Orthognathic (Jaw) Surgery

CLINICAL POLICY
ORTHOGNATHIC (JAW) SURGERY
Policy Number: SURGERY 069.7 T2
Effective Date: June 1, 2014
Table of Contents
Page
CONDITIONS OF COVERAGE...................................
BENEFIT CONSIDERATIONS....................................
COVERAGE RATIONALE...........................................
DEFINITIONS..............................................................
APPLICABLE CODES…..............................................
DESCRIPTION OF SERVICES...................................
REFERENCES............................................................
POLICY HISTORY/REVISION INFORMATION...........
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Related Policy:
• Surgical Treatment of
Obstructive Sleep
Apnea
• Temporomandibular
Joint Disorders
The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's
contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage
enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written
notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term
Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the
Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are
any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any
policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of
Coverage will govern.
CONDITIONS OF COVERAGE
Applicable Lines of
Business/Products
Benefit Type
Referral Required
This policy applies to Oxford Commercial plan
membership
General benefits package
No
(Does not apply to non-gatekeeper products)
Authorization Required
Yes
1, 2
Yes
1, 2
(Precertification always required for inpatient
admission)
Precertification with Medical
Director Review Required
Applicable Site(s) of Service
Outpatient, Office, Inpatient
(If site of service is not listed, Medical Director
review is required)
Special Considerations
1
Oxford's Dental Department will review requests for
services to be rendered by practitioners of the following
specialties: oral surgery, oral/maxillofacial surgery,
general or pediatric dentistry, endodontics, periodontics,
and orthodontics. All other specialties require Medical
Director (or designee) review through Oxford's Medical
Management Department.
2
Precertification with review by a Medical Director or their
designee
Orthognathic (Jaw) Surgery: Clinical Policy (Effective 06/01/2014)
©1996-2014, Oxford Health Plans, LLC
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BENEFIT CONSIDERATIONS
Plan Document Language
Before using this guideline, please check Member’s specific plan document and any federal or
state mandates, if applicable.
Essential Health Benefits for Individual and Small Group:
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA)
requires fully insured non-grandfathered individual and small group plans (inside and outside of
Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large
group plans (both self-funded and fully insured), and small group ASO plans, are not subject to
the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage
for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar
limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The
determination of which benefits constitute EHBs is made on a state by state basis. As such,
when using this guideline, it is important to refer to the enrollee’s specific plan document to
determine benefit coverage.
COVERAGE RATIONALE
Introduction
Oral surgery is standardly excluded from coverage. The following list represents the exceptions
to the oral surgery exclusion.
1. The following are eligible for coverage as reconstructive and medically necessary:
a. Acute traumatic injury, and post-surgical sequela (please see post-surgical sequela in
Definition section below)
b. Cancerous or non-cancerous tumors and cysts, cancer and post-surgical sequela (please
see cancer sequela and post-surgical sequela in Definition section below).
2. The following are eligible for coverage when the criteria are met (see below):
a. Obstructive sleep apneal (Refer to the Surgical Treatment of Obstructive Sleep Apnea
medical policy for additional information),
b. Cleft lip/palate (for cleft lip/palate related jaw surgery),
c. Congenital anomalies that meet the criteria for reconstructive. Depending on a patientspecific clinical review, examples might include: midface hypoplasia, Pierre Robin
Syndrome, Hemifacial Microsomia, and Treacher Collins Syndrome.
All orthognathic (jaw) surgeries are subject to some level of review.
For the above covered exceptions that require review (see Introduction section), the following
criteria should be applied.
Criteria for a Coverage Determination as Reconstructive and Medically Necessary
A requested procedure will be deemed reconstructive and medically necessary and therefore
covered when:
1. There is a physical abnormality and/or physiological abnormality that is causing a functional
impairment that requires correction, and
2. The proposed treatment is of proven efficacy; and is deemed likely to significantly improve or
restore the patient’s physiological function
For the above covered exceptions that require review, the following criteria should be applied.
Orthognathic surgery is a reconstructive procedure and is considered to be medically
necessary when both the skeletal deformity AND the functional impairment criteria below
are met:
Orthognathic (Jaw) Surgery: Clinical Policy (Effective 06/01/2014)
©1996-2014, Oxford Health Plans, LLC
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1. The presence of any of the following facial skeletal deformities associated with masticatory
malocclusion:
a. Anteroposterior discrepancies
1) Maxillary/Mandibular incisor relationship: overjet of 5mm or more, or a 0 to a negative
value (norm 2mm).
2) Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4mm or more
(norm 0 to 1mm).
3) These values represent two or more standard deviation from published norms.
b. Vertical discrepancies
1) Presence of a vertical facial skeletal deformity which is two or more standard
deviations from published norms for accepted skeletal landmarks.
2) Open Bite
a) No vertical overlap of anterior teeth.
b) Unilateral or bilateral posterior open bite greater than 2mm.
3) Deep overbite with impingement or irritation of buccal or lingual soft tissues of the
opposing arch.
4) Supraeruption of a dentoalveolar segment due to lack of occlusion.
c.
