Notification Issue Date:

Medicare Advantage Policy

Title:Orthognathic Surgery
Policy #:MA11.083a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.

The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.


Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

When performed as a cosmetic service, orthognathic surgery is not covered by the Company because cosmetic services are not covered by Medicare. Therefore, it is not eligible for reimbursement consideration. However, orthognathic surgery is considered medically necessary and, therefore, covered when nonsurgical correction has failed and the individual meets a criterion from the list of facial skeletal discrepancy measurements AND the list of functional impairments.

  • The presence of masticatory malocclusion as evidenced by any of the following facial skeletal deformity measurements developed by the American Association of Oral and Maxillofacial Surgeons (AAOMS) when such deformities cannot be adequately corrected by other nonsurgical interventions:
    • Anteroposterior discrepancies (According to the AAOMS, these discrepancies demonstrate two or more standard deviations from published norms.)
      • Maxillary/mandibular incisor relationship: overjet of 5 mm or more, or a 0 to negative value (norm 2 mm)
      • Maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm 0-1 mm)
    • Vertical discrepancies
      • Presence of a vertical facial skeletal deformity that is two or more standard deviations from published norms for accepted skeletal landmarks
      • Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch
      • Supraeruption of a dentoalveolar segment due to lack of occlusion
      • Open bite
        • No vertical overlap of anterior teeth
        • Unilateral or bilateral posterior open bite greater than 2 mm
    • Transverse discrepancies
      • Presence of a transverse skeletal discrepancy that is two or more standard deviations from published norms
      • 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
    • Asymmetries
      • Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry

  • When ANY of the following functional impairments exist and non-surgical correction of the dysfunction has failed:
    • Airway obstruction as evidenced by a diagnosis of moderate-to-severe sleep apnea*, which has been validated by polysomnogram at an attended sleep study in a certified sleep center when mandibular/maxillary surgery is required to correct facial skeletal deformities when BOTH of the following are met:
      • Individual meets criteria for initiation of CPAP or Bi-PAP but has failed a C/BI-PAP trial or is intolerant to C/BI-PAP.
      • Less-invasive interventions have failed to achieve less nasal/upper airway resistance (eg, weight loss, sleep posture repositioning, oral appliances).
      *Moderate-to-severe sleep apnea is generally defined as an apnea hypopnea index (AHI) or respiratory distress index (RDI) greater than or equal to 15 events an hour, or an AHI greater than five and less than or equal to 14 events per hour with additional symptoms (e.g., excessive daytime sleepiness, insomnia, mood disorders, hypertension). Individuals with severe OSA have greater than 30 events recorded per hour of sleep.
    • Persistent problems with mastication and swallowing once neurological or metabolic disorders have been ruled out by physical examination and/or other diagnostic testing
    • Malnutrition and significant weight loss that can be directly correlated to a facial skeletal deformity
    • Speech and articular dysfunction due to severe congenital facial skeletal defects (e.g., severe cleft deformity) when post-surgical improvement can be expected as determined by a speech and language pathologist
    • 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., fractured facial bones, fractured jaw, post-surgical resection for neoplastic growths)

Orthognathic surgery performed solely to change the appearance of any portion of the face, without the expectation for improving physiologic functioning is considered a cosmetic service and, therefore, not covered by the Company because cosmetic services are not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when not covered by Medicare.

It is 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.

Any pre- and/or post-surgical orthodontics performed to align permanent dentition (i.e., braces) are not covered under the medical benefit of the Company's Medicare Advantage plans.


The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

Medical necessity requirements will be applied that are distinct from this medical policy.


Subject to the terms and conditions of the applicable Evidence of Coverage, orthognathic surgery is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Services that are cosmetic are excluded for the Company’s Medicare Advantage plans because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

Subject to the applicable Evidence of Coverage, pre- and/or post-surgical orthodontics performed to align permanent dentition is not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is considered not covered.


Orthognathic (maxillofacial, craniofacial) surgery involves correction of aberrations of the structure and positioning of the maxilla (upper jaw) or mandible (lower jaw) in three standard reference planes: vertical, sagittal, and transverse. These anomalies usually occur as a result of growth differences between the maxilla and mandible that may be congenital or acquired during growth and development. However, they may also be caused by cleft lip and/or palate repair, craniofacial syndromes (e.g., Crouzon’s, Apert’s, Pfeiffer's), or trauma. Trauma that occurs in the developing skeleton may interfere with the normal growth of the jaws, whereas trauma in the mature skeleton may result in malpositioning of the jaws. When significant facial deformities are present, deficits often occur in vital functions such as mastication, swallowing, respiration, and speech.

