Clinical Policy: Orthognathic Surgery Reference Number: CP.MP.109

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1 Clinical Policy: Orthognathic Surgery Reference Number: CP.MP.109 Effective Date: 02/04 Last Review Date: 03/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description Orthognathic surgery is also referred to as jaw surgery, dentofacial skeletal surgery, craniofacial surgery and facial orthopedic surgery, (e.g., reconstruction of the mandibular ramus, mandibular osteotomy, maxilla osteotomy, reconstruction of the mandible/maxilla). Policy/Criteria I. It is the policy of Health Net of California that orthognathic surgery is medically necessary for the following indications: A. For correction of facial skeletal deformities that contribute to significant dysfunction, and where the severity of the deformities precludes adequate treatment through dental therapeutics and orthodontics alone for functional improvement B. Maxillary and/or mandibular facial skeletal deformities associated with significant malocclusion and/or masticatory dysfunction that contributes to difficulties in swallowing and/or choking, significant intraoral trauma while chewing and/or the ability to chew only soft or liquid foods when all of the following are met: 1. Symptoms must be documented in the medical records, must be significant, and must persist for at least 4 months (episodes witnessed at home, school, or work should be documented in the medical record.); and 2. Other causes of swallowing/choking problems have been ruled out, by history, physical, and/or other appropriate diagnostic studies, including: a. Allergies, post nasal drip (diagnostic studies, therapeutic trial of antihistamine and/or decongestant) b. Neurologic or metabolic diseases c. Hypothyroidism if enlarged tongue present on clinical exam 3. Significant facial skeletal deformities based on cephalometric analysis (i.e., quantitative measurements based on key anatomic landmarks) as follows: a. Anteroposterior discrepancies when any of the following is met: i. Maxillary/mandibular incisor relationship: overjet * of 5 millimeter (mm) or more, or a 0 to a negative value (normal is 2 mm); or ii. Maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more (normal is 0 to 1 mm) ** * Note: Overjet bite characterized by a protrusive excursive movement front to back motion recalcitrant to control. Overjet of up to 5mm may be treatable with routine orthodontic therapy. Page 1 of 12

2 ** Note: These values represent mandibular and maxillary relationships that vary by more than two standard deviations from published norms on cephalometric analysis. b. Vertical facial skeletal deformity when any of the following is met: i. Presence of a vertical skeletal discrepancy which is more than 2 standard deviations from published norms for accepted skeletal landmarks ii. Open Bite: a) No vertical overlap of anterior teeth b) Unilateral or bilateral posterior open bite greater than 2 mm iii. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch iv. Supra-eruption of a dentoalveolar segment due to lack of opposing occlusion creating dysfunction not amenable to conventional prosthetics. c. Transverse discrepancies when any of the following is met: i. Presence of a transverse skeletal discrepancy which is more than two standard deviations from published norms for accepted ii. skeletal landmarks 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. d. Asymmetries: i. Anteroposterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry. Note: One oral splint or appliance is covered for orthognathic surgery. All other appliances/splints are considered incidental to the final splint. C. For restoration of function following significant accidental injury, infection or tumor. D. For correction of obstructive sleep apnea (OSA) when all of the following criteria are met: 1. Patient has clinically significant OSA due to type II obstruction (oropharynx/ hypopharynx, palate) and/or type III obstruction (hypopharynx, base of the tongue) confirmed by fiberoptic pharyngoscopy and cephalometric radiographs with tracing; and Note: If OSA is due to type I obstruction (oropharynx), the obstruction has been treated unsuccessfully by uvulopalatopharyngoplasty (UPPP). Individuals with type I obstruction (soft palate) should receive uvulopalato-pharyngoplasty (UPPP). OSA caused by hypopharyngeal obstruction can be corrected by advancement of the mandible and hyoid bone, which results in advancement of pharyngeal muscles and the base of tongue resulting in expansion of the airway. Mandibular osteotomy/ genioglossus advancement with hyoid myotomy/suspension (GAHM) is usually Page 2 of 12

