by Wyn Staheli
December 28th, 2017
Orthognathic surgery is corrective jaw surgery, which payers classify as either medically necessary or aesthetic (not medically necessary). With most payers, surgery performed to correct functional impairments, after conservative measures have failed, would be considered medically necessary.
Conditions considered medically necessary for this surgery may include:
- Skeletal deformities of the maxilla or mandible causing significant dysfunction of the muscles
that move the jaw and the temporomandibular joints, including: antero-posterior discrepancies, vertical discrepancies, transverse discrepancies, or asymmetries (Q67.0)
- Irritation of buccal or lingual soft tissues from the opposing arch in a patient with a deep overbite
- Skeletal discrepancies associated with sleep apnea, airway defects, and soft tissue discrepancies
- Acute traumatic facial injuries and/or their post surgical sequela
- Benign tumors, malignant tumors, cysts, or their post-surgical sequela
- Congenital anomalies like midface hypoplasia (Q87.0), Pierre Robin Syndrome (Q87.0), Hemifacial microsomia (Q67.4), and Treacher Collins Syndrome (Q75.4)
- Cleft palate (Q35.-), Cleft lip (Q36.-), or both cleft palate with cleft lip (Q37.-)
- Obstructive sleep apnea (G47.33)
- Speech deficits supporting speech impairment (R47.-)
- Supraeruption of a dento-alveolar segment due to lack of opposing occlusion creating dysfunction with failed trial of prosthetics
Note: Always check individual payer policies to identify the specific criteria that must be met for the diagnosis to qualify as medically necessary for orthognathic surgery, as each payer policy may slightly differ from the other.
TIP: Orthognathic surgery for temporomandibular joint pathology, pain, or dysfunction is generally considered experimental/investigational and therefore excluded from coverage. There may be exceptions to this so be sure to verify specific payer policies.