In most situations, orthognathic surgery involves osteotomies (cutting of bone) or ostectomies (removal of bone) of the maxilla and/or mandible. The LeFort procedure, which consists of a horizontal osteotomy through the maxilla above the lips, is the foundation of most maxillary surgery. The site of a mandibular osteotomy is dependent on the deformity to be corrected and the surgeon’s preference for repair. The affected bones are repositioned into normal alignment and are held in place with miniplates and/or surgical screws (rigid fixation). Most orthognathic procedures are performed on young adults after skeletal growth has been completed. The procedures are normally provided as inpatient surgery under general anesthesia, although some procedures are currently being provided in the outpatient setting. Surgeries that are necessary for the success of orthognathic surgery (e.g., mentoplasty and/or genioplasty) may be performed as adjunctive procedures. Bone grafting may also be necessary to maintain proper alignment; in most cases, bone is harvested from the hip or other donor sites, or bone graft substitutes are used.

Distraction osteogenesis is a newer procedure for lengthening the mandible. The procedure produces a callus at the site of the osteotomy, which is then distracted with fixators until new bone formation is stimulated.

Although a definitive relationship between functionally significant malocclusion and functional deficits has not been reported, significant malocclusion is supported in the literature as an indication for treatment with orthognathic surgery. With the goal of improving function through surgical correction, the American Association of Oral and Maxillofacial Surgeons (AAOMS) has developed specific indications for orthognathic surgery in cases where facial skeletal deformities are associated with masticatory malocclusion.

A number of syndromes produce congenital deformities of the facial skeleton, most notably Apert’s and Crouzon’s syndromes, both of which involve maxillary and midface retrusion with Class III dental occlusion. Orthognathic surgery has been shown to improve respiration, occlusion, and speech in individuals with these conditions.

Up to 26 percent of individuals who undergo cleft lip and/or palate repair in childhood develop maxillary hypoplasia that requires orthognathic surgery due to Class III malocclusions and speech deficits. Causes include tight scar tissue resulting from previous surgical procedures, the mechanical molding action of the muscles, and the presence of a pharyngeal flap. The LeFort I osteotomy is typically used to correct maxillary hypoplasia. However, in cases where a combination of mandibular prognathism and maxillary hypoplasia occurs, mandibular setback may be required along with maxillary advancement. Surgical repair should be delayed until the individual reaches skeletal maturity. In cases where speech articulation is adversely affected because of severe skeletal malocclusions, improvement has been reported after orthognathic surgery.

Obstructive sleep apnea syndrome (OSAS) can be a result of maxillary and mandibular deficiencies when associated with narrowed posterior airway space (PAS) and lowered air volume. Studies have demonstrated positive changes on polysomnography and decreases in apnea indices after maxillomandibular advancement in individuals with maxillary and/or mandibular deficiencies. In fact, surgery results in reduction of apnea/hypopnea indices similar to that attained by continuous positive airway pressure (CPAP). However, surgery is indicated only for individuals with maxillary and/or mandibular deficiencies that are surgically correctable who have failed conservative therapies for OSAS.

Orthognathic procedures involving mandibular or maxillary osteotomies include the LeFort I, LeFort II, and LeFort III procedures, maxillary segmental osteotomies, sagittal split osteotomy of the mandibular ramus, vertical ramal osteotomy, inverted L and C osteotomies, mandibular body segmental osteotomies, and mandibular symphysis osteotomies. These procedures can be used and modified depending on the site and type of deformity. Generally, orthognathic surgery is safe and well tolerated; the most frequently reported complication is a neurosensory deficit in the region of the inferior alveolar nerve that, in most cases, resolves within a year.

Difficulties with mastication and swallowing may indicate an underlying neurologic or metabolic disorder. Neurological disorders that affect the central nervous system (CNS) can include cerebral vascular accident (CVA), Parkinson's disease, and amyotrophic lateral sclerosis (ALS), while examples of peripheral nervous system (PNS) disorders include Bell's Palsy and myasthenia gravis. The ability to chew and swallow food is also impaired by Sjogren's syndrome, which causes a decrease in salivary flow as does some commonly prescribed classes of medications, such as anti-cholinergics, antihistamines, and certain antihypertensives.

