MEDICAL POLICY                                                             No. 91273-R7                                 OR...
MEDICAL POLICY                        Orthognathic Surgery                                     No. 91273-R7               ...
MEDICAL POLICY                       Orthognathic Surgery                                   No. 91273-R7     Special Notes...
MEDICAL POLICY                        Orthognathic Surgery                         No. 91273-R721141    Reconstruction mid...
MEDICAL POLICY                           Orthognathic Surgery                                           No. 91273-R7      ...
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MEDICAL POLICY No. 91273-R7

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MEDICAL POLICY No. 91273-R7

  1. 1. MEDICAL POLICY No. 91273-R7 ORTHOGNATHIC SURGERYEffective Date: August 1, 2006 Review Dates: 1/93, 7/95, 10/97, 4/99, 10/00, 8/01, 12/01, 4/02, 2/03, 1/04, 1/05, 12/05, 12/06, 12/07, 12/08, 12/09Date Of Origin: November 15, 1988 Status: CurrentI. DESCRIPTIONII. POLICY/CRITERIA A. Orthognathic surgery is a covered benefit when medically necessary to correct functional impairment. Functional impairment is defined as a decrease or lack of normal action or function of a body part due to congenital or developmental defect, pain, illness, or injury that prevents or interferes with activities of daily living. B. Orthognathic surgery for cosmetic/aesthetic or dental reasons is not a covered benefit. C. Refer to the group benefit summary for member co-payment. The base plan co-payment is 50%. If the skeletal abnormality requiring orthognathic surgery was manifest at birth and is necessary for restoration of normal functioning in an infant, then the 50% co-payment does not apply. Examples include Pierre Robin Syndrome, Cornelia de Lange Syndrome, Russell Silver Syndrome, and Sotos Syndrome. D. Documentation of previous and proposed treatment must be provided and must include evidence of conservative treatment (e.g. orthodontia, bite splint). E. Documentation of functional impairment and medical necessity must be provided. Priority Health members will be eligible for orthognathic surgery if all of the following are documented: 1. A skeletal disorder exists. A skeletal disorder exists if any of the following is present: a. Nasion perpendicular to A point (McNamara analysis) > +2 mm or the SNA angle is <80 degrees or >84 degrees b. Nasion perpendicular to B point (McNamara analysis) > -4 mm or the SNB angle is <78 degrees or >82 degrees c. The PA cephalogram shows a transverse discrepancy of 7 mm. or greater. 2. Functional occlusion is absent. Functional occlusion is absent if any of the following exists: a. Interdigitation (contact during bite) of fewer than 6 pairs of premolars and molars. Page 1 of 5
  2. 2. MEDICAL POLICY Orthognathic Surgery No. 91273-R7 b. Unopposed lower incisors in mandibular retrognathia are super- erupted. c. First and second molars are the only teeth in contact and the front teeth are open 4 mm. or more with jaw closed (apertognathia) 3. Conventional orthodontic treatment cannot yield a stable, functional post treatment occlusion (defined as interdigitation of any combination of 6 pairs of premolars and molars) without worsening the patient’s aesthetic condition. Orthodontic review of models and photos may be necessary to answer this question. 4. The Priority Health Medical Director will request case review by a dental/oral surgery consultant, but retains final decision-making authority. 5. Dental services (e.g. x-rays, bite splint, orthodontia) provided either before or after surgery are not a covered benefit. 6. If the treatment is determined to be medically necessary, only the following services will be covered: a. Referral care for evaluation and treatment b. Cephalometric x-rays c. Surgery and post-operative care, including post-operative radiographs d. Surgical facility/hospitalIII. MEDICAL NECESSITY REVIEW Required for Medicaid members onlyIV. APPLICATION TO PRODUCTS Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable. HMO/EPO: This policy applies to insured HMO/EPO plans. POS: This policy applies to insured POS plans. PPO: This policy applies to insured PPO plans. ASO: For self-funded plans, consult individual plan documents. If there is a conflict between this policy and a self-funded plan document, the provisions of the plan document will govern. INDIVIDUAL: For individual policies, consult the individual insurance policy. If there is a conflict between this medical policy and the individual insurance policy document, the provisions of the individual insurance policy will govern. MEDICARE: Coverage is determined by the Centers for Medicare and Medicaid Services (CMS). MEDICAID: Coverage is determined by the Michigan Medicaid Provider Manual and the Michigan Medicaid Fee Schedule at: http://www.michigan.gov/mdch/0,1607,7-132- 2945_42542_42543_42546_42551-159815--,00.html. MICHILD: For MICHILD members, this policy will apply unless MICHILD certificate of coverage limits or extends coverage. Page 2 of 5