3 performed first and, if 6 month follow-up polysomnogram demonstrates unsuccessful surgery maxillary and mandibular advancement osteotomy (MMO) is usually offered. 2. A full polysomnogram has been performed and documented results confirm a diagnosis of OSA and support the need for treatment; and 3. The individual has not responded to or not tolerated nasal continuous positive airway pressure (ncpap); and 4. A presurgical physical evaluation is performed and supports the need for orthognathic surgery. E. For correction of structural abnormalities of the jaws secondary to congenital anomalies, such as: 1. Le Fort III and orbital osteotomy procedures for mid-face hypoplasia (i.e., Crouzon syndrome, Apert syndrome, Pfeiffer syndrome, cleft deformity, etc.) which have resulted in any of the following: a. Disorders of the eyes (eye muscle dysfunction, corneal exposure/corneal ulceration, globe herniation, visual acuity loss); or b. Respiratory problems (nasal airway obstruction, sleep apnea); or c. Unintelligible speech noticeable to lay person or primary care physician and significantly impairs the patient s ability to communicate and the speech deficit is not amenable to speech therapy. 2. Mandibular intraoral vertical ramus osteotomy, bilateral sagittal split ramus osteotomy, mandibular osteotomy for congenital micrognathia resulting in respiratory obstruction (i.e., Pierre Robin syndrome) or maxillary deficiency associated with cleft deformities. Note: Le Fort I for congenital disorders should be referred for individual consideration. F. Malnutrition related to an inability to masticate properly when both of the following are met: 1. Patient has had a significant weight loss for greater than 4 months; and 2. Patient has low serum albumin related to malnutrition II. It is the policy of Health Net of California that the following are considered not medically necessary: A. Orthognathic surgeries for the improvement of an individual's facial structure in the absence of significant malocclusion correction, whether or not these are associated with psychological disorders, because they are considered purely cosmetic in nature. B. Orthognathic surgeries to reshape or enhance the size of the chin to restore facial harmony and chin projection (e.g., mentoplasty, genioplasty, chin augmentation, mandibular osteotomies, ostectomies, chin implant) to address genial hypoplasia, hypertrophy, or asymmetry when performed either as an isolated procedure or with other surgical procedures because they are considered purely cosmetic in nature. Page 3 of 12

4 C. Orthognathic surgeries for the treatment of temporomandibular joint (TMJ) disorders or myofascial pain dysfunction due to a lack of a cause-and-effect relationship between malocclusion and TMJ dysfunction in the scientific literature. D. Other orthognathic surgeries for correction of articulation disorders and other impairments in the production of speech because there is inadequate scientific evidence published in the peer-reviewed medical literature validating the effectiveness of this indication. E. Orthognathic surgery for correction of distortions within the sibiliant sound class or for other distortions of speech quality (e.g., hypernasal or hyponasal speech). III. The Oral and Maxillofacial Surgeon must obtain precertification and include the following documentation: A. A written explanation of the member's clinical course, including dates and nature of any previous treatment; and B. Physical evidence of a skeletal, facial or craniofacial deformity defined by study models, photographs, orthodontic measurements and pre-orthodontic imaging / radiologic study reports; and C. A detailed description of the functional impairment considered to be the direct result of the skeletal abnormality. Background Orthognathic surgery refers to the surgical repositioning of the maxilla, mandible, and the dentoalveolar segments to achieve facial and occlusal balance when the severity of orofacial deformities are such that they cannot be treated through orthodontic treatment alone. While orthodontics alone can correct many bite problems if only the teeth are involved, orthognathic surgery may be required if the jaws also need repositioning. Malocclusion caused by abnormal jaw relation may be caused by a deficiency or excess of bony tissue in one or both jaws. The underlying abnormality may be congenital or may become evident as an individual grows and develops. Jaw growth is a gradual process, and in some instances, the upper and lower jaws may grow at different rates that can result in difficulties biting, chewing, speaking, swallowing, breathing problems and long-term oral health. Traumatic events in the mature skeleton can displace the normal elements and require repositioning osteotomies if improperly reduced initially. Traumatic events in the developing facial skeleton can disturb normal subsequent growth. Oral-facial clefts of the soft and/or hard palate due to faulty fusion may cause problems with feeding, ear infections, hearing loss and speech and language development, as well as dental problems. Other etiologies that can result in significant dentofacial abnormalities include neoplastic growth, surgical resection, and iatrogenic radiation. Maxillofacial deformities can be divided broadly into 3 major categories: (1) dental dysplasias, (2) skeletal dysplasias, and (3) dentoskeletal dysplasias. Dental dysplasias are limited strictly to malocclusions that result from abnormal spatial relationship of the dentition and not from the skeletal position of the upper and lower jaws. These can be corrected with orthodontic treatment. In patients with skeletal dysplasia only, the dentition is in good alignment, but the maxilla and/or mandible are dysplastic. Skeletal dysplasias require correcting the skeletal deformity without Page 4 of 12

