inv-17: Transverse discrepancy (bilateral) threshold

Transverse discrepancy (bilateral)Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater

Measurement conditionGiven normal axial inclination of the posterior teeth

Relationship to normsRepresents two or more standard deviations from published norms (transverse skeletal discrepancy)

inv-18: Transverse discrepancy (unilateral) threshold

Transverse discrepancy (unilateral)Unilateral maxillary palatal cusp to mandibular fossa discrepancy of 3 mm or greater

Measurement conditionGiven normal axial inclination of the posterior teeth

Relation to transverse standardPart of AAOMS transverse discrepancy criteria (two or more standard deviations from norms)

inv-19: Asymmetry threshold

Asymmetry thresholdAnteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry

Clinical significanceAsymmetry must be associated with occlusal asymmetry to meet criteria for reconstructive surgery

Measurement framingPresented as part of verifiable clinical measurements per AAOMS guidelines

Documentation Required

Medical Record Requirements

The patient's medical record must contain legible documentation that fully supports the medical necessity for the requested services. Failure to provide adequate documentation may result in denial of the request.

Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
Maintain documentation in the patient's medical record and make it available upon request.

Documentation Required

Required Medical Record Documentation

Documentation should specifically address the clinical criteria that establish reconstructive medical necessity (for example: facial skeletal deformity measurements, functional impairments such as masticatory or swallowing dysfunction, or speech impairment) and include any imaging or specialist evaluations used to support the diagnosis.

Document objective measurements (e.g., overjet >= 5 mm, molar discrepancy >= 4 mm, asymmetries > 3 mm, or vertical deformity ≥ 2 SD from norms).
Provide evidence of functional impairment (e.g., inability to chew solid foods, choking on incompletely masticated foods, malnutrition, or documented speech impairment).

Denial Risk

Insufficient Documentation May Result in Denial

Requests lacking sufficient medical record documentation that fully supports medical necessity — including missing objective measurements, absence of documented functional impairment, or unavailable diagnostic testing — may be denied.

Insufficient documentation of the deformity or functional impairment may lead to denial.
Failure to make records available upon request may result in denial or delay.

Cosmetic procedures do not primarily restore physiologic function

Policy implicationProcedures performed for cosmetic purposes only are not considered Reconstructive and medically necessary

inv-31: Functional or Physical Impairment — definition

DefinitionDeviation from normal function of a tissue or organ resulting in significantly limited capacity to perform physical activities (functional or physical impairment)

ManifestationsMay include difficulties with physical/motor tasks, independent movement, or basic life functions

Policy useAt least one documented functional impairment (e.g., masticatory/swallowing dysfunction or speech impairment) is required in addition to skeletal deformity for coverage

inv-32: Anteroposterior discrepancy — horizontal overjet or molar relationship deviations from normative values

DefinitionHorizontal overjet or molar relationship deviations from normative values (e.g., overjet ≥ +5 mm or zero/negative; molar discrepancy ≥ 4 mm)

Normative frameThese values represent two or more standard deviations from published norms (established norm = 2 mm)

Clinical relevanceListed as anteroposterior discrepancy criteria associated with masticatory malocclusion

inv-33: Vertical discrepancy — vertical facial skeletal deformity defined as two or more standard deviations from published norms

DefinitionVertical facial skeletal deformity defined as two or more standard deviations from published norms for accepted skeletal landmarks

Specific manifestationsIncludes open bite (no anterior vertical overlap or posterior open bite >2 mm), deep overbite with tissue impingement, or supra-eruption due to lack of occlusion

Policy contextClassified under vertical discrepancies for orthognathic surgery indications

inv-34: Transverse discrepancy — total bilateral palatal cusp to mandibular fossa discrepancy thresholds

DefinitionTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral ≥ 3 mm, given normal axial inclination

Relation to standardsRepresents a transverse skeletal discrepancy of two or more standard deviations from published norms

Measurement conditionAssessed with normal axial inclination of posterior teeth

inv-35: Asymmetry — anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry

DefinitionAnteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry

Clinical requirementAsymmetry must be accompanied by occlusal asymmetry to meet the AAOMS/coverage criteria

Role in coverageListed as a primary skeletal deformity category that may substantiate reconstructive orthognathic surgery when functional impairment is also present