Transverse discrepancies
1) Presence of a transverse skeletal discrepancy which is two or more standard
deviations from published norms.
2) Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or
greater, or a unilateral discrepancy of 3mm or greater, given normal axial inclination
of the posterior teeth.
d. Asymmetries
1) Anteroposterior, transverse or lateral asymmetries greater than 3mm with
concomitant occlusal asymmetry.
2. One or more of the following functional impairments:
a. Masticatory (chewing) and swallowing dysfunction due to malocclusion (e.g., inability to
incise/and or chew solid foods, choking on incompletely masticated solid foods, damage
to soft tissue during mastication, malnutrition)
b. Documentation of speech deficits to support existence of speech impairment
c. Obstructive sleep apnea or airway dysfunction
DEFINITIONS
Cancer Sequela: A pathological condition resulting from a cancer, e.g. destruction of bone in the
jaw from radiation therapy.
Functional/Physical Impairment: A physical/functional or physiological impairment causes
deviation from the normal function of a tissue or organ. This results in a significantly limited,
impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is
exhibited by difficulties in one or more of the following areas: physical and motor tasks;
independent movement; performing basic life functions
Jaw Surgery: Surgical procedures to address facial trauma, neoplasms, facial clefts, surgical
resection and iatrogenic radiation.
Orthognathic Surgery: is the surgical correction of skeletal anomalies or malformations involving
the mandible (lower jaw) or maxilla (upper jaw). These malformations may be present at birth or
may become evident as the individual grows and develops. Causes include congenital or
developmental anomalies.
Orthognathic (Jaw) Surgery: Clinical Policy (Effective 06/01/2014)
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Post-Surgical Sequela: a pathological condition resulting from surgery to the jaw, eg. slippage of
hardware used to stabilize a fractured jaw.
APPLICABLE CODES
The codes listed in this policy are for reference purposes only. Listing of a service or device code
in this policy does not imply that the service described by this code is a covered or non-covered
health service. Coverage is determined by the Member’s plan of benefits or Certificate of
Coverage. This list of codes may not be all inclusive.
CPT Code
21076
21079
21080
21081
21082
21083
21120
21121
21122
21123
21125
21127
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21188
Description
Impression and custom preparation; surgical obturator prosthesis
Impression and custom preparation; interim obturator prosthesis
Impression and custom preparation; definitive obturator prosthesis
Impression and custom preparation; mandibular resection prosthesis
impression and custom preparation; palatal augmentation prosthesis
Impression and custom preparation; palatal lift prosthesis
Genioplasty; augmentation (autograft, allograft, prosthetic material)
Genioplasty; sliding osteotomy, single piece
Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or
bone wedge reversal for asymmetrical chin)
Genioplasty; sliding, augmentation with interpositional bone grafts (includes
obtaining autografts)
Augmentation, mandibular body or angle; prosthetic material
Augmentation, mandibular body or angle; with bone graft, onlay or interpositional
(includes obtaining autograft)
Reconstruction midface, LeFort I; single piece, segment movement in any
direction (e.g., for Long Face Syndrome), without bone graft
Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction,
without bone graft
Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any
direction, without bone graft
Reconstruction midface, LeFort I; single piece, segment movement in any
direction, requiring bone grafts (includes obtaining autografts)
Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction,
requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral
alveolar cleft)
Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any
direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted
bilateral alveolar cleft or multiple osteotomies)
Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins
Syndrome)
Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes
obtaining autografts)
Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts
(includes obtaining autografts); without LeFort I
Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts
(includes obtaining autografts); with LeFort I
Reconstruction midface, LeFort III (extra and intracranial) with forehead
advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
autografts); without LeFort I
Reconstruction midface, LeFort III (extra and intracranial) with forehead
advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
autografts); with LeFort I
Reconstruction midface, osteotomies (other than LeFort type) and bone grafts
(includes obtaining autografts)
Orthognathic (Jaw) Surgery: Clinical Policy (Effective 06/01/2014)
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CPT Code
21193
21194
21195
21196
21198
21199
21206
21210
21215
21244
21245
21246
21247
Description
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without
bone graft
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with
bone graft (includes obtaining graft)
Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid
fixation
Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid
fixation
Osteotomy, mandible, segmental
Osteotomy, mandible, segmental; with genioglossus advancement
Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
Graft, bone; mandible (includes obtaining graft)
Reconstruction of mandible, extraoral, w/ transosteal bone plate
Reconstruction of mandible or maxilla, subperiosteal implant, partial
Reconstruction of mandible or maxilla, subperiosteal implant; complete
Reconstruction of mandibular condyle with bone and cartilage autografts
(includes obtaining grafts) (e.g., for hemifacial microsomia)
CPT® is a registered trademark of the American Medical Association.
®
CDT Code
D5934
D5935
D5982
D5988
D7471
D7472
D7473
D7490
D7610
D7630
D7650
D7671
D7680
D7710
D7730
D7750
D7770
D7780
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
Description
Mandibular resection prosthesis with guide flange
Mandibular resection prosthesis without guide flange
Surgical stent
Surgical splint
Removal of lateral exostosis (maxilla or mandible)
Removal of torus palatinus
Removal of torus mandibularis
Radical resection of maxilla or mandible
Maxilla – open reduction (teeth immobilized, if present)
Mandible – open reduction (teeth immobilized if present)
Malar and/or zygomatic arch – open reduction.
