Medical Policy

Policy Num:      13.009.003
Policy Name:    Orthognathic Surgery
Policy ID:          [13.009.003]  [Ac / L / M+ / P+]  [0.00.00]

Last Review:       October 24, 2024
Next Review:      October 20, 2025
 

Related Policies: None

Orthognathic Surgery

Summary

Are procedures that include surgical manipulation of the maxilla and /or the mandible to restore the correct anatomical and functional relationship in those patients that present skeletal-dental facial anomalies. These anomalies may be present at birth, as the individual grows and develops or may be the result of traumatic injuries.

Objective

    To correct by surgical manipulation the skeletal/dental position to:

a.    Repair of congenital anomalies that may cause different problems

b.    Repair of abnormalities caused by tumors, trauma etc

c.    Malocclusion that can’t be corrected with orthodontics services alone

d.    Sleep apnea

Policy Statements

   These surgeries may be recognized for payment as long as one of the following criteria is met:

1.       That there is enough functional inability resulting from illness, trauma, congenital or development

anomalies. This functional inability must be directly related to facial skeletal deformities of the maxilla or mandible (that is, other causes have been ruled out) and must include one or more of the following:

                 a.    Intraoral trauma directly related to malocclusion.

b.    Difficulty in swallowing.

c.     Speech difficulty resulting in unintelligible language, which has not responded to speech therapy.

d.    Documented loss of biting or chewing functions.

e.    Documented constriction of the person’s airway.

2.    Significant Over or Under jet documented by any of the following:

a.    Reverse over jet of 3mm or more, in cases of maxillary deficiency or protruded jaw.

b.    An over jet of 4mm or more in cases of mandible deficiencies.

c.    Open bite of 4mm or more .

d.    Impinging deep bite of 7mm or more.

e.    Less than 8 mm, posterior teeth in functional intercuspation as a result of abnormal growth or development. (As opposed to the loss of teeth in the arch).

3.    Malocclusions not amenable to conventional orthodontic correction.

Policy Guidelines

    To consider preauthorization of orthognathic surgeries, the following documents are required:

1.    Must be submitted with the form DD-191 filled-out in all its parts

2.    Report that includes diagnostic (ICD-10) and the corresponding CPT code

3.    Antero-posterior cephalometric radiography (for facial asymmetries)

4.    Cephalometric tracing with the corresponding measures.

5.    Extra and intra oral views pre-and post-orthodontics treatment

6.    Referral from the orthodontist in dento skeletal cases

7.    Referral of the primary doctor in sleep Apnea and studies done to patient.

8.    Report on patients with tumors or traumas including radiographic images

Benefit Application

BlueCard/National Account Issues - N/A

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Orthognathic Surgery is procedures that include surgical manipulation of the maxilla and or the mandible to

  restore the correct anatomical and functional relationship in those patients that present skeletal-dental facial anomalies.

Definition of interest;

Angle’s Classification of Malocclusion:

       A classification of the forms of malocclusion.

        Class I. The normal anteroposterior relationship of the lower jaw to the upper jaw. The mesiobuccal cusp of the maxillary first permanent molar     occludes in the buccal groove of the mandibular first permanent molar.

          Class II. The posterior relationship of the lower jaw to the upper jaw. The mesiobuccal cusp of the maxillary first permanent molar occludes mesial  to the buccal groove of the mandibular first permanent molar.

          Class III. The anterior relationship of the lower jaw to the upper jaw. The mesiobuccal cusp of the maxillary first permanent molar occludes distal to the buccal groove of the mandibular first permanent molar.

Ankylosis:

        Abnormal immobility, union or fusion. Most common between two bones at their articulation (TMJ)

Cleft Lip:

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

Closed Bite:

        An abnormal overbite; decreased vertical dimension because of tooth abrasion or absence of supportive posterior teeth. A condition where the space between the jaws is less than it should be.

Condylectomy:

        Surgical removal of a condyle

Macrognathi:

         Abnormally large jaws

Malocclusion:

         Abnormalities in the positioning and relationship of teeth. A deviation from normal occlusal relationship.

Micrognathism:

           Abnormal smallness of jaws; lack of normal development of jaw. Occlusal Plane;

           The imaginary surface in wich upper and lower teeth meets in occlusion.

   Open Bite:

          A condition that prevents the anterior mandibular teeth from achieving proper occlusal relationship to the maxilla. It may be caused due to fractures,dislocation, tongue habits, genetic or developmental abnormalities; failure of the anterior maxillary teeth to occlude normally with the mandible; more than the correct amount of jaw opening.

Osteotomy:

           The cutting of bone; usually refers to Orthognathic Surgery.

Overbite:

           Vertical overlap of the upper teeth over the lower teeth; overlapping of mandibular incisors by maxillary incisors.

Overjet:

            The horizontal overlap of the upper teeth over the lower teeth; projection of maxillary incisors beyond mandibular incisors.

Prognathism:

            Facial disharmony due to prominence or projection of one or both jaws, occurring most frequent on the mandible.

Retrognathism:

             A disharmony as a result of one or both jaws (usually the mandible) being posterior to normal facial relationship.

T.M.J. Syndrome:

            The symptoms associated with malfunction of the temporomandibular joint.

