Certain jaw and cranio-facial deformities may cause significant functional impairment. These deformities include apertognathia (either lateral or anterior not correctable by orthodontics alone), significant asymmetry of the lower jaw, significant class 2 and class 3 occlusal discrepancies, and cleft palate. Aetna considers orthognathic surgery medically necessary for correction of the following skeletal deformities of the maxilla or mandible when it is documented that these skeletal deformities are contributing to significant dysfunction, and where the severity of the deformities precludes adequate treatment through dental therapeutics and orthodontics alone:
Maxillary and/or Mandibular Facial Skeletal Deformities Associated with Masticatory Malocclusion
Aetna considers orthognathic surgery medically necessary for correction of skeletal deformities of the maxilla or mandible when it is documented that these skeletal deformities are contributing to significant masticatory dysfunction, and where the severity of the deformities precludes adequate treatment through dental therapeutics and orthodontics:
Maxillary/mandibular incisor relationship: overjet of 5 millimeter (mm) or more, or a 0 to a negative value (norm 2 mm),
Maxillary/mandibular antero-posterior molar relationship discrepancy of 4 mm or more (norm 0 to 1 mm).
Note: These values represent 2 or more standard deviations (SDs) from published norms.
Presence of a vertical facial skeletal deformity which is 2 or more SDs from published norms for accepted skeletal landmarks
No vertical overlap of anterior teeth greater than 2 mm
Unilateral or bilateral posterior open bite greater than 2 mm
Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch
Supraeruption of a dento-alveolar segment due to lack of opposing occlusion creating dysfunction not amenable to conventional prosthetics.
Presence of a transverse skeletal discrepancy which is 2 or more SDs from published norms.
Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth.
Antero-posterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.
Facial Skeletal Discrepancies Associated with Documented Sleep Apnea, Airway Defects, and Soft Tissue Discrepancies
Aetna considers orthognathic surgery medically necessary in cases where it is documented that mandibular and maxillary deformities are contributing to airway dysfunction, where such dysfunction is not amenable to non-surgical treatments, and where it is shown that orthognathic surgery will decrease airway resistance and improve breathing.
For example, studies demonstrate that persons with vertical hyperplasia of the maxilla have an associated increase in nasal resistance, as do persons with maxillary hypoplasia with or without clefts. Following orthognathic surgery, such individuals routinely demonstrate decreases in nasal airway resistance and improved respiration.
Aetna considers orthognathic surgery medically necessary for members with underlying craniofacial skeletal deformities that are contributing to obstructive sleep apnea. See CPB 0004 - Obstructive Sleep Apnea in Adults. Before surgery, such individuals should be properly evaluated to determine the cause and site of their disorder and appropriate non-surgical treatments attempted when indicated.
Temporomandibular Joint Pathology
Aetna considers orthognathic surgery for correction of temporomandibular joint disease or myofascial pain dysfunction experimental and investigational because its effectiveness for these indications has not been established. See CPB 0028 - Temporomandibular Disorders.
Aetna considers orthognathic surgery medically necessary for treatment of speech impairments accompanying severe cleft deformity. Orthognathic surgery may help to reduce the flattening of the face that is characteristic of severe cleft deformity. By using osteotomy techniques along with bone and cartilage grafts, the upper and lower jaws and facial skeletal framework are moved and appropriately reconstructed. Pre-surgical orthodontic treatment is usually recommended.
Aetna considers other orthognathic surgeries experimental and investigational for correction of articulation disorders and other impairments in the production of speech because there is inadequate evidence from prospective clinical studies in the peer-reviewed published medical literature of the effectiveness of orthognathic surgery for this indication.
Aetna considers orthognathic surgery for correction of distortions within the sibilant sound class or for other distortions of speech quality (e.g., hyper-nasal or hypo-nasal speech) not medically necessary as these distortions do not cause functional impairment.
Unaesthetic Facial Features and Psychological Impairments
Orthognathic surgery is considered cosmetic for correction of unaesthetic facial features, regardless of whether these are associated with psychological disorders.
Mentoplasty or genial osteotomies/ostectomies (chin surgeries) are always considered cosmetic when performed as an isolated procedure to address genial hypoplasia, hypertrophy, or asymmetry, and may be considered cosmetic when performed with other surgical procedures.
Aetna considers the use of condylar positioning devices in orthognathic surgery experimental and investigational because their effectiveness in orthognathic surgery has not been established.
Aetna considers orthognathic surgery experimental and investigational for all indications other than those listed above because their effectiveness for indications other than the ones listed above has not been established.
Note: Precertification requests or claims for orthognathic surgery are subject to review by Aetna's Oral and Maxillofacial Surgery Unit.
Orthodontic Treatment Prior to Orthognathic Surgery
Orthodontic treatment may be needed prior to orthognathic surgery to position the teeth in a manner that will provide for an adequate occlusion following surgical repositioning of the jaws. For plans that require precertification, orthognathic surgery must be precertified prior to pre-surgical orthodontic treatment. The interim occlusion that is achieved by orthodontic treatment may be dysfunctional prior to the completion of the orthognathic surgical phase of the treatment plan. Therefore, all requests for orthognathic surgery must be reviewed/precertified by an the Aetna Oral and Maxillofacial Surgery Unit prior to the initiation of pre-surgical orthodontic care. Failure to obtain precertification of orthognathic surgery prior to orthodontic care may result in the denial of benefits.
Note: Orthognathic surgery may be subject to precertification review in plans that include precertification requirements. The following documentation should be forwarded to Aetna's Oral and Maxillofacial Surgery Unit for review: a written explanation of the member's clinical course, including dates and nature of any previous treatment; physical evidence of a skeletal, facial or craniofacial deformity defined by study models and pre-orthodontic imaging; and a detailed description of the functional impairment considered to be the direct result of the skeletal abnormality.
Orthognathic surgery is the revision by ostectomy, osteotomy or osteoplasty of the upper jaw (maxilla) and/or the lower jaw (mandible) intended to alter the relationship of the jaws and teeth. These surgical procedures are intended (i) to correct skeletal jaw and cranio-facial deformities that may be associated with significant functional impairment, and (ii) to reposition the jaws when conventional orthodontic therapy alone is unable to provide a satisfactory, functional dental occlusion within the limits of the available alveolar bone. Congenital or developmental defects can interfere with the normal development of the face and jaws. These birth defects may interfere with the ability to chew properly, and may also affect speech and swallowing. In addition, trauma to the face and jaws may create skeletal deformities that cause significant functional impairment. Functional deficits addressed by this type of surgery are those that affect the skeletal masticatory apparatus such that chewing, speaking and/or swallowing are impaired.
There is limited evidence of the effectiveness of orthognathic surgery on temporomandibular disorders. Abrahamsson et al (2007) examined if orthognathic surgery does affect the prevalence of signs and symptoms of temporomandibular disorders (TMDs). A literature survey in the PubMed and Cochrane Library electronic databases was performed and covered the period from January 1966 to April 2006. The inclusion criteria were controlled, prospective or retrospective studies comparing TMDs before and after orthognathic surgery in patients with malocclusion. There were no language restrictions, and 3 reviewers selected and extracted the data independently. The quality of the retrieved articles was evaluated by 4 reviewers. The search strategy resulted in 467 articles, of which 3 met the inclusion criteria. Because of few studies with unambiguous results and heterogeneity in study design, the scientific evidence was insufficient to evaluate the effects that orthognathic surgery had on TMD. Moreover, the studies had problems with inadequate selection description, confounding factors, and lack of method error analysis. The authors concluded that to obtain reliable scientific evidence, additional well-controlled and well-designed studies are needed to determine how and if orthognathic surgery alters signs and symptoms of TMD.
Lindenmeyer et al (2010) performed a systematic review of the best available research literature investigating the relation of oral and maxillofacial surgical procedures to the onset or relief of chronic painful TMD. A comprehensive review of the databases CINAHL, Cochrane Library, Embase, Medline, NHS Evidence--Oral Health, PsycINFO, Web of Knowledge, and MetaLib was undertaken by 2 authors up to June 2009 using search terms appropriate to establishing a relation between orofacial surgical procedures and TMD. The search was restricted to English-language publications. Of the 1,777 titles reviewed, 35 articles were critically appraised, but only 32 articles were considered eligible. These were observational studies that fell into 2 groups; 9 were seeking to establish a surgical cause for TMD. Of these, only 2 of a series of 3 claimed that there was a significant link, but this claim was based on weak data (health insurance records) and was abandoned in a subsequent report. Twenty-three studies were seeking to achieve relief by orthognathic surgical intervention. These were also negative overall, with 7 articles showing varying degrees of mostly non-significant improvement, whereas 16 showed no change or a worse outcome. No published report on the putative effect of implant insertion was found. The authors concluded that these apparently contradictory approaches underline a belief that oral surgical trauma or gross malocclusion has a causative role in the onset of TMD. However, there was no overall evidence of a surgical causal etiology or orthognathic therapeutic value. This review emphasized that it is in the patients' best interest to carry out prospective appropriately controlled randomized trials to clarify the situation.
