Orthognathic Surgery – Minnesota ProductsThese services may or may not be covered by all HealthPartners plans. Please see ...
2.    Orthodontic treatment pre and post orthognathic surgery is not covered under this medical benefit. Associated      o...
D7943-osteotomy – mandibular rami with bone graft            D7944-osteotomy-Segmented or subapical            D7945-osteo...
Orthognathic literally means straight jaws.Orthognathic surgery involves widening, shortening, or lengthening the bones, i...
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Orthognathic Surgery … Minnesota Products


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Orthognathic Surgery … Minnesota Products

  1. 1. Orthognathic Surgery – Minnesota ProductsThese services may or may not be covered by all HealthPartners plans. Please see your plan documents for yourown coverage information. If there is a difference between this general information and your plan documents, yourplan documents will be used to determine your coverage.Administrative ProcessRequires prior approval.CoverageOrthognathic Surgery must be approved by HealthPartners and received from an in-network orthognathic surgeryprovider. Coverage is for charges directly related to Orthognathic Surgery only--such as surgeons, anesthesia, andhospital expenses. Note: Some products may allow this benefit to be received out of network. Please check yourmember contract or call Member Services for this information.Orthognathic Surgery is generally covered as per the indications listed below. If coverage for orthognathic surgery isavailable, the following clinical documentation is required to support medical necessity for orthognathic surgery: 1. Medical history and physical examination with reference to symptoms related to the orthognathic deformity 2. Description of specific anatomic deformity present 3. Lateral and anterior-posterior cephalometric radiographs 4. Cephalometric tracings 5. Copy of medical records from treating physician documenting evaluation, diagnosis and previous management of the severe functional medical impairment(s) 6. Diagnostic quality (clear) photographs that fully demonstrate the dental occlusionIndications that are covered1. Orthognathic Surgery must be performed while the member is enrolled in a HealthPartners Plan.2. Orthognathic Surgery will generally be covered when both a severe facial deformity AND a functional impairment exists (see definitions below), There must be a reasonable probability that a functional occlusion cannot be obtained with orthodontic treatment alone.A functional impairment consists of any of the following criteria, A-C: A. Difficulty with chewing or swallowing, with symptoms documented in the medical or dental record and persisting for at least 12 months. Other causes of swallowing, choking, or chewing problems must be ruled out through physical exam and/or appropriate diagnostic study including, but not limited to, allergies, neurologic or metabolic disease, or hypothyroidism. B. Documented malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity. C. Airway obstruction (such as obstructive sleep apnea), when documented by a polysomnogram, and BOTH of the following: 1. Criteria for continuous positive airway pressure (CPAP) device are satisfied and documentation demonstrates a previously failed trial of CPAP AND 2. Documentation demonstrates the member previously failed less invasive surgical procedures or has craniofacial skeletal abnormalities that are associated with a narrowed posterior airway space and tongue-based obstruction.3. Requests for orthognathic surgery/orthodontic treatment plan must be submitted for preauthorization and approved by HealthPartners PRIOR to initiation of orthodontic treatment. (Cases submitted for surgery subsequent to orthodontic treatment to align and level teeth for orthognathic surgery will not be covered).Indications that are not covered1. There is no coverage for treatment received out of the orthognathic surgery provider network.Orthognathic Surgery 9-14-10.doc Page 1 of 4
  2. 2. 2. Orthodontic treatment pre and post orthognathic surgery is not covered under this medical benefit. Associated orthodontic and/or dental orthopedic treatment including rapid maxillary expansion is not covered.3. If the member’s condition requires orthodontic treatment, the member must demonstrate that this orthodontic care has been arranged. If the member does not have a clear plan to acquire the required pre and post orthodontic treatment associated with the surgery, orthognathic surgery will not be covered.4. Orthognathic surgery is generally not covered for the following conditions: A. Primarily to provide a cosmetic improvement with only a limited (mild to moderate) improvement in function. Examples are genioplasty and midface vertical height reduction and other orthodontic occlusal deficiencies that can be compensated by orthodontic treatment alone. Presence of a skeletal mal-relationship alone will not be deemed justification for approval unless it is deemed severe and surgery is medically necessary to create dental compensation/function. B. Posterior cross bite with functional intercuspation (surgical rapid palatal expansion prior to orthodontic treatment is not a covered service). C. Distraction osteogenesis techniques.5. Orthognathic surgery is generally not a treatment for temporomandibular disorder (TMD). Any TMD related symptoms must be evaluated before prior authorization for orthognathic surgery. If a treating surgeon or orthodontist recommends that orthognathic surgery be undertaken in the presence of TMD related symptoms, the member may be referred to an appropriate network TMD clinic for evaluation before starting prior authorization for orthognathic surgical care.Orthognathic Surgery Codes: (including, but not limited to the following)CPT Copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.  