ModifiedUnitedHealthcarePolicy CS088OH.D

Orthognathic (Jaw) Surgery (for Ohio Only)

This policy governs medical necessity and coverage criteria for orthognathic (jaw) surgery for UnitedHealthcare members in Ohio; it defines when surgery is considered reconstructive and medically necessary and lists applicable codes and supporting evidence.

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for Ohio Only)

Policy CodePolicy CS088OH.D

Change TypeCDT code description revision

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization and document objective skeletal measurements and an associated functional impairment when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Revised description for CDT codes D5934 and D5935.

Archived previous policy version CS088OH.C.

Ohio-onlystate-specific application

InterQual referencedInterQual referenced

Multiple listsprocedure codes provided

D5934,D5935CDT codes revised

2026-04-01

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Orthognathic (Jaw) Surgery

Reconstructive / Medically Necessary Criteria

Orthognathic (jaw) surgery is considered Reconstructive and medically necessary when InterQual criteria are met OR when ALL of the following policy-specific criteria are satisfied:

Policy-specified coverage criteria

Deformity types: Anteroposterior, vertical, transverse, or asymmetry meeting the numeric thresholds in policy.see thresholds
Values represent two or more standard deviations from published norms.
Functional impairment: Masticatory and swallowing dysfunction due to skeletal malocclusion (e.g., inability to bite/chew solid foods, choking on incompletely masticated solid foods, damage to soft tissue during mastication, malnutrition) OR documentation of speech impairment due to facial skeletal deformity.clinical documentation

InterQual option: Meets InterQual CP: Procedures — Orthognathic Surgery or Orthognathic Surgery (Pediatric).InterQual criteria

When InterQual criteria are met, surgery is considered reconstructive and medically necessary.

Medical necessity — AAOMS-based indications

Covered when documented objective measurements meet AAOMS-stated thresholds or when there are documented signs of dysfunction associated with the skeletal deformity:

AAOMS measurable skeletal deformity criteria: Anteroposterior, vertical, or transverse skeletal deformity meeting AAOMS thresholds (e.g., horizontal overjet ≥5 mm or zero to negative; maxillary/mandibular molar discrepancy ≥4 mm; transverse bilateral ≥4 mm or unilateral ≥3 mm; vertical deformity two or more standard deviations from norms including open bite with no anterior overlap or posterior open bite >2 mm).see thresholds

These values represent two or more standard deviations from published norms for accepted skeletal landmarks.

Functional or associated disorders: Presence of documented signs of dysfunction associated with the skeletal deformity (examples include airway dysfunction such as sleep apnea, temporomandibular joint disorders, psychosocial disorders, or speech disorders).clinical documentation

Surgery may be indicated when dysfunction is documented and attributable to the skeletal deformity.

This policy does not address surgical treatment for obstructive sleep apnea (OSA) or temporomandibular joint (TMJ) disorders. Providers should refer to the UnitedHealthcare Ohio-specific policies titled Obstructive and Central Sleep Apnea Treatment (for Ohio Only) and Treatment of Temporomandibular Joint Disorders (for Ohio Only) for coverage and medical necessity guidance when those conditions are the primary indication for surgery.["3"]

When submitting requests for orthognathic procedures where OSA or TMJ pathology is implicated, document whether the surgical indication is primarily for a skeletal deformity meeting the orthognathic policy criteria or primarily for OSA/TMJ. If the latter, follow the referenced Ohio policies for review and authorization to avoid inappropriate denials or delays.["3","6"]

Orthognathic (jaw) surgery is a surgical procedure and is not subject to FDA regulation. FDA approval or clearance of a related device or material alone does not determine coverage; coverage decisions are based on the medical necessity criteria described in this policy and applicable UnitedHealthcare/Ohio requirements.["22"]

Orthognathic surgery is not considered reconstructive and medically necessary when performed for cosmetic purposes only. Procedures performed solely to change or improve appearance without associated functional impairment will be excluded from coverage.["6"]

In addition, surgery that does not meet the policy’s required objective deformity measurements and associated functional impairment criteria (for example, those detailed in the InterQual criteria or the numeric thresholds in this policy) is considered not medically necessary and may be denied.["3","6"]

Applicable Procedure and Dental Codes

Applicable CPT Codes (group 1)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.