The etiology of other significant dentofacial anomalies that may require surgical correction is variable. Trauma to the mature facial skeleton can displace the normal elements and require repositioning osteotomies if, initially, there was an improper reduction. In the developing facial skeleton, traumatic events can disturb normal subsequent growth. Additionally, neoplastic growth, surgical resection, and iatrogenic radiation may cause significant acquired dentofacial anomalies that may also result in functional impairment.

Although orthognathic surgery is performed for correction of facial deformities and improvement in function, an improved appearance can also result. The provision of aesthetically pleasing features and improved psychosocial function comprise a large part of the body of literature available on orthognathic surgery. The psychosocial aspects of orthognathic surgery have been investigated for changes brought about by surgery. Most of the research relies on patient satisfaction questionnaires and is, therefore, challenged by low response rates and recall bias. Improvement in psychosocial functioning is included in the statement of Criteria for Orthognathic Surgery issued by the American Association of Oral and Maxillofacial Surgeons. However, cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

Abrahamsson C, Ekberg E, Henrikson T, Bondemark L. Alterations of temporomandibular disorders before and after orthognathic surgery: a systematic review. Angle Orthod. 2007;77(4):729-734.

Aghabeigi B, Hiranaka D, Keith DA, et al. Effect of orthognathic surgery on the temporomandibular joint in patients with anterior open bite (abstract). Int J Adult Orthodon Orthognath Surg. 2001;16(2):153-160.

American Academy of Oral and Maxillofacial Surgeons (AAOMS). Criteria for orthognathic surgery. Rosemont, IL: AAOMS; 2015. Available at: Accessed March 31, 2017.

American Academy of Oral and Maxillofacial Surgeons (AAOMS). Craniofacial anomalies. White Paper. [AAOMS Web site]. March 2017. Available at: Accessed March 31, 2017.

Barerra JE, Powel NB, Riley RW. Facial skeletal surgery in the management of adult obstructive sleep apnea syndrome. Clin Plast Surg. 2007;34(3):565-573.

Bennett ME, Phillips CL. Assessment of health-related quality of life for patients with severe skeletal disharmony: A review of the issues. Int J Adult Orthodon Orthognath Surg. 1999;14(1):65-75.

Bergstrom K, Halling A, Huggare J, Johansson L. Treatment difficulty and treatment outcome in orthodontic care. Eur J Orthod. 1998;20:145-157.

Chanchareonsook N, Samman N, Whitehill TL. The effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopnaryngeal status: a critical review. Cleft Palate Craniofac J. 2006;43(4):447-487.

Cohen SR, Corrigan M, Wilmot J, Trotman CA. Cumulative operative procedures in patients aged 14 years and older with unilateral or bilateral cleft lip and palate. Plast Reconstr Surg. 1995;96(2):267-271.

Conradt R, Hochban W, Brandenburg U, et al. Long-term follow-up after surgical treatment of obstructive sleep apnoea by maxillomandibular advancement (abstract). Eur Respir J.1997;10(1):123-128.

Conradt R, Hochban W, Heitmann J, et al. Sleep fragmentation and daytime vigilance in patients with OSA treated by surgical maxillomandibular advancement compared to CPAP therapy. J Sleep Res. 1998;7(3):217-223.

Cope JB, Samchukov ML, Cherkashin AM. Mandibular distraction osteogenesis: A historic perspective and future directions. Am J Orthod Dentofacial Orthop. 1999;115(4):448-460.

Dalston RM, Vig PS. Effects of orthognathic surgery on speech: A prospective study (abstract). Am J Orthod. 1984;86(4):291-298.

Davies J, Turner S, Sandy JR. Distraction osteogenesis – a review. Br Dent J. 1998;185(9):462-7.

DeLuke DM, Marchand A, Robles EC, Fox P. Facial growth and the need for orthognathic surgery after cleft palate repair: Literature review and report of 28 cases. J Oral Maxillofac Surg. 1997;55(7):694-697.

Ehmer U, Broll P. Mandibular border movements and masticatory patterns before and after orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 1992;7(3):153-159.

Ellis E 3rd, Throckmorton GS, Sinn DP. Bite forces before and after surgical correction of mandibular prognathism. J Oral Maxillofac Surg. 1996;54(2):176-181.

Elsalanty ME, Genecov DG, Genecov JS. Functional and aesthetic endpoints in orthognathic surgery. J Craniofac Surg. 2007;18(4):725-733.

Evidence of Coverage.

