Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Mentoplasty or Genioplasty

Policy #:11.14.01g

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, mentoplasty or genioplasty is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. However, mentoplasty or genioplasty is considered medically necessary and, therefore, covered to treat any of the following conditions:
  • Congenital craniofacial deformities such as, but not limited to, Pierre Robin syndrome
  • Craniofacial trauma with resultant facial asymmetry
  • Deformities related to radiation treatment and tumorous growths
  • Obstructive sleep apnea (OSA) that is documented by a physician with expertise in the area of sleep disordered breathing who definitively asserts that the proposed procedure is likely to significantly improve the identified abnormality. A diagnosis of OSA confirmed by sleep testing is required.
  • Lip incompetence that results in slurred speech, or xerostomia (dry mouth)
  • Systemic bone metabolic disorders that lead to speech and/or chewing dysfunction such as, but not limited to, fibrous dysplasia and acromegaly
  • Diseases that cause restriction of mandibular and chin development such as, but not limited to, rheumatoid arthritis
  • Craniofacial physiological function abnormalities, such as, but not limited to, facial fracture, iatrogenic disorder, or facial paralysis (e.g., Bell's palsy)

In exceptional circumstances where there is marked deformity resulting from severe local trauma, sequelae of radiation therapy, tumor, or severe congenital or acquired craniofacial anomaly, mentoplasty or genioplasty performed in the absence of additional maxillofacial procedures may be considered medically necessary and, therefore, covered. Photographs demonstrating the deformity may be required to determine coverage.

COSMETIC

Mentoplasty or genioplasty performed solely to change the appearance of any portion of the face, without the expectation for improving physiologic functioning is 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.

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.

All requests for mentoplasty or genioplasty require review by the Company and must include, but may not be limited to, color photographs and facial X-rays, letter of medical necessity from the provider, and results of any clinically indicated diagnostic studies to document the deformity.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, mentoplasty or genioplasty is covered under the medical benefits of the Company's products when medical necessity criteria as listed in the medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company.

Description

Mentoplasty and genioplasty are surgical procedures that alter the structure and appearance of an individual's chin. Mentoplasty, which is generally considered cosmetic in nature, reshapes the chin with an implant made of alloplastic material. Chin implants use a variety of materials, which may include silicone, metal, other man-made material, or allographic/tissue from an individual's own body. Implants with human tissue are semi-permanent because the tissue will age with time. Implants with metal or synthetic materials such as silicone or polythene are permanent.

Genioplasty involves the use of an inferior border osteotomy in order to advance or reduce the chin area. This procedure is most often performed for medical indications such as congenital deformities, craniofacial trauma with resultant facial asymmetry, and deformities related to radiation treatment and tumorous growths. A reduction genioplasty is permanent and may involve the removal of, or sliding of, bone tissue to reposition the chin point (i.e., osseous movement).

Mentoplasty or genioplasty is often performed during reconstructive surgical procedures to correct an underlying deformity (such as in the treatment of craniofacial deformities, craniofacial trauma, and surgically correctable causes of obstructive sleep apnea). Mentoplasty or genioplasty procedures are frequently performed in conjunction with other maxillofacial surgeries; however, they can sometimes be stand-alone procedures.

Although mentoplasty and genioplasty are designed to correct existing abnormalities or deformities of the chin to improve physiological function, they are sometimes solely cosmetic services to enhance the individual's appearance. 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 does not constitute improvement in physiologic function.
References


American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Chin surgery. Understanding mentoplasty. [AAFPRS Web site]. 2017. Available at:
https://www.aafprs.org/patient/procedures/mentoplasty.html. Accessed March 28, 2017.

American Association of Oral and Maxillofacial Surgeons (AAOMS). Facial cosmetic surgery. [AAOMS Web site]. 2013. Available at:
http://myoms.org/assets/uploads/documents/Ebook_facial_cosmetic_R.pdf. Accessed March 28, 2017.