5 altering the occlusion. In dentoskeletal dysplasias, the dentition is malpositioned within each arch and with each other; additionally, the skeletal relationship of the upper and lower jaws is abnormal. Correction requires aligning the dentition within each arch with orthodontic treatment and restoring the maxillary-mandibular dental relationship with skeletal osteotomies and repositioning. Diagnosis is based on a comprehensive assessment that includes clinical examination, skeletal evaluation with standardized radiographs, and dental evaluation with study dental casts addressed as an integral part of the workup. Clinical assessment should be directed specifically at evaluating the relative position and size of each of the facial skeletal elements, the degree of zygomatic projection, and the maxillary and mandibular positions in space relative to each other and to the cranial-orbital region. The nasolabial angle, upper lip length, lip competency, labialmental sulcus, and cervicomental angle should be documented. Any facial asymmetry should be noted along with the relationship of the maxillary dental mid line to the mandibular dental mid line and the dental mid lines to the facial mid line. The intraoral examination should focus on the dental alignment within each arch and relationship of the dental arches to each other. The degree of dental display on repose and smile also should be recorded with the amount of gingival display. 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. Mandibular surgical advancement is necessitated most commonly by mandibular retrognathia (state of the mandible being located posterior to the normal position) or by mandibular prognathism (abnormal protrusion of the mandible). Sagittal split ramal osteotomy remains the most versatile and commonly performed procedure to restore facial skeletal balance and occlusal (pertaining to the contacting surfaces of the opposing teeth) harmony. In extreme cases of mandibular prognathism, some surgeons prefer the intraoral vertical osteotomy or the inverted L osteotomy. In situations of mandibular advancement in which the mandibular rami is hypoplastic and cannot be sagittally split, the inverted L and the C osteotomy with bone grafts are preferred. Following any significant surgical movement of the mandible, fixation may be accomplished with miniplates 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. Nutritionally balanced, blenderized diets are important for proper healing in the patient in IMF. Deformities of the maxilla, maxillary retrognathia (hypoplasia) with or without apertognathia (open bite) or maxillary protrusion (hyperplasia) and vertical deficiency or excess, may be corrected by LeFort I and segmental osteotomies. Most maxillofacial deformities can be managed with 3 basic osteotomies: the mid face with the LeFort I-type osteotomy, the lower face with the sagittal split ramal osteotomy of the mandible, and the horizontal osteotomy of the symphysis of the chin. The LeFort I osteotomy allows for correction primarily at the occlusal level affecting the upper lip position, nasal tip and alar base region, and the columella labial angle without altering the orbitozygomatic region. The elements of the facial skeleton can be Page 5 of 12