Alveolus – open reduction, may include stabilization of teeth
facial bones – complicated reduction with fixation and multiple surgical
approaches
Maxilla – open reduction
Mandible – open reduction
Malar and/or zygomatic arch – open reduction.
Alveolus – open reduction stabilization of teeth
Facial bones – complicated reduction with fixation and multiple surgical
approaches.
Osteoplasty - for orthognathic deformities
Osteotomy – mandibular rami. see also codes: 21193, 21195, 21196
Osteotomy – mandibular rami w/ bone graft; includes obtaining the graft. see
also code: 21194
Osteotomy – segmented or subapical – per sextant or quadrant. see also codes:
21198, 21206
Osteotomy – body of mandible. see also codes: 21193, 21194, 21195, 21196
Lefort i (maxilla – total)
Lefort i (maxilla – segmented)
Lefort ii or lefort iii (osteoplasty of facial bones for midface hypoplasia or
retrusion) w/o bone graft
Lefort ii or lefort iii – w/ bone graft
Osseous, osteoperiosteal or cartilage graft of the mandible or facial bones –
autogenous or nonautogenous, by report
Orthognathic (Jaw) Surgery: Clinical Policy (Effective 06/01/2014)
©1996-2014, Oxford Health Plans, LLC
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®
CDT Code
D7953
D7955
D7995
D7996
D7997
Description
Bone replacement graft for ridge preservation – per site
Repair of maxillofacial soft and/or hard tissue defect
Synthetic graft - mandible or facial bones, by report. see also code 21299
Implant - mandible for augmentation purposes (excluding alveolar ridge), by
report.
Appliance removal (not by dentist who placed appliance), includes removal of
archbar
CDT® is a registered trademark of the American Dental Association.
DESCRIPTION OF SERVICES
Orthognathic surgery is the surgical correction of abnormalities of the mandible (lower jaw),
maxilla (upper jaw), 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. The overall
goal of treatment is to improve function through correction of the underlying skeletal deformity.
REFERENCES
The foregoing Oxford policy has been adapted from an existing UnitedHealthcare Coverage
Determination Guideline that was researched, developed and approved by the UnitedHealthcare
Coverage Determination Committee (CDG-A-028, effective 05/01/2014).
1. American Society of Plastic Surgeons (ASPS) available: http://www.plasticsurgery.org/
2. American Association of Oral and Maxillofacial Surgeons: http://www.aaoms.org/
3. MCG Care Guidelines, Mandibular Osteotomy # A-0247
4. MCG Care Guidelines, Maxillomandibular Osteotomy and Advancement #A-0248
POLICY HISTORY/REVISION INFORMATION
Date
•
06/01/2014
Action/Description
Revised coverage rationale:
o Removed documentation requirements
o Added language to indicate oral surgery is eligible for
coverage as reconstructive and medically necessary for:
 Acute traumatic injury, and post-surgical sequela
 Cancerous or non-cancerous tumors and cysts, cancer
and post-surgical sequela
o Added language to indicate oral surgery is eligible for
coverage when criteria are met for:
 Obstructive sleep apnea
 Cleft lip/palate (for cleft lip/palate related jaw surgery)
 Congenital anomalies that meet the criteria for
reconstructive depending on clinical review; examples
might include mid-face hypoplasia, Pierre Robin
Syndrome, Hemifacial Microsomia, and Treacher Collins
Syndrome
o Added language to indicate oral surgery procedures will be
deemed reconstructive and medically necessary and
therefore covered when:
 There is a physical abnormality and/or physiological
abnormality that is causing a functional impairment that
requires correction, and
 The proposed treatment is of proven efficacy; and is
Orthognathic (Jaw) Surgery: Clinical Policy (Effective 06/01/2014)
©1996-2014, Oxford Health Plans, LLC
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Date
•
06/01/2014
•
•
•
Action/Description
deemed likely to significantly improve or restore the
patient’s physiological function
o Added reference link to policy titled Surgical Treatment of
Obstructive Sleep Apnea
Revised definitions:
o Removed definition of high quality photograph
o Added definition of post-surgical sequela
Updated list of applicable CPT codes; added 21076, 21079,
21080, 21081, 21082, 21083, 21188, 21206, 21210, 21215,
21244, 21245, and 21246
Added list of applicable CDT (HCPCS) codes: D5934, D5935,
D5982, D5988, D7471, D7472, D7473, D7490, D7610, D7630,
D7650, D7671, D7680, D7710, D7730, D7750, D7770, D7780,
D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948,
D7949, D7950, D7953, D7955, D7995, D7996, and D7997
Archived previous policy version SURGERY 069.6 T2
Orthognathic (Jaw) Surgery: Clinical Policy (Effective 06/01/2014)
©1996-2014, Oxford Health Plans, LLC
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