Applicable CPT Codes (group 2)CPT

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).
21125	Augmentation, mandibular body or angle; prosthetic material.
21127	Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft).
21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction, (e.g., for Long Face Syndrome), without bone graft.
21142	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft.
21143	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft.
21145	Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts).

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Applicable CDT CodesCDT

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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Revised CDT CodesCDT

D5934	CDT code description revised (see policy)
D5935	CDT code description revised (see policy)

inv-10: Anteroposterior overjet — Horizontal overjet threshold and examples

ThresholdHorizontal overjet of 5 mm or more, or a horizontal overjet of 0 to a negative value

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

Example measurement siteMaxillary/mandibular incisor relationship (used to measure overjet)

inv-11: Anteroposterior molar discrepancy — Discrepancy threshold of 4 mm or more

ThresholdMaxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more

Norm

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. UnitedHealthcare uses InterQual® CP: Orthognathic Surgery (and Orthognathic Surgery - Pediatric) as the primary medical necessity criteria for prior authorization decisions. When InterQual criteria apply, providers must obtain prior authorization and ensure submitted requests clearly reference the applicable InterQual criteria.

InterQual CP: Orthognathic Surgery; InterQual CP: Orthognathic Surgery (Pediatric)

Prior Authorization

Prior Authorization and Criteria Sourcing

If InterQual does not contain applicable criteria for the requested orthognathic procedure, UnitedHealthcare will apply this policy’s clinical criteria and/or UnitedHealthcare Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines approved by the Ohio Department for Medicaid Services. Providers should cite the source(s) used when submitting authorization requests.

When InterQual is not applicable, reference UnitedHealthcare policy/guidelines approved by Ohio Medicaid where relevant.

Definitions and Thresholds

inv-25: Reconstructive Procedures — Definition distinguishing reconstructive intent

DefinitionReconstructive procedures: primary purpose is treatment of a medical condition or improvement/restoration of physiologic function; related to injury, sickness, or congenital anomaly; primary result is not improved appearance

IncludesSurgery or procedures that restore physiologic function rather than solely change appearance

Exclusion noteProcedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic, not reconstructive

inv-26: Cosmetic Procedures — Definition distinguishing cosmetic intent

DefinitionCosmetic procedures: procedures or services that change or improve appearance without significantly improving physiological function

Distinguishing point

Background and Evidence Summary

Orthognathic surgery corrects skeletal abnormalities of the mandible, maxilla, or both to improve facial form and physiologic function. It is commonly performed in combination with orthodontic treatment to address malocclusion and restore mastication, swallowing, and speech function.["3","6"]

Indications include congenital, developmental, traumatic, or disease-related deformities that produce measurable anteroposterior, vertical, transverse, or asymmetry deficits and are associated with functional impairment. Clinical planning typically involves coordinated surgical and orthodontic care to achieve both functional restoration and stable occlusion.["3","6"]

Policy Revision History and Material Changes

2026-04-01revised_codesLatest

Revised descriptions for CDT codes D5934 and D5935; supporting information updated and previous policy version archived.

Policy Summary

PayerUnitedHealthcare

PolicyOrthognathic (Jaw) Surgery (for Ohio Only)

Policy CodePolicy CS088OH.D

Change TypeCDT code description revision

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization and document objective skeletal measurements and an associated functional impairment when requesting coverage.

SourceLink

On This Page

Normal molar relationship = 0 to 1 mm

SignificanceValue represents two or more standard deviations from published norms

inv-12: Vertical/open bite — Definitions and thresholds for open bite / posterior open bite

Vertical deformity thresholdPresence of a vertical facial skeletal deformity two or more standard deviations from published norms for accepted skeletal landmarks

Anterior open biteNo vertical overlap of anterior teeth

Posterior open biteUnilateral or bilateral posterior open bite greater than 2 mm

inv-13: Transverse discrepancy — Bilateral ≥4 mm or unilateral ≥3 mm

Bilateral transverse thresholdTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm

Unilateral transverse thresholdUnilateral palatal cusp to mandibular fossa discrepancy ≥ 3 mm

ContextGiven normal axial inclination of the posterior teeth; represents two or more standard deviations from norms

inv-14: Asymmetry threshold — Anteroposterior, transverse, or lateral asymmetries > 3 mm

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

Measurement contextAsymmetries measured relative to accepted skeletal landmarks and occlusal alignment

Clinical noteValues represent two or more standard deviations from published norms when applicable

inv-15: Anteroposterior/Transverse/Vertical discrepancy thresholds — Examples of measurement thresholds (summary)