  3. 3. MEDICAL POLICY Orthognathic Surgery No. 91273-R7 Special Notes: See Temporomandibular Joint Disorders (TMJD) Policy See Dental Services Policy See Certificate of CoverageV. CODING INFORMATION Services billed with the following diagnoses are subject to limitations of the orthognathic benefit. 524.00 Unspecified major anomaly of jaw size 524.01 Maxillary hyperplasia 524.02 Mandibular hyperplasia 524.03 Maxillary hypoplasia 524.04 Mandibular hypoplasia 524.05 Macrogenia 524.06 Microgenia 524.09 Other specified major anomaly of jaw size 524.10 Unspecified anomaly of relationship of jaw to cranial base 524.11 Maxillary asymmetry 524.12 Other jaw asymmetry 524.19 Other specified anomaly of relationship of jaw to cranial base 524.70 Unspecified alveolar anomaly Procedures: Services subject to Orthognathic benefit include: Anesthesia services Injection and Injectable medications Imaging & Radiology Labs Office Visits Physician Services Radiology Preventative Services Surgery & Reconstructive Surgery, including but not limited to: 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21121 Genioplasty; sliding osteotomy, single piece 21122 Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin) 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) 21125 Augmentation, mandibular body or angle; prosthetic material 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) 21137 Reduction forehead; contouring only 21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) 21139 Reduction forehead; contouring and setback of anterior frontal sinus wall Page 3 of 5
  4. 4. MEDICAL POLICY Orthognathic Surgery No. 91273-R721141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), without bone graft21142 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft21143 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)21146 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft)21147 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies)21150 Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher- Collins Syndrome)21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I21155 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I21160 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation21198 Osteotomy, mandible, segmental;21199 Osteotomy, mandible, segmental; with genioglossus advancement21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)21208* Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)21209* Osteoplasty, facial bones; reduction21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)21215 Graft, bone; mandible (includes obtaining graft)21244 Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial21246 Reconstruction of mandible or maxilla, subperiosteal implant; complete Page 4 of 5
  5. 5. MEDICAL POLICY Orthognathic Surgery No. 91273-R7 * Not Covered for Priority Medicaid If the above surgical procedures are billed for other diagnosis, prior authorization will be required. VI. REFERENCESAMA CPT Copyright Statement:All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by theAmerican Medical Association.This document is for informational purposes only. It is not an authorization, certification, explanation ofbenefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage.Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effectas of the date services are rendered. Priority Health’s medical policies are developed with the assistanceof medical professionals and are based upon a review of published and unpublished information including,but not limited to, current medical literature, guidelines published by public health and health researchagencies, and community medical practices in the treatment and diagnosis of disease. Because medicalpractice, information, and technology are constantly changing, Priority Health reserves the right to reviewand update its medical policies at its discretion.Priority Health’s medical policies are intended to serve as a resource to the plan. They are not intended tolimit the plan’s ability to interpret plan language as deemed appropriate. Physicians and other providersare solely responsible for all aspects of medical care and treatment, including the type, quality, and levelsof care and treatment they choose to provide.The name “Priority Health” and the term “plan” mean Priority Health, Priority Health Managed Benefits,Inc., Priority Health Insurance Company and Priority Health Government Programs, Inc. Page 5 of 5

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