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Medical Policy

Policy Num:     13.009.001
Policy Name:    Maxillary Obturators
Policy ID:          [13.009.001]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:     August 22, 2023
Next Review:     Policy Archived

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Related Policies: None

Maxillary Obturators

Summary

Maxillary obturators are considered a maxillofacial prosthesis. Maxillary prosthetic devices are generally removable and are used to correct palatal or nasopharyngeal defects. These defects may be congenital, pathological or may be the result of trauma or surgery.

The treatment goal is to restore function (chew, swallow, speech) and a normal appearance of the face. This is achieved by artificially closing the defect using a prosthetic obturator or through surgical reconstruction of the defect.

Objective

Restore function (chew, swallow, speech) and a normal appearance of the face. this is achieved by artificially closing the defect using a prosthetic obturator or through surgical reconstruction of the defect.

Policy Statements

These services are covered for all patients that have a palatal or nasopharyngeal defect that impairs the person’s ability to swallow efficiently or speak clearly. Although surgery is preferred, it is not always feasible because of the person’s age, health complications or anatomical  causes.

The main goal of maxillary obturator (either temporary or permanent) is to close the gap in the palate or the nasopharynx to make swallowing and speaking possible.

Policy Guidelines

·   Maxillary obturators require predetermination and are used to;

     ·   Closure of the defect between the oral cavity and nasal/sinuses

     ·   Provide a stable base for dentition and maxilla to occlude the jaw, therefore allowing to chew food appropriately

     ·   Restore facial appearance, including projection and symmetry of the middle facial zone

     ·   Support  structures superior to maxilla, specially the orbit, to prevent visual disturbances

Benefit Application

BlueCard/National Account Issues

N/A

Background

 Maxillary prosthetic devices (obturators) are generally removable and are used to correct palatal or nasopharyngeal defects. These defects may be congenital, pathological or may be the result of trauma or surgery.

Definitions of interest;

Cleft lip;

       A congenital deformity where there is non-union or inadequacy of soft and/or hard tissues. It may be unilateral or bilateral.

Cleft Palate;

      Congenital fissure of the roof of the mouth produced by failure of the two maxillae to unite during embryonic development and often associated with cleft   lip.

Obturators;

       An appliance designed to fill in a cleft palate defect. It is usually held in place with clasp that attach to teeth.

Regulatory Status

N/A

Rationale

  Palatal or nasopharyngeal defects.

Population Reference No. 1 

Individuals: With palatal or nasopharyngeal defects. Interventions of interest is: Maxillary obturators. Comparators of interest is: Surgical reconstruction. Relevant outcomes include: Correct palatal or nasopharyngeal defects, restore chew function, restore speech, restore swallowing function,  restore face appereance ,  support of structure superior to maxilla (specially the orbit) and quality of life.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.    Coding Companion for Plastics, and Dermatology, 2020.

2.    CPT - 2020, Surgical/Musculoskeletal System.

3.    Minsley GE, Warren DW, Hinton V. Physiologic responses to maxillary resection and subsequent obturation. J Prosthet Dent 1987; 57:338.

4.    Watson RM, Gray BJ. Assessing effective obturation. J Prosthet Dent 1985; 54:88.

5.    Muzaffar AR, Adams WP Jr, Hartog JM, et al. Maxillary reconstruction: functional and aesthetic considerations. Plast Reconstr Surg 1999; 104:2172.

6.    Shipman B. Evaluation of occlusal force in patients with obturator defects. J Prosthet Dent 1987; 57:81.

Codes

Appplicable Modifiers

N/A

Policy History