Farella M, Michelotti A, Bocchino T, et al. Effects of orthognathic surgery for class III malocclusion on signs and symptoms of temporomandibular disorders and on pressure pain thresholds of the jaw muscles. Int J Oral Maxillofac Surg. 2007;36(7):583-587.

Gaggl A, Schultes G, Karcher H. Aesthetic and functional outcome of surgical and orthodontic correction of bilateral clefts of lip, palate, and alveolus. Cleft Palate Craniofac J. 1999;36(5):407-412.

Goodday RH, Percious DS, Morrison AD, Robertson CG. Obstructive sleep apnea syndrome: Diagnosis and management (abstract). J Can Dent Assoc. 2001;67(11):652-658.

Hassan T, Naini FB, Gill DS. The effects of orthognathic surgery on speech: A review. J Oral Maxillofac Surg. 2007;65(12):2536-2543.

Hochban W, Conradt R, Brandenburg U, et al. Surgical maxillofacial treatment of obstructive sleep apnea. Plast Reconstr Surg. 1997;99(3):619-626.

Hori M, Okaue M, Hasegawa M, et al. Worsening of pre-existing TMJ dysfunction following sagittal split osteotomy: A study of three cases (abstract). J Oral Sci. 1999;41(3):133-139.

Kang SH, Yoo JH, Yi CK. The efficacy of postoperative prophylactic antibiotics in orthognathic surgery: A prospective study in Le Fort I osteotomy and bilateral intraoral vertical ramus osteotomy. Yonsei Med J. 2009;50(1):55-59.

Keller EE, Hill AJ Jr., Sather AH. Orthognathic surgery. Review of mandibular body procedures. Mayo Clin Proc. 1976;51(2):117-133.

Kinaan BK. Overjet and overbite distribution and correlation: A comparative epidemiological English-Iraqi study. Br J Orthod (abstract). 1986;13(2):79-86.

Lachner J, Waite PD, Wooten V. Treatment of obstructive sleep apnea with methods of orthognathic surgery (abstract). Dtsch Z Mund Kiefer Gesichtschir. 1990;14(4):272-275.

Lee AS, Whitehill TL, Ciocca V, Samman N. Acoustic and perceptual analysis of the sibilant sound /s/ before and after orthognathic surgery. J Oral Maxillofac Surg. 2002;60(4):364-372.

Linton JL. Comparative study of diagnostic measures in borderline surgical cases of unilateral cleft lip and palate and noncleft Class III malocclusions. Am J Orthod Dentofacial Orthop. 1998;113(5):526-537.

Liu A, Zhang Z, Wang X. The effect of orthognathic surgery on temporomandibular joint function (abstract). Zhonghua Kou Qiang Yi Xue Za Zhi. 2000;35(2):135-137.

Lupori JP, Van Sickels JE, Holmgreen WC. Outpatient orthognathic surgery: Review of 205 cases. J Oral Maxillofac Surg. 1997;55(6):558-563.

Mackary GJ, Carlson GW, Wood RJ, Bostwick J, III. Plastic and maxillofacial surgery. In: Sabiston DC, Jr., ed. Sabiston’s Textbook of Surgery. Philadelphia, PA: W.B. Saunders; 1997:1298-1315.

Maurer P, Otto C, Eckert AW, Schubert J. Complications in surgical treatment of malocclusions. Report of 50 years experience (abstract). Mund Kiefer Gesichtschir. 2001;5(6):357-361.

McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, orthodontic treatment and temporomandibular disorders: A review (abstract). J Orofac Pain. 1995;9(1):73-90.

Moe KS. Maxillary and lefort fractures treatment and management. [Medscape Web site]. 02/08/2016. Available at: Accessed March 31, 2017.

Nicodemo D, Pereira MD, Ferreira LM. Self-esteem and depression in patients presenting angle class III malocclusion submitted for orthognathic surgery. Med Oral Patol Oral Cir Bucal. 2008;13(1):E48-51.

O'Gara M, Wilson K. The effects of maxillofacial surgery on speech and velopharyngeal function. Clin Plast Surg. 2007;34(3):395-402.

Pahkala RH, Kellokoski JK. Surgical-orthodontic treatment and patients' functional and psychosocial well-being. Am J Orthod Dentofacial Orthop. 2007;132(2):158-164.

Panula K, Finne K, Oikarinen K. Incidence of complications and problems related to orthognathic surgery: A review of 655 patients. J Oral Maxillofac Surg. 2001;59(10):1128-36.