6 repositioned, redefining the face through a variety of well-established osteotomies, including LeFort I-type osteotomy, LeFort II-type osteotomy, LeFort III-type osteotomy, maxillary segmental osteotomies, sagittal split osteotomy of the mandibular ramus, vertical ramal osteotomy, inverted L and C osteotomies, mandibular body segmental osteotomies, and mandibular symphysis osteotomies. The LeFort II and III osteotomies generally are part of the treatment plan in the major craniofacial dysotosis syndromes. A cleft palate occurs in early pregnancy when separate areas of the face have developed individually do not join together properly. Specific syndromes associated with cleft lip/palate include Apert syndrome, Crouzon syndrome, DiGeorge syndrome and Pierre Robin syndrome. A cleft palate can range from just an opening at the back of the soft palate to a nearly complete separation of the roof of the mouth. Repair may be indicated in severe cases and is usually performed when the child is about 12 months old, before learning to talk. In general, the surgeon will make an incision on both sides of the separation and move tissue from each side of the cleft to the center or midline of the roof of the mouth. This procedure rebuilds the palate, joining muscle together and providing enough length in the palate so the child can eat and learn to speak properly. While cleft palate surgery involves only a small part of the mouth in some children, in others it involves a larger area from the front to the back of the mouth. In any case this surgery is usually more extensive than cleft lip surgery. Clefts involving the gum line may require an operation to place an alveolar bone graft. This facilitates proper growth of the permanent teeth. Depending on how fast they are developing, alveolar bone grafts may be done between the ages of 6 and 10 years. If the jaws are poorly aligned, surgery can also be performed to align the bite.. Two orthognathic procedures have been used to correct obstructive sleep apnea caused by hypopharyngeal obstruction: (1) the conservative procedure of mandibular osteotomy/ genioglossus advancement with hyoid myotomy/suspension (GAHM) and the more aggressive procedure maxillary and mandibular advancement osteotomy (MMO). The surgical concept is to advance the mandible and hyoid bone, which results in advancement of pharyngeal muscles and the base of tongue resulting in expansion of the airway. The National Institutes of Health in a technology statement cited that one of the significant problems with temporomandibular disease (TMD) treatment is that the disease is classified primarily on signs and symptoms rather than etiology. There is no consensus in the practicing community regarding TMD problems and when or how they should be treated. The efficacy of current treatments has not been adequately studied in clinical trials. The superiority of surgery or other methods as compared to placebo controls or no treatment controls remains undetermined. Coding Implications This clinical policy references Current Procedural Terminology (CPT ). CPT is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2015, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Page 6 of 12

7 Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT Codes Description Genioplasty Augmentation, mandibular body or angle; prosthetic material LeForte I procedures LeForte II procedures Le Forte III procedures Mandibular ramus osteotomy (Horizontal, Vertical, C or L) procedures Mandibular sagittal split osteotomyprocedures Mandibular segmental osteotomy Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) Osteoplasty (facial bones) Graft, bone; nasal, maxillary or malar areas (include obtaining graft) Cephalogram (cephalometric radiograph) Orthopantogram (panorex) HCPCS Description Codes D7940 Osteoplasty for orthognathic deformities D7944 Osteotomy segmented or subapical per sextant or quadrant 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 ICD-10-CM Diagnosis Codes that Support Coverage Criteria ICD-10-CM Description Code E22.Ø Acromegaly and pituitary gigantism D56- D56.9 Thalassemia G47.3Ø Sleep Apnea, unspecified G51.9 Facial nerve disorders K00- K00.9 Disorders of tooth development and eruption M26- M26.9 Dentofacial anomalies (including malocclusion) M27- M27.9 Other diseases of jaw Page 7 of 12

8 ICD-10-CM Description Code M85.2 Hyperostosis of skull M89.38 Hypertrophy of bone, other site M89.8X8 Other specified disorders of bone, other site M95.2 Other acquired deformity of head Q18-Q18.9 Other congenital malformations of face and neck Q67.Ø Congenital facial asymmetry Q67.1 Congenital compression facies Q67.2 Dolichocephaly Q67.3 Plagiocephaly Q67.4 Other congenital deformities of skull, face and jaw Q75.Ø Craniosynostosis Q75.2 Hypertelorism Q75.9 Congenital malformation of skull and face bones, unspecified Q77.4 Achondroplasia Q77.6 Chondroectodermal dysplasia Q78.Ø Osteogenesis imperfecta Q78.2 Osteopetrosis Q Neurofibromatosis (nonmalignant) Q87.Ø Congenital malformation syndromes predominantly affecting facial appearance Q87.4Ø Marfan's syndrome, unspecified Q98.4 Klinefelter syndrome, unspecified Q99.8 Other specified chromosome abnormalities Reviews, Revisions, and Approvals Date Approval Date Initial Review 2/04 2/04 Update no changes 4/06 4/06 Removed modified condylotomy from #3 listed under not medically 1/08 1/08 necessary as this procedure is not considered orthognathic surgery. Added revision that some states may require coverage of dental and 3/10 3/10 orthodontic services under the medical benefit if considered an integral part of reconstructive surgery Added reference to the Health Net Cleft Palate and Other Craniofacial 3/11 3/11 Disorders Policy Added reference to Oregon (ORS ) mandates for dates or service 3/12 3/12 after Jan 2013 Update no revisions 3/ Transferred to new template 3/17 3/17 Page 8 of 12

