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1 MP Orthgnathic Surgery Medical Plicy Sectin Surgery Issue 12/2013 Original Plicy Date 12/2013 Last Review Status/Date Lcal Plicy created 12/2013 Return t Medical Plicy Index Disclaimer Our medical plicies are designed fr infrmatinal purpses nly and are nt an authrizatin, r an explanatin f benefits, r a cntract. Receipt f benefits is subject t satisfactin f all terms and cnditins f the cverage. Medical technlgy is cnstantly changing, and we reserve the right t review and update ur plicies peridically. Descriptin Orthgnathic surgery refers t the surgical repsitining f the maxilla, mandible and the dentalvelar segments t achieve facial and cclusal balance. One r mre f the jaw(s) can be simultaneusly repsitined t treat varius types f malcclusins and jaw defrmities. Surgical Prcedures In rthgnathic surgery, an stetmy is made in the affected jaw, and the bnes are repsitined in a mre nrmal alignment. The bnes are held in psitin with plates, screws and/r wires. Intermaxillary fixatin, a prcedure in which arch bars are placed in bth jaws, may als be needed t prvide added stability. Simultaneus stetmies may be perfrmed when defrmities must be crrected in bth jaws. Grafts frm the ribs, hip r skull may be perfrmed fr patients with deficient bne tissue; allplastic bne replacement may als be required. Orthgnathic surgery is generally perfrmed under general anesthesia n an inpatient basis. Althugh smetimes perfrmed fr csmetic purpses, rthgnathic surgery is generally cnsidered t be medically necessary when perfrmed t treat a significant abnrmality that is causing significant functinal impairment. Patients with bne r sft tissue deficiency f the face may require distractin stegenesis. In this prcedure, a distractin device is applied t the bne, and a cntrlled fracture is created and gradually separated allwing new bne frmatin in the distracted segments. This allws the facial bne and adjacent sft tissue t elngate. Plicy Orthgnathic surgery is permitted when the fllwing medical necessity criteria are met: Presence f: ANY f the facial skeletal defrmities listed belw in sectin 1 AND ANY f the functinal deficits listed belw in sectin 2 AND NONE f the exclusins listed belw in sectin 3 42 Memrial Drive Suite 1 Pinehurst, N.C Phne (910) Fax (910) FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
2 Plicy Guidelines 1. Facial Skeletal Defrmities anterpsterir discrepancies maxillary/mandibular incisr relatinship: verjet f 5mm r mre, r a 0 t negative value (nrm = 2mm) maxillary/mandibular anterpsterir mlar relatinship discrepancy f 4mm r mre (nrm = 0 t 1mm) vertical discrepancies presence f a vertical facial skeletal defrmity which is tw r mre standard deviatins frm published nrms fr accepted skeletal landmarks pen bite n vertical verlap f anterir teeth greater than 2mm unilateral r bilateral psterir pen bite greater than 2mm deep verbite with impingement r irritatin f buccal r lingual sft tissues f ppsing arch supraeruptin f a dentalvelar segment due t lack f ppsing cclusin creating a dysfunctin nt amenable t cnventinal prsthetics transverse discrepancies presence f a transverse skeletal discrepancy which is tw r mre standard deviatins frm published nrms ttal bilateral maxillary palatial cusp t mandibular fssa discrepancy f 4mm r greater, r a unilateral discrepancy f 3mm r greater, given nrmal axial inclinatin f the psterir teeth asymmetries anterpsterir, transverse r lateral asymmetries greater than 3mm, with cncmitant cclusal asymmetry 2. Functinal Deficits Persistent inability t masticate and swallw fd adequately when ther causes such as neurlgical r metablic diseases have been ruled ut by physical exam and/r apprpriate diagnstic testing malnutritin, significant wight lss, r failure t thrive speech dysfunctin directly related t jaw defrmity, as determined by a speech and language pathlgist 42 Memrial Drive Suite 1 Pinehurst, N.C Phne (910) Fax (910) FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
