Commercial

Medical Policy

Title:

Mentoplasty or Genioplasty

Policy #:

11.14.01h

Policy

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 semipermanent 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

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):402-406.

American Association of Oral and Maxillofacial Surgeons (AAOMS). Clinical Paper: Criteria for Orthognathic Surgery. [AAOMS web site]. 2017. Available at https://www.AAOMS.org/docs/practice_resources/clinical_resources/ortho_criteria.pdf. Accessed April 14, 2023.

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 April 14, 2023.

American Cleft Palate-Craniofacial Association (ACPA). Parameters of Care. Inroduction to The Parameters for Evaluation and Treatment of Patients with Cleft Lip/Palate or Other Craniofacial Differences. [ACPA Web site]. 2018. Available at: https://acpa-cpf.org/team-care/standardscat/parameters-of-care/. Accessed April 14, 2023.

American Society of Plastic Surgeons (ASPS). Orthognathic Surgery. [ASPS Web site]. 2023. Available at: https://www.plasticsurgery.org/reconstructive-procedures/orthognathic-surgery. Accessed April 14, 2023.

American Society of Plastic Surgeons (ASPS). Chin Surgery. [ASPS Web site]. 2023. Available at: https://www.plasticsurgery.org/cosmetic-procedures/chin-surgery. Accessed April 14, 2023.

Bear SE, Priest JH. Sleep apnea syndrome: correction with surgical advancement of the mandible. J Oral Surg. 1980;38(7):543-549.

Becking AG, Zijderveld SA, Tuinzing DB. Management of posttraumatic malocclusion caused by condylar process fractures. J Oral Maxillofac Surg.1998;56(12):1370-1374.

Chaiyasate K. Craniofacial syndromes. [Medscape Web site]. 07/18/2022. Available at: http://emedicine.medscape.com/article/1280034-overview. Accessed April 14, 2023.

Chang E, Lam S, Farrior E. Genioplasty Treatment & Managment. eMedicine [eMedicine Web site]. 11/30/2021. Available at: http://emedicine.medscape.com/article/839645-treatment. Accessed April 14, 2023.

Doud Galli S, Miller J. Chin Implants. Medscape, eMedicine [eMedicine Web site]. 03/01/2023. Available at: http://emedicine.medscape.com/article/842915-overview. Accessed April 14, 2023.

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):2389-2398.

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):892-897.

James D, Ma L. Mandibular reconstruction in children with obstructive sleep apnea due to micrognathia. Plastic Reconstr Surg. 1997;100(5):1131-1137.

Johnson GM, Todd DW. Cor pulmonale in severe Pierre Robin syndrome. Pediatrics. 1980;65(1):152-154.

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):887-895.

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):272-275.

Lewis MB, Pashayan HM. Management of infants with Robin anomaly. Clin Pediatr (Phila). 1980;19(8):519-521, 525-528.

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):147-152.

Nadjoni N, Vanroy S, Van De Casteele E. Minimally invasive genioplasty procedure. Plast Reconstr Surg Glob Open. 2017 Nov;5(11):e1575.

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):1414-1418.

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):55-57.

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):443-449.

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):149-154.

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):240-244.

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):734-741.

Sabiston D. Textbook of Surgery. 15th ed. Philadelphia, PA: WB Saunders Co;1997:1313-1317.

Schwartz SI. Principles of Surgery. 7th ed. New York, NY: McGraw-Hill Professional; 1998:2114-2116.

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):741-751.

Yeow VK, Chen YR. Orthognathic surgery in craniomaxillofacial fibrous dysplasia. J Craniofac Surg. 1999;10(2):155-159.

Zachariades N, Mezitis M, Michelis A. Posttraumatic osteotomies of the jaws. Int J Oral Maxillofac Surg. 1993;22(6):328-331.

Coding

CPT Procedure Code Number(s)

21120, 21121, 21122, 21123, 21125, 21127

ICD - 10 Procedure Code Number(s)

N/A

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
M26.4	Malocclusion, unspecified
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
M26.89	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
Q38.5	Congenital malformations of palate, not elsewhere classified
Q38.6	Other congenital malformations of mouth
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
Q75.001	Craniosynostosis unspecified, unilateral
Q75.002	Craniosynostosis unspecified, bilateral
Q75.009	Craniosynostosis unspecified
Q75.01	Sagittal craniosynostosis
Q75.021	Coronal craniosynostosis unilateral
Q75.022	Coronal craniosynostosis bilateral
Q75.029	Coronal craniosynostosis unspecified
Q75.03	Metopic craniosynostosis
Q75.041	Lambdoid craniosynostosis, unilateral
Q75.042	Lambdoid craniosynostosis, bilateral
Q75.049	Lambdoid craniosynostosis, unspecified
Q75.051	Cloverleaf skull
Q75.052	Pansynostosis
Q75.058	Other multi-suture craniosynostosis
Q75.08	Other single-suture 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
Q77.3	Chondrodysplasia punctata
Q78.1	Polyostotic fibrous dysplasia
Q78.5	Metaphyseal dysplasia
Q78.6	Multiple congenital exostoses
Q78.8	Other specified osteochondrodysplasias
Q87.0	Congenital malformation syndromes predominantly affecting facial appearance
R47.81	Slurred speech
Z87.81	Personal history of (healed) traumatic fracture
Z92.3	Personal history of irradiation

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 11.14.01h:

10/01/2023

This policy has been identified for the ICD-10 Diagnosis Code update, effective 10/01/2023.

The following ICD-10 Diagnosis Code has been removed from the policy:

Q75.0 Craniosynostosis

The following ICD-10 Diagnosis Codes has been added to the policy:

Q75.001 Craniosynostosis unspecified, unilateral
Q75.002 Craniosynostosis unspecified, bilateral
Q75.009 Craniosynostosis unspecified
Q75.01 Sagittal craniosynostosis
Q75.021 Coronal craniosynostosis unilateral
Q75.022 Coronal craniosynostosis bilateral
Q75.029 Coronal craniosynostosis unspecified
Q75.03 Metopic craniosynostosis
Q75.041 Lambdoid craniosynostosis, unilateral
Q75.042 Lambdoid craniosynostosis, bilateral
Q75.049 Lambdoid craniosynostosis, unspecified
Q75.051 Cloverleaf skull
Q75.052 Pansynostosis
Q75.058 Other multi-suture craniosynostosis
Q75.08 Other single-suture craniosynostosis

Revisions From 11.14.01g:

05/03/2023	The policy has been reviewed and reissued to communicate the Company's continuing position on Mentoplasty or Genioplasty.
05/18/2022	This policy has been reissued in accordance with the Company's annual review process.
06/16/2021	The policy has been reviewed and reissued to communicate the Company's continuing position on Mentoplasty or Genioplasty.
09/09/2020	The policy has been reviewed and reissued to communicate the Company's continuing position on Mentoplasty or Genioplasty.
09/25/2019	The policy has been reviewed and reissued to communicate the Company's continuing position on Mentoplasty or Genioplasty.
08/29/2018	This 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:

10/1/2023

Version Issued Date:

9/29/2023

Version Reissued Date: