This policy addresses medically necessary, reconstructive and cosmetic/not medically necessary procedures involving the mandible, maxilla or both, with the exception of orthognathic surgery for the treatment of temporomandibular disorders.

Note:
Orthognathic surgery for obstructive sleep apnea is addressed in policy MED.00054, Treatment for Obstructive Sleep Apnea in Adults.

Medically Necessary:  In this policy, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment.  Some situations where various procedures are considered medically necessary are described below.

Reconstructive: In this policy, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.    Some situations where various procedures are considered reconstructive are described below.

Cosmetic: In this policy, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation.  Cosmetic services are often described as those which are primarily intended to preserve or improve appearance. Some situations where various procedures are considered cosmetic are described below.

Medically Necessary:

Orthognathic surgery is considered medically necessary to treat a significant physical functional impairment when the procedure can be reasonably expected to improve the physical functional impairment. Significant physical functional impairment includes any of the following:

1. Difficulty swallowing and/or choking, or ability to chew only soft or liquid food;
   • Symptoms must be documented in the medical record, must be significant and must persist for at least 4 months; and
   • Other causes of swallow/choking problems have been ruled out by history, physical exam and/or appropriate diagnostic studies including but not limited to, allergies, neurologic or metabolic disease or hypothyroidism
     OR
2. Speech abnormalities determined by a speech pathologist or therapist to be due to a malocclusion and not helped by orthodontia or at least six months of speech therapy;
   OR
3. Intra-oral trauma while chewing related to malocclusion (e.g., loss of food through the lips during   mastication, causing recurrent damage to the soft tissues of the mouth during mastication);
   OR
4. Masticatory dysfunction/malocclusion as documented by ANY of the following described in A, B, C, D or E:
   
   
   1. Anteroposterior discrepancies of greater than 2 standard deviations of published norms defined as EITHER of the following:
      1. Maxillary/Mandibular incisor relationship; overjet of 5mm or more, or a value less than or equal to zero (norm 2mm). (Note: Overjet up to 5mm may be treatable with routine orthodontic therapy); or
      2. Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm 0 to 1mm)
         OR
         
   2. Vertical discrepancies
      1. Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks
         OR
         
   3. Open bite
      1. No vertical overlap of anterior teeth; or
      2. Unilateral or bilateral posterior open bite greater than 2mm; or
      3. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch; or
      4. Supra-eruption of a dentoalveolar segment due to lack of occlusion
         OR
         
   4. Transverse Discrepancies
      1. Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms; or
      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
         OR
         
   5. Asymmetries
      1. Anteroposterior, transverse or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry
         

In addition to the above, when the condition involves treatment of malocclusion both of the following must be present:

1. Except for Class II malocclusion (mandibular retrognathic), completion of skeletal growth with long bone x-ray or serial cephalometrics showing no change in facial bone relationships over the last three to six month period (Class II malocculusions does not require this documentation); AND
2. Documentation of malocclusion with either intra-oral casts (if applicable) bilateral, lateral x-rays, cephalometric radiograph with measurements, panoramic radiograph or tomograms
   

When the condition involves treatment of skeletal deformity, the deformity must be documented either by CT, MRI, or x-ray.

Reconstructive:

Orthognathic surgery is considered reconstructive when a significant physical functional impairment is not present, but when there is a significant variation in the normal anatomy of the maxilla and mandible.

Note:
Orthognathic surgery for obstructive sleep apnea is addressed in policy MED.00054, Treatment for Obstructive Sleep Apnea in Adults.

This policy does not address orthognathic surgery for temporomandibular disorders.

Cosmetic/Not Medically Necessary:

Procedures intended to change a physical appearance that would be considered within normal human anatomic variation are considered cosmetic/not medically necessary.

A genioplasty (or anterior mandibular osteotomy) not associated with masticatory malocclusion is considered cosmetic/not medically necessary .

Note:
This policy does not apply to orthodontia (braces) services.

There is convincing evidence of the relationship between facial skeletal abnormalities and malocclusions, including Class II, Class III and open bite deformities. A strong correlation has been demonstrated between the state of the patient’s occlusion and his or her chewing efficiency, bite forces and restricted mandibular excursions. Orthognathic surgery has resulted in significant improvement in skeletal deformities that contribute to chewing, breathing and swallowing dysfunction and where the severity of the deformity cannot be corrected through dental therapeutics or orthodontics. The evidence to support this conclusion includes non-randomized controlled trials and case series studies.

Concepts of Medical Necessity, Reconstructive and Cosmetic
The coverage eligibility of medical and surgical therapies to treat musculoskeletal abnormalities is often based on a determination of whether the abnormality is considered medically necessary, reconstructive or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service “returns the patient to whole” as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive definitions, include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy.

Orthognathic surgery is the surgical correction of skeletal anomalies or malformations involving the mandible (lower jaw) or the maxilla (upper jaw). These malformations may be present at birth or they may become evident as the individual grows and develops. The American Association of Oral and Maxillofacial Surgeons classification of occlusion/malocclusion is as follows:

• Class I: A Class I occlusion exists with the teeth in a normal relationship when the mesial-buccal cusp of the maxillary first permanent molar coincides with the buccal groove of the mandibular first molar
  
• Class II: A Class II malocclusion occurs when the mandibular teeth are distal or behind the normal relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw or an excess of the upper jaw, and therefore, presents two types: (1) Division I is when the mandibular arch is behind the upper jaw with a consequential protrusion of the upper front teeth. (2) Division II exists when the mandibular teeth are behind the upper teeth, with a retrusion of the maxillary front teeth. Both of these malocclusions have a tendency toward a deep bite because of the uncontrolled migration of the lower front teeth upwards
  
• Class III: A Class III malocclusion occurs when the lower dental arch is in front of (mesial to) the upper dental arch. People with this type of occlusion usually have a strong or protrusive chin, which can be due to either horizontal mandibular excess or horizontal maxillary deficiency. Commonly referred to as an under bite.
  

Maxillary advancement is a type of orthognathic surgery that may be necessary to improve the facial contour and normalize dental occlusion when there is a relative deficiency of the midface region. This is done by surgically moving the maxilla with sophisticated bone mobilization techniques and fixing it securely into place.

Depending on the soft tissue profile of the face or the severity of an occlusal discrepancy, problems with the lower face may require surgery on the mandible. This can be done in conjunction with or separate from maxillary surgery. The mandible can be advanced, set back, tilted or augmented with bone grafts. A combination of these procedures may be necessary. Following any significant surgical movement of the mandible, fixation may be accomplished with mini-plates and screws or with a combination of interosseous wires and intermaxillary fixation (IMF). Rigid fixation (screws and plates) has the advantage of needing limited or no IMF. However, if interosseous wiring is used, IMF is maintained for approximately six weeks.

Anomaly: deviation from normal

Genioplasty: plastic surgery of the chin

Malformation: abnormal shape or structure

Malocclusion: imperfect contact with the mandibular and maxillary teeth

Mandible: the horseshoe-shaped bone forming the lower jaw

Maxilla: a paired bone that forms the skeletal base of the upper face, roof of the mouth, sides of the nasal cavity and floor of the orbit (contains the eye)

Orthodontics: the division of dentistry dealing with the prevention and correction of abnormally positioned or aligned teeth

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

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