American Cleft Palate-Craniofacial Association (ACPA). Parameters. For evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. [ACPA Web site]. November 2009. Available at:http://www.acpa-cpf.org/uploads/site/Parameters_Rev_2009.pdf. Accessed March 28, 2017.

Alvarez CM, Lessin ME, Gross PD. Mandibular advancement combined with horizontal advancement genioplasty for the treatment of obstructive sleep apnea in an edentulous patient. A case report. Oral Surg Oral Med Oral Pathol. 1987;64(4):402-6.

Bear SE, Priest JH. Sleep apnea syndrome: correction with surgical advancement of the mandible. J Oral Surg. 1980;38(7):543-9.

Becking AG, Zijderveld SA, Tuinzing DB. Management of posttraumatic malocclusion caused by condylar process fractures. J Oral Maxillofac Surg.1998;56(12):1370-4.

Chaiyasate K. Craniofacial syndromes. [Medscape Web site]. 02/21/2016. Available at:http://emedicine.medscape.com/article/1280034-overview. Accessed March 28, 2017.

Chang E, Lam S, Farrior E. Genioplasty Treatment & Managment. eMedicine [eMedicine Web site]. January 11, 2016. Available at: http://emedicine.medscape.com/article/839645-treatment. Accessed March 28, 2017.

Doud Galli S, Miller J. Chin Implants. Medscape, eMedicine [eMedicine Web site]. Updated April 2, 2014. Available at: http://emedicine.medscape.com/article/842915-overview. Accessed March 28, 2017.

Frodel JL. Evaluation and treatment of deformities of the chin. Facial Plast Surg Clin North Am. 2008;13(1):73-84.

Heller JB, Gabbay JS, Kwan D, et al. Genioplasty distraction osteogenesis and hyoid advancement for correction of upper airway obstruction in patients with Treacher Collins and Nager syndromes. Plast Reconstr Surg. 2006;117(7):2389-98.

Hendler BH, Costello BJ, Silverstein K, et al. A protocol for uvulopalatopharyngoplasty, mortised genioplasty, and maxillomandibular advancement in patients with obstructive sleep apnea: an analysis of 40 cases. J Oral Maxillofac Surg. 2001;59(8):892-7.

James D, Ma L. Mandibular reconstruction in children with obstructive sleep apnea due to micrognathia. Plastic Reconstr Surg. 1997;100(5):1131-7.

Johnson GM, Todd DW. Cor pulmonale in severe Pierre Robin syndrome. Pediatrics. 1980;65(1):152-4.

Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147(4):887-95.

Lachner J, Waite PD, Wooten V. Treatment of obstructive sleep apnea with methods of orthognathic surgery (Abstract). Dtsch Z Mund Keifer Gesichtschir. 1990;14(4):272-5.

Lewis MB, Pashayan HM. Management of infants with Robin anomaly. Clin Pediatr (Phila). 1980;19(8):519-21, 525-8.

Marks MW, Marks C. Fundamentals of Plastic Surgery. Philadelphia, PA: WB Saunders Co; 1997: 223.

McKinney P, Rosen PB. Reduction mentoplasty. Plastic Reconstr Surg. 1982;70(2):147-52.

Nimkarn Y, Miles PG, Waite PD. Maxillomandibular advancement surgery in obstructive sleep apnea syndrome patients: long-term surgical stability. J Oral Maxillofac Surg. 1995;53(12):1414-8.

Practice parameters for the use of polysomnography in the evaluation of insomnia. Standards of Practice Committee of the American Sleep Disorders Association. Sleep. 1995;18(1):55-7.

Reeves-Hoché MK, Hudgel DW, Meck R, et al. Continuous versus bilevel positive airway pressure for obstructive sleep apnea. Am J Respir Crit Care Med. 1995;151(2 Pt 1):443-9.

Reeves-Hoché MK, Meck R, Zwillich CW, et al. Nasal CPAP: an objective evaluation of patient compliance. Am J Respir Crit Care Med. 1994;149(1):149-54.