9 References 1. Hayes. Search & Summary. Le Fort 1 Maxillary Osteotomy for Maxillary Retrognathia. February 13, Archived Mar Fariña R, Valladares S, Torrealba R, et al. Orthognathic Surgery in Craniofacial Microsomia: Treatment Algorithm. Plastic and Reconstructive Surgery. January Volume 3. Issue 1. p e Hammoudeh JA, Howell LK, Boutros S, et al. Current Status of Surgical Planning for Orthognathic Surgery: Traditional Methods versus 3D Surgical Planning. Plast Reconstr Surg Glob Open Feb; 3(2): e Mar Hwi-Dong Jung, Kim SY, Hyung-Sik Park, et al. Orthognathic surgery and temporomandibular joint symptoms. Maxillofacial Plastic and Reconstructive Surgery. April 22, Buchanan EP, Hollier LH. Syndromes with craniofacial abnormalities. UpToDate. October 21, Updated December 18, Al-Nawas B, Kämmerer PW, Hoffmann C, et al. Influence of osteotomy procedure and surgical experience on early complications after orthognathic surgery in the mandible. J Craniomaxillofac Surg Nov Antonarakis GS, Watts G, Daskalogiannakis J. The Need for Orthognathic Surgery in Nonsyndromic Patients With Repaired Isolated Cleft Palate. Cleft Palate Craniofac J Jan Ronchi P, Cinquini V, Ambrosoli A, Caprioglio A. Maxillomandibular Advancement in Obstructive Sleep Apnea Syndrome Patients: a Restrospective Study on the Sagittal Cephalometric Variables. J Oral Maxillofac Res Jul 1;4(2):e5. ecollection Saman M, Abramowitz JM, Buchbinder D. Mandibular osteotomies and distraction osteogenesis: evolution and current advances. JAMA Facial Plast Surg May;15(3): Silva AC, Carvalho RA, Santos TS, et al. Evaluation of life quality of patients submitted to orthognathic surgery. Dental Press J Orthod Sept-Oct;18(5): Kucukkeles N, Nevzatoglu S, Koldas T. Rapid maxillary expansion compared to surgery for assistance in maxillary face mask protraction. The Angle orthodontist. 81 (1) (pp 42-49), Richardson S, Agni NA, Selvaraj D. Anterior maxillary distraction using a tooth-borne device for hypoplastic cleft maxillas - A pilot study. Journal of Oral and Maxillofacial Surgery. 69 (12) (pp e542-e548), Ueki K, Miyazaki M, Okabe K, et al. Assessment of bone healing after Le Fort I osteotomy with 3-dimensional. Journal of Cranio-Maxillofacial Surgery. 39 (4) (pp ), Iorio ML, Masden D, Blake CA, Baker SB. Presurgical planning and time efficiency in orthognathic surgery: the use of computer-assisted surgical simulation. Plast Reconstr Surg Sep;128(3):179e-181e. 15. Lopez PE, Guerrero CA, Mujica EV. Mandibular basal osteotomy: new designs and fixation techniques. J Oral Maxillofac Surg Mar;69(3): Page 9 of 12

10 16. American Society of Temporomandibular Joint Surgeons. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures. Available at: Hall HD, Indresano AT, Kirk WS, Dietrich MS. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg Aug;63(8): Baker B, Gibbons S, Woods M. Intra-alveolar distraction osteogenesis in preparation for dental implant placement combined with orthodontic/orthognathic surgical treatment: a case report. Aust Dent J Mar;48(1): Luther F, Morris DO, Hart C. Orthodontic preparation for orthognathic surgery: how long does it take and why? A retrospective study. Br J Oral Maxillofac Surg Dec;41(6): Naini FB, Hunt NP, Moles DR. The relationship between maxillary length, differential maxillary impaction, and the change in maxillary incisor inclination. Am J Orthod Dentofacial Orthop Nov;124(5): Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan Page 10 of 12

11 retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at for additional information Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 11 of 12

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