Orthognathic Surgery (Overbite/Underbite)

POLICY NUMBER

L.7.01.409

DESCRIPTION

Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both. The underlying abnormality may be present at birth, may become evident as an individual grows and develops, or may be the result of traumatic injuries. The severity of the deformities requiring surgery precludes adequate treatment through dental treatment alone. Orthodontic consultation may be needed to confirm that the surgery is necessary or to determine that an individual can receive improved function with orthodontic therapy alone.

Orthognathic surgery is performed to correct malocclusion, which cannot be improved with routine orthodontic therapy and where the functional impairments are directly caused by the malocclusion. Examples of conditions for which this surgery is used are mandibular prognathism, crossbite, open bite, overbite, underbite, mandibular deformity, and maxillary deformity.

The following surgical procedures would be considered orthognathic surgery: reconstruction of the mandibular ramus, mandibular osteotomy, maxillary osteotomy, and reconstruction of the mandible/maxilla, which are related to function. Osteotomy involves the surgical cutting of the bone to correct the deformity. Depending on the severity of the deformity, one of the following surgical methods is usually employed: linear osteotomy, sagittal osteotomy, or the complete division of the mandibular body. Teeth may also be moved in any direction, depending on each individual case.

Two orthognathic procedures have been used to correct obstructive sleep apnea caused by hypopharyngeal obstruction: the conservative procedure of mandibular osteotomy/genioglossus advancement, in which a small portion of the lower jaw which attaches to the tongue is moved forward, to pull the tongue away from the back of the airway, with hyoid myotomy, movement of the hyoid bone in the neck/suspension (GAHM) and the more aggressive procedure maxillary and mandibular advancement osteotomy (MMO). The surgical concept is to advance the mandible and hyoid bone, which results in advancement of pharyngeal muscles and the base of tongue resulting in expansion of the airway.

POLICY

Orthognathic surgery is considered medically necessary for ANY ONE of the following conditions:

1. Maxillary and/or mandibular facial skeletal deformities that result in masticatory malocclusion is considered medically necessary as evidenced by ANY ONE of the following: [Note: Medical indications relate verifiable clinical measurements to significant facial skeletal deformities.]

    A. Anterior discrepancies with ANY ONE of the following:

•  Maxillary/Mandibular incisor relationship: overjet of 5mm or more, or a 0 to a negative value (norm 2mm) (Note: Overjet up to 5mm may be treatable with routine orthodontic therapy) OR

• Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm 0 to 1mm) (These values represent two or more standard deviation from published norms) OR

• Maxillary-mandibular skeletal relationship: ANB greater than 2 standard deviations from published norms (White = 2, African American = 4, Asian = 4)  [ANB is cephalometric angle between the three points A (maxilla), N (nasion), B (mandible)]

OR

    B. Vertical discrepancies with ANY ONE of the following:

• Presence of a vertical facial skeletal deformity, which is two or more standard deviations from published norms for accepted skeletal landmarks. The normal middle facial height (N-ANS) = 53mm, the normal lower facial height (ANS-Me) = 65mm and the normal middle: lower skeletal height relationship  (ratio 5:6).   [ANS is anterior nasal spine (on the maxilla); Me is menton (lowest point on the mandible)]

OR

• Open bite with ANY ONE of the following:

  • No vertical overlap of anterior teeth

  • Unilateral or bilateral posterior open bite greater than 2mm

OR

• Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch OR

• Supra-eruption of a dentoalveolar segment due to lack of occlusion

OR

    C. Transverse discrepancies with ANY ONE of the following:

• Presence of a transverse skeletal discrepancy, which is two or more standard deviations from published norms OR

• 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

OR

    D. Asymmetries with anteroposterior, transverse or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry

2. Clinically significant obstructive sleep apnea (OSA) and the obstruction has been treated unsuccessfully by continuous positive airway pressure (CPAP) if ALL of the criteria below are met. Unsuccessful treatment is defined as persistent sleepiness and/or uncontrolled hypertension despite documented adherence to CPAP for three (3) months. Documented adherence is defined as at least four (4) hours of use 70 percent of nights as recorded with smart card technology.

