Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Orthognathic Surgery

Policy #:11.14.08d

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

When performed as a cosmetic service, orthognathic surgery is a benefit contract exclusion for all products of the Company and 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.

FACIAL SKELETAL DISCREPANCY MEASUREMENTS
  • 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
AND

FUNCTIONAL IMPAIRMENTS
  • 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 (e.g., 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 procedures for the sole purpose of improving appearance are considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are 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 a specific benefit contract exclusion exists.

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 products.

REQUIRED DOCUMENTATION

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.
Guidelines

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

BENEFIT APPLICATION

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

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

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

Description

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 do some commonly prescribed classes of medications, such as anticholinergics, 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.
References


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

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Company Benefit Contracts.

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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.

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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.

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.

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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.

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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.

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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.

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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.

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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.

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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.

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Coding

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

THE FOLLOWING CODES MAY BE USED TO REPORT THE APPLICATION AND SUBSEQUENT REMOVAL OF INTERNAL OR EXTERNAL FACIAL DISTRACTION SERVICES:

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)

N/A


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)

N/A


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)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.14.08d:
08/29/2018This policy has been reissued in accordance with the Company's annual review process.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 06/30/2017
Version Issued Date: 06/30/2017
Version Reissued Date: 08/30/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.