Orthognathic Surgery - Medical Policy Criteria - Regence

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Aug 7th, 2015 - Reviewed/Updated Aug 7th

Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury.

 [1] Note: This policy does not address the surgical management of sleep apnea,

which is addressed in a separate medical policy (see Cross References).

 Click here to read the entire Article/Policy

Article includes medical necessity on the following codes:

CODES  

NUMBER DESCRIPTION

21198 Osteotomy, mandible, segmental;

21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

21209 Osteoplasty, facial bones; reduction

21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

21215Graft, bone; mandible (includes obtaining graft)

21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

CDT

D7940 Osteoplasty –for orthognathic deformities

D7941 Osteotomy; mandibular rami

D7943 Osteotomy; mandibular rami with bone graft; includes obtaining the graft

D7944 Osteotomy; segmented of subapical –per sextant or quadrant

D7945 Osteotomy; body of mandible

D7946 LeFort I (maxilla –total)

D7947 LeFort I (maxilla –segmented)

D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion); without bone graft

D7949 LeFort II or LeFort III; with bone graft

D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones –autogenous or nonautogenous, by report

D7995 Synthetic graft –mandible or facial bones, by report

D7996 Implant –mandible for augmentation purposes (excluding alveolar ridge), by report