Subject:
Orthognathic Surgery
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both. The underlying abnormality may be present at birth or may become evident as the patient grows and develops, or may be the result of traumatic injuries. The severity of these deformities precludes adequate treatment through dental treatment alone.1
According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), the primary goal of treatment is to improve function through correction of the underlying skeletal deformity.
The classification and analysis of dentofacial skeletal deformities is complex and involves discrepancies in all planes of space. Per AAOMS, they can generally be classified as follows:
Congenital anomalies:
1. Cleft lip and palate
2. Congenital dentofacial skeletal deformities
Acquired anomalies:
1. Traumatic facial skeletal injuries
2. Cysts and Tumors of the Jaws
3. Obstructive Sleep Apnea
4. Temporomandibular joint disorders resulting in skeletal malocclusion
a. Rheumatoid arthritis
b. Degenerative arthritis
c. Condylar atrophy
5. Growth disturbances
Related Policies
- Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (Policy #006 in the Surgery Section)
- Temporomandibular Joint Dysfunction (Policy #079 in the Medicine Section)
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Contract exclusions and/or limitations related to orthognathic surgery will determine the available benefit.
II. For contracts that specify orthognathic surgery as a covered benefit and have specific benefit applications and/or limitations related to orthognathic surgery, such specific benefit applications and/or limitations will apply.
III. For contracts that offer orthognathic surgery as a covered benefit but do not have specific benefit applications and/or limitations related to orthognathic surgery, the following guidelines will be utilized to establish medical necessity and determine whether the procedure(s) is/are eligible for reimbursement under the member's medical health insurance benefits.
A. All of the following documentation are required to appropriately evaluate the medical necessity for the requested orthognathic surgery procedure. They can be submitted either hard copy or electronically.
- member's medical and dental records including list of symptoms and detailed description of the functional impairment considered to be the direct result of the skeletal abnormality
- medical, dental, and orthodontic history including dates and nature of any previous treatment
- bilateral lateral x-rays, panoramic radiograph or tomograms documenting skeletal, facial or craniofacial deformity
- cephalometric films and tracings including prediction tracings and cephalometric analysis
- photographs (optional but recommended)
- list of procedures to be performed (along with the appropriate CPT and HCPCS codes)
B. Orthognathic surgery procedure(s) is/are considered medically necessary when both criteria 1 and 2 are met:
1. Facial Skeletal Deformities
Presence of significant masticatory dysfunction or malocclusion as evidenced by any of the following facial skeletal deformity measurements developed by the American Association of Oral and Maxillofacial Surgeons (AAOMS) and such deformities cannot be adequately corrected by dental treatment alone (including orthodontics).
a. Anteroposterior discrepancies - according to the AAOMS, these values represent two or more standard deviation from published norms.
i. Maxillary/Mandibular incisor relationship (norm=2 mm)
- Horizontal overjet of +5 mm or more.
- Horizontal overjet of zero to a negative value.
ii. Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm 0 to 1 mm)
b. Vertical discrepancies
i. Presence of a vertical facial skeletal deformity, which is two or more standard deviations from published norms for accepted skeletal landmarks.
ii. Open bite
- No vertical overlap of anterior teeth.
- Unilateral or bilateral posterior open bite greater than 2 mm.
iii. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch.
iv. Supraeruption of a dentoalveolar segment due to lack of occlusion.
c. Transverse discrepancies
i. Presence of a transverse skeletal discrepancy, which is two or more standard deviations from published norms.
ii. Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth.
d. Asymmetries
i. Anteroposterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.
AND
2. Documented Functional Impairments
When any of the following functional impairments exist and are appropriately documented in the member's medical records, and non-surgical interventions have failed:
a. Persistent problems with mastication related to malocclusion (e.g., choking due to incomplete mastication of solid food);
b. Speech and articular dysfunction due to severe congenital facial skeletal deformities (e.g., severe cleft deformity) when post-surgical improvement can be expected as determined by a speech and language pathologist;
c. As part of an initial treatment plan to restore proper function after accidental injury, trauma, or other congenital or acquired facial skeletal deformity (e.g., fractures facial bones, fractures jaw, post-surgical resection of neoplastic growths).