Riley R, Guilleminault C, Powell N, Derman S. Mandibular osteotomy and hyoid bone advancement for obstructive sleep apnea: a case report. Sleep. 1984;7(1):79-82.

Riley R, Guilleminault C, Powell N, Simmons FB. Palatopharyngoplasty failure, cephalometric roentgenograms, and obstructive sleep apnea. Otolaryngol Head Neck Surg. 1985;93(2):240-4.

Robiony M, Costa F, Demitri V, Politi M. Simultaneous malaroplasty with porous polyethylene implants and orthognathic surgery for correction of malar deficiency. J Oral Maxillofac Surg. 1998;56(6):734-41.

Sabiston D. Textbook of Surgery. 15th ed. Philadelphia, PA: WB Saunders Co; 1997: 1313-17.

Schwartz SI. Principles of Surgery. 7th ed. New York, NY: McGraw-Hill Professional; 1998: 2114-16.

Sykes JM, Frodel JL Jr. Mentoplasty. In: Flint PW, Haughey BH, Lund V, et al., eds. Cummings Otolaryngology: Head & Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Mosby; 2015:chap 30.

Williams LA. Facial rejuvenation. Nurs Clin North Am. 1994;29(4):741-51.

Yeow VK, Chen YR. Orthognathic surgery in craniomaxillofacial fibrous dysplasia. J Craniofac Surg. 1999;10(2):155-9.

Zachariades N, Mezitis M, Michelis A. Posttraumatic osteotomies of the jaws. Int J Oral Maxillofac Surg. 1993;22(6):328-31.





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)

21120, 21121, 21122, 21123, 21125, 21127


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)

K11.7 Disturbances of salivary secretion

M26.03 Mandibular hyperplasia

M26.04 Mandibular hypoplasia

M26.05 Macrogenia

M26.06 Microgenia

M26.09 Other specified anomalies of jaw size

M26.19 Other specified anomalies of jaw-cranial base relationship

M26.50 Dentofacial functional abnormalities, unspecified

M26.51 Abnormal jaw closure

M26.52 Limited mandibular range of motion

M26.53 Deviation in opening and closing of the mandible

M26.54 Insufficient anterior guidance

M26.55 Centric occlusion maximum intercuspation discrepancy

M26.56 Non-working side interference

M26.57 Lack of posterior occlusal support

M26.59 Other dentofacial functional abnormalities

M26.4 Malocclusion, unspecified

M26.89 Other dentofacial anomalies

M27.8 Other specified diseases of jaws

M95.2 Other acquired deformity of head

M99.80 Other biomechanical lesions of head region

Q18.4 Macrostomia

Q18.5 Microstomia

Q18.8 Other specified congenital malformations of face and neck

Q18.9 Congenital malformation of face and neck, unspecified

Q38.6 Other congenital malformations of mouth

Q38.5 Congenital malformations of palate, not elsewhere classified

Q40.9 Congenital malformation of upper alimentary tract, unspecified

Q67.0 Congenital facial asymmetry

Q67.1 Congenital compression facies

Q67.2 Dolichocephaly

Q67.3 Plagiocephaly

Q67.4 Other congenital deformities of skull, face and jaw

Q75.0 Craniosynostosis

Q75.1 Craniofacial dysostosis

Q75.3 Macrocephaly

Q75.4 Mandibulofacial dysostosis

Q75.5 Oculomandibular dysostosis

Q75.8 Other specified congenital malformations of skull and face bones

Q75.9 Congenital malformation of skull and face bones, unspecified

Q87.0 Congenital malformation syndromes predominantly affecting facial appearance

Q78.1 Polyostotic fibrous dysplasia

Q77.3 Chondrodysplasia punctata

Q78.5 Metaphyseal dysplasia

Q78.6 Multiple congenital exostoses

Q78.8 Other specified osteochondrodysplasias

R47.81 Slurred speech

Z92.3 Personal history of irradiation

Z87.81 Personal history of (healed) traumatic fracture



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.14.01g:
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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