Anteroposterior examplesHorizontal overjet ≥ 5 mm or 0 to negative; molar discrepancy ≥ 4 mm

Transverse examplesTotal bilateral palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral ≥ 3 mm

Vertical examplesVertical deformity ≥ 2 standard deviations from norms; open bite = no anterior overlap or posterior open bite > 2 mm

Documentation Required

Clinical Documentation Requirements

Submit documentation that demonstrates the specific skeletal deformity measurements and associated functional impairment. Documentation should include (but is not limited to) cephalometric or clinical measurements showing anteroposterior, vertical, transverse, or asymmetry discrepancies as defined in policy and objective evidence of functional impairment (masticatory/swallowing dysfunction, speech impairment, etc.).

Anteroposterior: horizontal overjet ≥ 5 mm or 0 to negative value; molar discrepancy ≥ 4 mm.
Vertical: deformity ≥ 2 standard deviations from norms, or open bite with no anterior overlap or posterior open bite > 2 mm.
Transverse: bilateral palatal cusp to fossa discrepancy ≥ 4 mm or unilateral ≥ 3 mm.
Asymmetry: AP/transverse/lateral asymmetry > 3 mm with occlusal asymmetry.
Functional impairment: documented inability to bite/chew solid foods, choking on incompletely masticated foods, soft tissue injury during mastication, malnutrition, or speech impairment due to skeletal deformity.

Denial Risk

State/Contract Governance and Potential Denial

Coverage determinations must also reference and comply with applicable federal, state (Ohio Administrative Code [OAC]), or contractual plan requirements. If those requirements conflict with this policy, the federal, state (OAC), or contractual requirements govern and may result in a different coverage decision or denial.

Check federal, OAC, or contract terms before relying on this policy.
In the event of conflict, federal/state/contract requirements prevail and may trigger denial.

Denial Risk

Cosmetic Purpose Exclusion (Denial Risk)

Surgery performed solely for cosmetic purposes is not considered reconstructive or medically necessary and may be denied. Providers must clearly indicate when a procedure is reconstructive and supply supporting documentation showing functional deficits and objective skeletal measurements.

Cosmetic-only procedures are not covered (denial risk).
Provide documentation demonstrating reconstruction intent and functional necessity.

Primary intent is appearance change rather than restoration of physiologic function

Clinical implicationSurgery performed solely for cosmetic purposes is not considered reconstructive and may be denied

inv-27: Functional or Physical Impairment — Definition for impairment used in coverage decisions

DefinitionFunctional or Physical Impairment: deviation from normal function causing significantly limited capacity to perform physical activities or basic life functions, exhibited by difficulties in physical/motor tasks, independent movement, or basic life functions

Use in coverageRequired documentation of one or more associated functional impairments (e.g., masticatory/swallowing dysfunction, speech impairment) supports medical necessity

AssessmentDemonstrated by clinical evidence of impaired function related to the skeletal deformity

inv-28: Anteroposterior discrepancy — Definition and example thresholds

DefinitionAnteroposterior discrepancy: deviations in incisor or molar relationships (e.g., horizontal overjet ≥5 mm or molar discrepancy ≥4 mm) representing two or more standard deviations from published norms

ExamplesMaxillary/mandibular incisor relationship: horizontal overjet ≥5 mm or 0 to negative; molar relationship discrepancy ≥4 mm

Established normEstablished norm for anteroposterior relationships = 2 mm

inv-29: Vertical discrepancy — Definition referencing deviations two or more SD from norms

DefinitionVertical discrepancy: presence of a vertical facial skeletal deformity two or more standard deviations from published norms for accepted skeletal landmarks

Open bite criteriaNo vertical overlap of anterior teeth or unilateral/bilateral posterior open bite > 2 mm

Other vertical findingsDeep overbite with soft tissue impingement or supraeruption of a dentoalveolar segment may also indicate vertical deformity

inv-30: Transverse discrepancy — Definition and measurement thresholds

DefinitionTransverse discrepancy: presence of a transverse skeletal discrepancy two or more standard deviations from published norms

Measurement thresholdsTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral discrepancy ≥ 3 mm, given normal axial inclination of posterior teeth

Clinical contextUsed to document significant maxillary and/or mandibular transverse skeletal deformities associated with masticatory malocclusion