3 myfacial pain that has persisted fr at least six mnths, despite cnservative treatment, such as physical therapy and splints airway bstructin, such as bstructive sleep apnea, when dcumented by sleep study and when: cnservative treatment, such as cntinuus psitive airway pressure (CPAP) r ral appliance has been attempted cnservative treatment has been unsuccessful despite patient cmpliance 3. Exclusins Orthgnathic surgery is specifically nt cvered when prvided fr: The treatment f temprmandibular jint syndrme r temprmandibular disrders Csmetic purpses r crrectin f unaesthetic facial features Is a direct cntract exclusin Cdes Number Descriptin CPT Applicatin f hal type appliance fr maxillfacial fixatin, includes remval (separate prcedure) Augmentatin, mandibular bdy r angle; prsthetic material Augmentatin, mandibular bdy r angle; with bne graft, nlay r interpsitinal (includes btaining autgraft) Recnstructin midface, LeFrt I; single piece, segment mvement in any directin (eg, fr Lng Face Syndrme), withut bne graft Recnstructin midface, LeFrt I; tw pieces, segment mvement in any directin, withut bne graft Recnstructin midface, LeFrt I; three r mre pieces, segment mvement in any directin, withut bne graft Recnstructin midface, LeFrt I; single piece, segment mvement in any directin, requiring bne grafts (includes btaining autgrafts) Recnstructin midface, LeFrt I; tw pieces, segment mvement in any directin, requiring bne grafts (includes btaining autgrafts) (eg, ungrafted unilateral alvelar cleft) Recnstructin midface, LeFrt I; three r mre 42 Memrial Drive Suite 1 Pinehurst, N.C Phne (910) Fax (910) FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
4 pieces, segment mvement in any directin, requiring bne grafts (includes btaining autgrafts) (eg, ungrafted bilateral alvelar cleft r multiple stetmies) Recnstructin midface, LeFrt II; anterir intrusin (eg, Treacher-Cllins Syndrme) Recnstructin midface, LeFrt II; any directin, requiring bne grafts (includes btaining autgrafts) Recnstructin midface, LeFrt III (extracranial), any type, requiring bne grafts (includes btaining autgrafts); withut LeFrt I Recnstructin midface, LeFrt III (extracranial), any type, requiring bne grafts (includes btaining autgrafts); with LeFrt I Recnstructin f mandibular rami, hrizntal, vertical, C, r L stetmy; withut bne graft Recnstructin f mandibular rami, hrizntal, vertical, C, r L stetmy; with bne graft (includes btaining graft) Recnstructin f mandibular rami and/r bdy, sagittal split; withut internal rigid fixatin Recnstructin f mandibular rami and/r bdy, sagittal split; with internal rigid fixatin Ostetmy, mandible, segmental; Ostetmy, maxilla, segmental (eg, Wassmund r Schuchard) Osteplasty, facial bnes; augmentatin (autgraft, allgraft, r prsthetic implant) Osteplasty, facial bnes; reductin Graft, bne; nasal, maxillary r malar areas (includes btaining graft) Graft, bne; mandible (includes btaining graft) Recnstructin f mandibular cndyle with bne and cartilage autgrafts (includes btaining grafts) (eg, fr hemifacial micrsmia) ICD-9 Diagnsis Unspecified disease f respiratry system Unspecified anmaly Other specified anmaly Unspecified anmaly Other specified anmaly Unspecified anmaly f dental arch relatinship Unspecified anmaly f dental arch relatinship 42 Memrial Drive Suite 1 Pinehurst, N.C Phne (910) Fax (910) FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
5 524.4 Malcclusin, unspecified Other dentfacial functinal abnrmalities Other specified diseases f the jaws Other anmalies f nse Of skull, face, and jaw V41.6 Prblems with swallwing and masticatin Index Orthgnathic 42 Memrial Drive Suite 1 Pinehurst, N.C Phne (910) Fax (910) FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
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