Procedure Codes: 21110 - Application of interdental fixation device, non-fracture or dislocation 21125 - Augmentation, mandibular body or angle; prosthetic material 21127 - Augmentation, mandibular body or angle; with bone graft 21141 - Le Fort 1 single piece 21142 - Le Fort 1 two pieces, without bone graft 21143 - Le Fort 1 three pieces, without bone graft 21145 - Le Fort 1 with bone graft 21146 - Le Fort 1 two pieces 21147 - Le Fort 1 three or more pieces 21150 - Le Fort II, anterior intrusion 21151 - Le Fort II, any direction, requiring bone grafts 21154 - Le Fort III, requiring bone grafts without Le Fort I 21155 - Le Fort II, requiring bone grafts with Le Fort I 21159 - Le Fort III, requiring bone grafts without Le Fort I 21160 - Le Fort III, requiring bone grafts with Le Fort I 21188 - Reconstruction midface, osteotomies (other than Le Fort type) and bone grafts 21193 - Bilateral Vertical Osteotomy (reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy without bone graft) 21194 - Bilateral Vertical Osteotomy (reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy with bone graft) 21195 - Reconstruction of the mandibular rami and/or body, sagittal split, without internal rigid fixation 21196 - Sagittal Split Osteotomy with rigid fixation 21198 - Mandibular Osteotomy 21206 - Osteotomy, maxilla, segmental 21208 - Osteoplasty, facial bones; augmentation 21209 - Osteoplasty, facial bones; reduction 21210 - Graft, bone; nasal, maxillary or malar areas 21215 - Graft, bone; mandible 21247 - Reconstruction of mandibular condyle with bone and cartilage autografts CDT Codes: D7940-osteoplasty for orthognathic deformities D7941-osteotomy-mandibular ramiOrthognathic Surgery 9-14-10.doc Page 2 of 4
  3. 3. D7943-osteotomy – mandibular rami with bone graft D7944-osteotomy-Segmented or subapical D7945-osteotomy-body of mandible D7946-LeFort I maxilla, total D7947-LeFort I maxilla, segmented D7948-LeFort II of LeFort III without bone graft D7949-LeFort II of LeFort III with bone graft Diagnosis Codes: 519.9 - Unspecified disease of respiratory system 524.00 - Unspecified 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 524.07 - Excessive tuberosity of jaw 524.09 - Other specified 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 524.20- Unspecified Anomaly of dental arch relationship 524.21 - Malocclusion, Angle’s class I 524.22 - Malocclusion, Angle’s class II 524.23 - Malocclusion, Angle’s class III 524.24 - Open anterior occlusal relationship 524.25 - Open posterior occlusal relationship 524.26 - Excessive horizontal overlap 524.27 - Reverse articulation 524.28 - Anomalies of interarch distance 524.29 - Other anomalies of dental arch relationship 524.4 - Malocclusion, unspecified 524.50 - Dentofacial functional abnormality, unspecified 524.51 - Abnormal jaw closure 524.52 - Limited mandibular range of motion 524.53 - Deviation in opening and closing of the mandible 524.54 - Insufficient anterior guidance 524.55 - Centric occlusion max intercuspation discrepancy 524.56 - Non-working side interference 524.57 - Lack of posterior occlusal support 524.59 - Other dentofacial functional abnormalities 524.60 - Temporomandibular joint disorders, unspecified 524.61 - Mandibular joint disorders, adhesions and ankylosis 524.62 - Arthralgia of temporomandibular joint 524.63 - Articular disc disorder 524.69 - Other specified temporomandibular joint disorders 524.8 - Other specified dentofacial anomalies 524.81 - Anterior soft tissue impingement 524.82 - Posterior soft tissue impingement 524.89 - Other specified dentofacial anomalies 524.9 - Unspecified dentofacial anomalies 526.89 - Other specified disease of the jaw 744.9 - Unspecified congenital anomalies of face and neck 748.1 - Other anomalies of nose 754.0 - Congenital musculoskeletal deformities of skull, face, and jaw 756.0 - Congenital anomalies of skull and face bones 784.0 - Headache (facial pain, pain in head NOS)DefinitionsOrthognathic Surgery 9-14-10.doc Page 3 of 4
  4. 4. Orthognathic literally means straight jaws.Orthognathic surgery involves widening, shortening, or lengthening the bones, in any dimension, in the upper orlower jaws to correct severe skeletal facial deformities. Trauma, congenital or acquired conditions and severedisproportional growth of the bones in the face and jaw can cause these skeletal deformities.Treatment of severe skeletal facial deformities may require dental, orthodontic or surgical treatments. Surgery isperformed when the severe facial deformity causes demonstrable difficulty in breathing, chewing, and swallowing andwhen the deformity is determined to be too severe for correction by orthodontics alone (as determined upon reviewby a licensed orthodontist and dentist).ProductsThis information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your planhas limits or will not cover some items. If there is a difference between this general information and your plandocuments, your plan documents will be used to determine your coverage. This information is not the same forMedicare. If you have questions or would like help, please call Member Services at 952-883-7979 or 1-800-233-9645.Number O002-02; Medical Director and Benefits Committee Approval 07/01/99; Revised 11/14/02, 5/5/09; AnnualReview 06/01/06, 8/1/07, 7/1/08, 5/21/09, 9/14/10.Bibliography1. The American Association of Oral and Maxillofacial Surgeons 2008 Criteria for Orthognathic Surgerywww.aaoms.org/docs/practice_mgmt/ortho_criteria.pdfOrthognathic Surgery 9-14-10.doc Page 4 of 4