C. Orthognathic surgery for members with obstructive sleep apnea (OSA), please refer to a separate policy on 'Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome' (Policy #006 in the Surgery Section).
D. Orthognathic surgery for members with temporomandibular joint (TMJ) dysfunction, please refer to a separate policy on 'Temporomandibular Joint Dysfunction' (Policy #079 in the Medicine Section).
E. Other indications for orthognathic surgery are not considered medically necessary and thus, not eligible for reimbursement under the member's medical health insurance benefits. These include, but are not limited to, correction of distortions within the sibilant sound class or for other distortions of speech quality (e.g., hyper-nasal or hypo-nasal speech), restoration of a non-functional occlusion and other deformities which can be adequately corrected by dental treatment alone (including orthodontics).
F. Orthognathic surgery for correction of other articulation disorders and other impairments in the production of speech are considered investigational since there is insufficient evidence published in the medical literature to support its effectiveness.
G. When deemed medically necessary, it may be appropriate for orthognathic surgery to be provided in staged procedures, and surgical interventions may consist of different surgical procedures performed on different dates of service.
H. Cosmetic components of medically necessary surgical procedures (e.g., genioplasty) will not be covered under the medical health insurance benefits.
I. Dental components of medically necessary surgical procedures will not be covered under the medical health insurance benefits. These include, but not limited to, any orthodontia or tooth movement including pre- and post-surgical banding, removal of third molars or wisdom teeth (removal of bony and partial bony impacted wisdom teeth may be a contractual benefit), prosthetics (crowns, full or partial dentures), implant placement or procedures that involve the gingiva, alveolar bone, or teeth and their supporting structures.
J. Orthognathic surgery when performed primarily to change the physical appearance of the member that would be considered within normal human anatomic variation whether or not they are associated with psychological disorders, is considered cosmetic and thus, not medically necessary.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Orthognathic Surgery
References:
1. American Association of Oral and Maxillofacial Surgeons. Clinical Resources. Recommended Criteria for Orthognathic Surgery (2015). Available at: http://www.aaoms.org/images/uploads/pdfs/ortho_criteria.pdf
2. Horizon BCBSNJ. Guideline for Determining Necessity for Orthognathic Surgery.
3. American Association of Oral and Maxillofacial Surgeons. Clinical Resources. Guidelines to Evaluation of Impairment of the Oral Maxillofacial Region (2014). Available at: http://www.aaoms.org/images/uploads/pdfs/impairment_guidelines.pdf
4. American Association of Oral and Maxillofacial Surgeons. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParCare 2012). Available at: http://www.aaoms.org/images/uploads/pdfs/parcare_assessment.pdf.
5. Milliman Care Guidelines. 20th Edition. Mandibular Osteotomy. ACG: A-0247 (AC).
6. Milliman Care Guidelines. 20th Edition. Maxillomandibular Osteotomy and Advancement. ACG: A-0248 (AC).
7. UpToDate. Syndromes with craniofacial abnormalities. Literature review current through December 2016. Topic last updated October 18, 2016.
8. American Cleft Palate-Craniofacial Association. Parameters for Evaluation and Treatment of Patients with Cleft Lip/Palate or Other Craniofacial Anomalies. November 2009.
9. Mandibular/Maxillary (Orthognathic) Surgery Medical Policy. Anthem.
10. Orthognathic Surgery Commercial Medical Policy. Independence.
11. Buchanan EP, Hollier Jr LH. Syndromes with craniofacial abnormalities. TePas E, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on February 12, 2019.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
21125
21127
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21188
21193
21194
21195
21196
21198
21199
21206
21208
21209
21210
21215
21244
21245
21246
21247
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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