In a Cochrane review, Luther et al (2010) examined the effectiveness of orthodontic intervention in reducing symptoms in patients with TMD (compared with any control group receiving no treatment, placebo treatment or reassurance) and investigated if active orthodontic intervention leads to TMD. The Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE and EMBASE were searched. Hand-searching of orthodontic journals and other related journals was undertaken in keeping with the Cochrane Collaboration hand-searching program. No language restrictions were applied. Authors of any studies were identified, as were experts offering legal advice, and contacted to identify unpublished trials. Most recent search was April 13, 2010. All randomized controlled trials (RCTs) including quasi-randomized trials assessing orthodontic treatment for TMD were included. Studies with adults aged equal to or above 18 years old with clinically diagnosed TMD were included. There were no age restrictions for prevention trials provided the follow-up period extended into adulthood. The inclusion criteria required reports to state their diagnostic criteria for TMD at the start of treatment and for participants to exhibit 2 or more of the signs and/or symptoms. The treatment group included treatment with appliances that could induce stable orthodontic tooth movement. Patients receiving splints for 8 to 12 weeks and studies involving surgical intervention (direct exploration/surgery of the joint and/or orthognathic surgery to correct an abnormality of the underlying skeletal pattern) were excluded. The outcomes were: how well were the symptoms reduced, adverse effects on oral health and quality of life. Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in triplicate and independently by 3 review authors. As no 2 studies compared the same treatment strategies (interventions) it was not possible to combine the results of any studies. The searches identified 284 records from all databases. Initial screening of the abstracts and titles by all review authors identified 55 articles that related to orthodontic treatment and TMD. The full articles were then retrieved and of these articles only 4 demonstrated any data that might be of value with respect to TMD and orthodontics. After further analysis of the full texts of the 4 studies identified, none of the retrieved studies met the inclusion criteria and all were excluded from this review. The authors concluded that there are insufficient research data on which to base clinical practice on the relationship of active orthodontic intervention and TMD. There is an urgent need for high quality RCTs in this area of orthodontic practice.
There is a lack of evidence to support the use of condylar positioning devices in orthognathic surgery. Costa et al (2008) stated that in the past few years, many devices have been proposed for preserving the pre-operative position of the mandibular condyle during bilateral sagittal split osteotomy. The authors stated that accurate mandibular condyle re-positioning is considered important to obtain a stable skeletal and occlusal result, and to prevent the onset of TMD. Condylar positioning devices (CPDs) have led to longer operating times, the need to keep inter-maxillary fixation as stable as possible during their application, and the need for precision in the construction of the splint or intra-operative wax bite. The authors reviewed the literature concerning the use of CPDs in orthognathic surgery since 1990 and their application to prevent skeletal instability and contain TMD since 1995. They concluded that there is no scientific evidence to support the routine use of CPDs in orthognathic surgery.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
42200 - 42281
CPT codes not covered for indications listed in the CPB:
Other CPT codes related to the CPB:
21120 - 21123
HCPCS codes covered if selection criteria are met:
D5954 - D5959
Palatal augmentation and lift prosthesis
D7940 - D7955
Other repair procedures
Other HCPCS codes related to the CPB:
D8010 - D8999
ICD-9 codes covered if selection criteria are met:
524.00 - 524.29
Major anomalies of jaw size and dental arch relationship
524.4 - 524.59
Malocclusion and dentofacial functional abnormalities
749.00 - 749.04
749.20 - 749.25
Cleft palate with cleft lip
Obstructive sleep apnea (adult) (pediatric) [associated with facial skeletal deformities]
ICD-9 codes not covered for indications listed in the CPB:
524.60 - 524.69
Temporomandibular joint disorders
Other plastic surgery for unacceptable cosmetic appearance
Other ICD-9 related to the CPB:
Other speech disturbance
786.00 - 786.09
Dyspnea and respiratory abnormalities [associated with obstructive airway defects]
The above policy is based on the following references:
McCarthy JG, Stelnicki EJ, Grayson BH. Distraction osteogenesis of the mandible: A ten-year experience. Semin Orthod. 1999;5(1):3-8.
Baker NJ, David S, Barnard DW, et al. Occlusal outcome in patients undergoing orthognathic surgery with internal fixation. Br J Oral Maxillofac Surg. 1999;37(2):90-93.
Bennett ME, Phillips CL. Assessment of health-related quality of life for patients with severe skeletal disharmony: A review of the issues. Int J Adult Orthodon Orthognath Surg. 1999;14(1):65-75.
Cope JB, Samchukov ML, Cherkashin AM. Mandibular distraction osteogenesis: A historic perspective and future directions. Am J Orthod Dentofacial Orthop. 1999;115(4):448-460.
Drew SJ, Schwartz MH, Sachs SA. Distraction osteogenesis. N Y State Dent J. 1999;65(1):26-29.
Buttke TM, Proffit WR. Referring adult patients for orthodontic treatment. J Am Dent Assoc. 1999;130(1):73-79.
Davies J, Turner S, Sandy JR. Distraction osteogenesis--a review. Br Dent J. 1998;185(9):462-467.
American Society of Plastic and Reconstructive Surgeons (ASPRS). Orthognathic Surgery: Recommended Criteria for Third-Party Payer Coverage. Arlington Heights, IL: ASPRS; September 1997.
