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MP 7.01.201 Orthognathic Surgery

Medical Policy
Section
Surgery
Original Policy Date
08/01/2007
Last Review Status/Date
Local Policy created 08:2007
Issue
5:2007
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description
Orthognathic surgery refers to the surgical repositioning of the maxilla, mandible and the dentoalveolar segments to achieve facial and occlusal balance.  One or more of the jaw(s) can be simultaneously repositioned to treat various types of malocclusions and jaw deformities.

Surgical Procedures

In orthognathic surgery, an osteotomy is made in the affected jaw, and the bones are repositioned in a more normal alignment.  The bones are held in position with plates, screws and/or wires.  Intermaxillary fixation, a procedure in which arch bars are placed in both jaws, may also be needed to provide added stability.  Simultaneous osteotomies may be performed when deformities must be corrected in both jaws.  Grafts from the ribs, hip or skull may be performed for patients with deficient bone tissue; alloplastic bone replacement may also be required.  Orthognathic surgery is generally performed under general anesthesia on an inpatient basis.  Although sometimes performed for cosmetic purposes, orthognathic surgery is generally considered to be medically necessary when performed to treat a significant abnormality that is causing significant functional impairment.

Patients with bone or soft tissue deficiency of the face may require distraction osteogenesis. In this procedure, a distraction device is applied to the bone, and a controlled fracture is created and gradually separated allowing new bone formation in the distracted segments.  This allows the facial bone and adjacent soft tissue to elongate.


Policy
Orthognathic surgery is permitted when the following medical necessity criteria are met:

Presence of:

  • ANY of the facial skeletal deformities listed below in section 1 AND
  • ANY of the functional deficits listed below in section 2 AND
  • NONE of the exclusions listed below in section 3


Policy Guidelines
1. Facial Skeletal Deformities

  • anteroposterior discrepancies
    • maxillary/mandibular incisor relationship: overjet of 5mm or more, or a 0 to negative value (norm = 2mm)
    • maxillary/mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm = 0 to 1mm)
  • vertical discrepancies
    • presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks
    • open bite
      • no vertical overlap of anterior teeth greater than 2mm
      • unilateral or bilateral posterior open bite greater than 2mm
    • deep overbite with impingement or irritation of buccal or lingual soft tissues of opposing arch
    • supraeruption of a dentoalveolar segment due to lack of opposing occlusion creating a dysfunction not amenable to conventional prosthetics
  • transverse discrepancies
    • presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms
    • total bilateral maxillary palatial cusp to mandibular fossa discrepancy of 4mm or greater, or a unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth
  • asymmetries
    • anteroposterior, transverse or lateral asymmetries greater than 3mm, with concomitant occlusal asymmetry

2. Functional Deficits

  • Persistent inability to masticate and swallow food adequately when other causes such as neurological or metabolic diseases have been ruled out by physical exam and/or appropriate diagnostic testing
  • malnutrition, significant wight loss, or failure to thrive
  • speech dysfunction directly related to jaw deformity, as determined by a speech and language pathologist
  • myofacial pain that has persisted for at least six months, despite conservative treatment, such as physical therapy and splints
  • airway obstruction, such as obstructive sleep apnea, when documented by sleep study and when:
    • conservative treatment, such as continuous positive airway pressure (CPAP) or oral appliance has been attempted
    • conservative treatment has been unsuccessful despite patient compliance

3. Exclusions

Orthognathic surgery is specifically not covered when provided for:

  • The treatment of tempormandibular joint syndrome or temporomandibular disorders

  • Cosmetic purposes or correction of unaesthetic facial features
  • Is a direct contract exclusion 

 


Codes

Number

Description

CPT 

21110

Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)

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 (eg, for Long Face Syndrome), without bone graft

 

21142

Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft

21143 Reconstruction midface, LeFort I; three 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)
21146 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)
21147 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)
21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)
21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)
21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I
21155 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I
21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)
21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation
21198 Osteotomy, mandible, segmental;
21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)
21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209 Osteoplasty, facial bones; reduction
21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21215 Graft, bone; mandible (includes obtaining graft)
21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)

ICD-9 Diagnosis 

519.9

Unspecified disease of respiratory system

524.00 Unspecified anomaly
524.09 Other specified anomaly
  524.10 Unspecified anomaly
  524.19 Other specified anomaly
  524.20 Unspecified anomaly of dental arch relationship
  524.29 Unspecified anomaly of dental arch relationship
  524.4 Malocclusion, unspecified
  524.59 Other dentofacial functional abnormalities
  526.89 Other specified diseases of the jaws
  748.1 Other anomalies of nose
  754.0  Of skull, face, and jaw
  V41.6 Problems with swallowing and mastication


Index

Orthognathic

Policy History

Date Action Reason
08/01/07 Add policy to Surgery section; local policy New policy
3/12/09 Update policy  Policy renumbered to accomodate new TEC policy (7.01.115)


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