Regulatory Status

N/A

Rationale

Correct by orthognathic surgery any discrepancy caused by congenital deformities, disease or trauma affecting the patient life to give a better quality of life, esthetics and functionality.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American];LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflectiveof and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g.,women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population Reference No. 1 

Individuals: With congenital or developmental deformities affecting dento maxillofacial structures. Intervention of interest is: Orthognathic Surgery. Comparators of interest: Orthodontics services. Relevant outcomes include: Quality of life ,correction of dento skeletal deformities, correct masticatory function, correct phonetic (speech), Improved occlusion, enhance stability of orthodontic results, Improved or prevent associated temporomandibular joint and/or muscular disorders .

Population Reference No. 2 

Individuals: With repair tumors defect or traumas. Intervention of interest is: Orthognathic Surgery. Comparators of interest: Artificial face prosthesis. Relevant outcomes include: Bring back the patient to the most esthetic form as possible, quality of life, correct masticatory function (if it is the case).

Population Reference No. 3 

Individuals: With sleep apnea. Intervention of interest is: Orthognathic Surgery. Comparators of Interest: CPAPdental Appliances, weight lost regiment. Relevant outcomes include: Most cases solution of sleep apnea problem 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, OMS and Dermatology, 2019.

2.      CPT 2019 Surgical/Musculoskeletal System.

3.      Patel PK. Craniofacial, orthognathic surgery. http//www.emedicine.com/plastic/topicl77.htmhttp//www.emedicine.com/p1astic/topic177.htm. (verified 9/22/04)

4.      American Association of Oral and Maxillofacial Surgeons. Criteria for orthognathic surgery.

www.aaoms.org/orthocriteria.cfin (verified 9/27/04)

5.      Cain KK, Rugh JD, Hatch JP, Hurst CL. Readiness for orthognathic surgery: a survey of practitioner opinion. Int J Adult Orthodon Orthognath Surg 2002; 1 7(1):7-11

6.      Kim JC, Mascarenhas AK, Joo BH et al. Cephalometric variables as predictors of Class II treatment outcome. Am J Orthod Dentofacial Orthop 2000;118(6):636-40

7.      Mogavero FJ, Buschang PH, Wolford LM. Orthognathic surgery effects on maxillary growth in patients with vertical maxillary excess, Am J Orthod. Dentofacial Orthop 997;111(3):288-96

8.      Proffit WR, White RP Jr. Who needs surgical-orthodontic treatment? Int, J Adult Orthodon Orthognath Surg 1990;5(2):81-9

9.      Proffit WR, Phillips C, Tulloch JF et al. Surgical versus orthodontic correction of skeletal Class II malocclusion in adolescents: effects and indications Int, J Adult Orthodon Orthognath Surg 1992;7(4):209-20

10.    Throckmorton GS, Buschang PH, Ellis E 3rd. Morphologic and biomechanical determinants in the selection of orthognathic surgery procedures. J Oral Maxillofac Surg 1999;57(9);1044-56

11.    Thomas PM. Orthodontic camouflage versus orthognathic surgery in the treatment of mandibular deficiency. J Oral Maxillofac. Surg. 1995;53(5):579-87

12.    Throckmorton GS, Ellis E 3rd, Sinn DP. Functional characteristics of retrognathic patients before and after mandibular advancement surgery. J Oral Maxillofac Surg 1995;53(8):898-908

13.    Vallino LD. Speech, velopharyngeal function, and hearing before and after orthognathic surgery. J Oral Maxillofac Surg 1990;48(12):1274-81

14.    Wilmot JJ, Barber HD, Chou DG et al. Associations between severity of dentofacial deformity and motivation for orthodontic-orthognathic surgery treatment. Angle Orthod 1993;63(4):283-8

15.    Wolford LM, Karras SC, Mehra P. Considerations for orthognathic surgery during growth, part 1: mandibular deformities. Am J Orthod Dentofacial Orthop 2001;119(2):95-101

16.    Wolford LM, Karras SC, Mehra P. Considerations for orthognathic surgery during growth, part 2: maxillary deformities; Am J Orthod Dentofacial Orthop 2001; 119(2):102-5

17.    Zarrinkelk HM, Throckmorton GS, Ellis E 3rd et al. Functional and morphologic changes after combined maxillary intrusion and mandibular advancement surgery. J Oral Maxillofac Surg 1996;54(7):828-37

18.    Posnick, Jeffrey C. (September 2013). Orthognatic Surgery: Principles and Practice. Amsterdam: Elsevier. pp. 61–68

19.    Eckert AW, Maurer P, Kriwalsky MS, Schubert J (September 2006). "P.292 Complications in orthognathic surgery". J Craniomaxillofac Surg 34 (Suppl 1): 206

20.    Bill J, Proff P, Bayerlein T, Blens T, Gedrange T, Reuther J (September 2006). "Orthognathic surgery in cleft patients". J Craniomaxillofac Surg 34 (Suppl 2): 77–81

21.    Uechi J, Okayama M, Shibata T, et al. (December 2006). "A novel method for the 3- dimensional simulation of orthognathic surgery by using a multimodal image-fusion technique". Am J Orthod Dentofacial Orthop 130 (6): 786–98. doi:10.1016/j.ajodo.2006.03.025. PMID 17169742.

Codes

Appplicable Modifiers

N/A

Policy History