Barkate HE. Orthognathic surgery by distraction osteogenesis: A literature review. Dentistry. 1997;17(3):14, 16-18.
Lupori JP, Van Sickels JE, Holmgreen WC. Outpatient orthognathic surgery: Review of 205 cases. J Oral Maxillofac Surg. 1997;55(6):558-563.
Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 1995;10(2):97-107.
Ruhl CM, Bellian KT, Van Meter BH, et al. Diagnosis, complications, and treatment of dentoskeletal malocclusion. Am J Emerg Med. 1994;12(1):98-104.
Sinn DP, Ghali GE. Advances in orthognathic surgery. Curr Opin Dent. 1992;2:38-41.
Hunt OT, Johnston CD, Hepper PG, et al. The psychosocial impact of orthognathic surgery: A systematic review. Am J Orthod Dentofacial Orthop. 2001;120(5):490-497.
Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database Syst Rev. 2003;(1):CD003812.
American Academy of Oral and Maxillofacial Surgeons (AAOMS). Criteria for orthognathic surgery. Reimbursement and Appeal Resources. Health Policy and Third Party Payor Relations Resources. Rosemont, IL: AAOMS; 2002. Available at: http://www.aaoms.org/allied/allied_template.asp?content_type_id=126&entity_id=122. Accessed April 15, 2003.
Tulloch JF, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. Am J Orthod Dentofacial Orthop. 2004;125(6):657-667.
Van Lierde KM, Schepers S, Timmermans L, et al. The impact of mandibular advancement on articulation, resonance and voice characteristics in Flemish speaking adults: A pilot study. Int J Oral Maxillofac Surg. 2006;35(2):137-144.
Chanchareonsook N, Samman N, Whitehill TL. The effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status: A critical review. Cleft Palate Craniofac J. 2006;43(4):477-487.
Fedorowicz Z, Nasser M, Newton T, Oliver R. Resorbable versus titanium plates for orthognathic surgery. Cochrane Database Syst Rev. 2007;(2):CD006204.
Hassan T, Naini FB, Gill DS. The effects of orthognathic surgery on speech: A review. J Oral Maxillofac Surg. 2007;65(12):2536-2543.
Abrahamsson C, Ekberg E, Henrikson T, Bondemark L. Alterations of temporomandibular disorders before and after orthognathic surgery: A systematic review. Angle Orthod. 2007;77(4):729-734.
Lye KW. Effect of orthognathic surgery on the posterior airway space (PAS). Ann Acad Med Singapore. 2008;37(8):677-682.
Won CH, Li KK, Guilleminault C. Surgical treatment of obstructive sleep apnea: Upper airway and maxillomandibular surgery. Proc Am Thorac Soc. 2008;5(2):193-199.
Costa F, Robiony M, Toro C, et al. Condylar positioning devices for orthognathic surgery: A literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(2):179-190.
Kang SH, Yoo JH, Yi CK. The efficacy of postoperative prophylactic antibiotics in orthognathic surgery: A prospective study in Le Fort I osteotomy and bilateral intraoral vertical ramus osteotomy. Yonsei Med J. 2009;50(1):55-59.
Danda AK, Wahab A, Narayanan V, Siddareddi A. Single-dose versus single-day antibiotic prophylaxis for orthognathic surgery: A prospective, randomized, double-blind clinical study. J Oral Maxillofac Surg. 2010;68(2):344-346.
Dan AE, Thygesen TH, Pinholt EM. Corticosteroid administration in oral and orthognathic surgery: A systematic review of the literature and meta-analysis. J Oral Maxillofac Surg. 2010;68(9):2207-2220.
Garg M, Cascarini L, Coombes DM, et al. Multicentre study of operating time and inpatient stay for orthognathic surgery. Br J Oral Maxillofac Surg. 2010;48(5):360-363.
Lindenmeyer A, Sutcliffe P, Eghtessad M, et al. Oral and maxillofacial surgery and chronic painful temporomandibular disorders -- a systematic review. J Oral Maxillofac Surg. 2010;68(11):2755-2764.
Luther F, Layton S, McDonald F. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev. 2010;(7):CD006541.
Pineiro-Aguilar A, Somoza-Martín M, Gandara-Rey JM, Garcia-Garcia A. Blood loss in orthognathic surgery: A systematic review. J Oral Maxillofac Surg. 2011;69(3):885-892.
Danda AK, Ravi P. Effectiveness of postoperative antibiotics in orthognathic surgery: A meta-analysis. J Oral Maxillofac Surg. 2011;69(10):2650-2656.
Mattos CT, Vilani GN, Sant'Anna EF, et al. Effects of orthognathic surgery on oropharyngeal airway: A meta-analysis. Int J Oral Maxillofac Surg. 2011;40(12):1347-1356.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.