    A. A full polysomnogram has been performed and documented results confirm a diagnosis of OSA and support the need for treatment AND

B. OSA has been unsuccessfully treated with nasal continuous positive airway pressure (nCPAP) AND

C. A presurgical physical evaluation is performed and supports the need for orthognathic surgery AND

D. The site of obstruction (oropharynx [palate] and/or hypopharynx [base of tongue]) is confirmed by fiberoptic pharyngoscopy and cephalometric radiographs with tracing or volumetric computed tomography (CT) evaluation of the airway.

The following are considered not medically necessary:

• Orthognathic surgery performed for malocclusion when the criteria listed above are not met.

• Orthognathic surgery where significant risk of recurrence of symptoms or structural abnormalities exist. For treatment of mandibular excess, skeletal maturation must be documented by either:

(a) closure of the epiphyses at the wrist by radiography; OR(b) no change in mandibular or facial growth on serial cephalometric radiographs over six months

The following are considered cosmetic and not eligible for coverage:

• Orthognathic surgery performed primarily for cosmetic purposes

• Orthognathic surgery performed to reshape or enhance the size of the chin to restore facial harmony and chin projection (e.g., genioplasty, mentoplasty chin augmentation, chin implants, mandibular osteotomies, ostectomies). Procedures to address genial hypoplasia, hypertrophy or asymmetry, when performed either as an isolated procedure or with other procedures, are considered cosmetic in nature.

• Cosmetic augmentation of the mandibular angle or body or malar/infraorbital regions unless there is a documented craniofacial syndrome that results in hypoplasia of the mandible or upper midface regions. This procedure may be performed to add prominence and balance to the face.

Braces and any other orthodontic services are considered dental in nature and are not covered as a medical benefit.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

12/31/2014: Approved by Medical Policy Advisory Committee. Effective 01/01/2015.

08/31/2015: Medical policy revised to add ICD-10 codes.

06/01/2016: Policy number L.7.01.409 added. Policy Guidelines updated to add medically necessary definition.

09/29/2017: Code Reference section updated to revise code descriptions for ICD-10 procedure codes 0NNR0ZZ, 0NNR3ZZ, 0NNR4ZZ, 0NQR0ZZ, 0NQR3ZZ, 0NQR4ZZ, 0NQRXZZ, 0NRR07Z, 0NRR0JZ, 0NRR0KZ, 0NRR37Z, 0NRR3JZ, 0NRR3KZ, 0NRR47Z, 0NRR4JZ, 0NRR4KZ, 0NUR07Z, 0NUR0JZ, 0NUR0KZ, 0NUR37Z, 0NUR3JZ, 0NUR3KZ, 0NUR47Z, 0NUR4JZ, and 0NUR4KZ. Effective 10/01/2017.

12/22/2020: Code Reference section updated to add HCPCS codes D7993 and D7994, effective 01/01/2021. Removed deleted ICD-10 procedure codes 0NNS0ZZ, 0NNS3ZZ, 0NNS4ZZ, 0NQS0ZZ, 0NQS3ZZ, 0NQS4ZZ, 0NQSXZZ, 0NRS07Z, 0NRS0JZ, 0NRS0KZ, 0NRS37Z, 0NRS3JZ, 0NRS3KZ, 0NRS47Z, 0NRS4JZ, 0NRS4KZ, 0NUS07Z, 0NUS0JZ, 0NUS0KZ, 0NUS37Z, 0NUS3JZ, 0NUS3KZ, 0NUS47Z, 0NUS4JZ, and 0NUS4KZ.

12/29/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

09/29/2023: Code Reference section updated to add new ICD-10 diagnosis codes Q75.001, Q75.002, Q75.009, Q75.01, Q75.021, Q75.022, Q75.029, Q75.03, Q75.041, Q75.042, Q75.049, Q75.051, Q75.052, Q75.058, and Q75.08, effective 10/01/2023.

12/08/2023: Policy reviewed; no changes.

03/12/2025: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis code Q75.0.

SOURCE(S)

1. Criteria for Orthognathic Surgery, American Association of Oral and Maxillofacial Surgeons

2. Oral & Maxillofacial Surgery Physician Advisory Group

3. Orthognathic Surgery Corporate Medical Policy, Blue Cross Blue & Shield of North Carolina

4. Orthognathic Surgery Medical Policy, Blue Cross Blue & Shield of Tennessee

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Medically Necessary Codes

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