Patel PK. Othognathic surgery. [Medscape Web site]. 10/05/2016. Available at: Accessed March 31, 2017.

Posnick JC. Craniofacial dystosis. Staging of reconstruction and management of the midface deformity. Neurosurg Clin N Am. 1991;2(3):683-702.

Prinsell JR. Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest. 1999;116(6):1519-1529.

Proffit WR, Phillips C, Tulloch JF, Medland PH. Surgical versus orthodontic correction of skeletal Class II malocclusion in adolescents: Effects and indications. Int J Adult Orthod Orthognath Surg. 1992;7(4):209-220.

Ruscello DM, Tekieli ME, Van Sickels JE. Speech production before and after orthognathic surgery: A review (abstract). Oral Surg Oral Med Oral Pathol. 1985;59(1):10-14.

Schendel SA, Powell NB. Surgical orthognathic management of sleep apnea. J Craniofac Surg. 2007;18(4):902-911.

Selber JC, Rosen HM. Aesthetics of facial skeletal surgery. Clin Plast Surg. 2007;34:437-445.

Sinn DP, Ghali GE. Advances in orthognathic surgery. Curr Opin Dent. 1992;20:38-41.

Song HC, Throckmorton GS, Ellis E 3rd, Sinn DP. Functional and morphologic alterations after anterior or inferior repositioning of the maxilla. J Oral Maxillofac Surg. 1997;55:41-49.

Steinberg B, Padwa BL, Boyne P, Kaban L. State of the art in oral and maxillofacial surgery: Treatment of maxillary hypoplasia and anterior palatal and alveolar clefts. Cleft Palate Craniofac J. 1999;36(4):283-291.

Thomas PM, Tucker MR. Complex orthodontic problems: The orthognathic patient with temporomandibular disorders. Semin Orthod. 1999;5(4):244-256.

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

Wolfe SA, Bucky L. Facial osteotomies. In: Georgiade GS, Riefkohl R, Levin LS, eds. Georgiade Plastic, Maxillofacial, and Reconstructive Surgery. Baltimore, MD: Williams & Wilkins;1997:297-320.

Wood RJ, Jurkiewicz MJ. Plastic and reconstructive surgery. In: Schwartz SI, ed. Principles of Surgery. New York, NY: McGraw-Hill; 1999:2091-1123.

Yamada K, Hanada K, Hayashi T, Ito J. Condylar bony change, disk displacement, and signs and symptoms of TMJ disorders in orthognathic surgery patients (abstract). Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(5):603-610.

Yi B, Zhang XE, Zhang ZK, et al. Orthognathic surgery correction of mandibular hypoplasia accompanying obstructive sleep apnea syndrome (abstract). Chin J Dent Res. 1999;2(3-4):59-64.

Zarrinkelk HM, Throckmorton GS, Ellis E 3rd, Sinn DP. Functional and morphologic changes after combined maxillary intrusion and mandibular advancement surgery. J Oral Maxillofac Surg. 1996;54(7):828-837.


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

21085, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21247

20670, 20680, 20690, 20692, 20693, 20694

Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.

ICD - 10 Procedure Code Number(s)


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.

ICD -10 Diagnosis Code Number(s)


HCPCS Level II Code Number(s)

D7940 Osteoplasty - for orthognathic deformities

D7941 Osteotomy - mandibular rami

D7943 Osteotomy - mandibular rami with bone graft; includes obtaining the graft

D7944 Osteotomy - segmented or subapical

D7945 Osteotomy - body of mandible

D7946 LeFort I (maxilla - total)

D7947 LeFort I (maxilla - segmented)

D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft

D7949 LeFort II or LeFort III - with bone graft

Revenue Code Number(s)


Coding and Billing Requirements

Policy History

09/25/2019This policy has been reissued in accordance with the Company's annual review process.
08/29/2018This policy has been reissued in accordance with the Company's annual review process.
06/30/2017This version of the policy will become effective 06/30/2017.

The policy has been reviewed and updated to communicate the Company’s continuing position on orthognathic surgery and the addition of language to further address services performed due to recent trauma and/or accident that may be eligible for coverage.

The following CPT codes have been removed from this policy:

21345, 21346, 21347, 21348, 21421, 21422, 21423

04/27/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthognathic Surgery.
04/29/2015 The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthognathic Surgery.
01/01/2015This is a new policy.

Version Effective Date: 06/30/2017
Version Issued Date: 06/30/2017
Version Reissued Date: 09/26/2019