MP 7.01.113 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. 28374 Phne (910) 715-8100 Fax (910) 715-8101 FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
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. 28374 Phne (910) 715-8100 Fax (910) 715-8101 FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
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 21110 Applicatin f hal type appliance fr maxillfacial fixatin, includes remval (separate prcedure) 21125 21127 21141 21142 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 21143 pieces, segment mvement in any directin, withut bne graft Recnstructin midface, LeFrt I; single piece, 21145 segment mvement in any directin, requiring bne grafts (includes btaining autgrafts) Recnstructin midface, LeFrt I; tw pieces, segment mvement in any directin, requiring 21146 bne grafts (includes btaining autgrafts) (eg, ungrafted unilateral alvelar cleft) 21147 Recnstructin midface, LeFrt I; three r mre 42 Memrial Drive Suite 1 Pinehurst, N.C. 28374 Phne (910) 715-8100 Fax (910) 715-8101 FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
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 21150 intrusin (eg, Treacher-Cllins Syndrme) Recnstructin midface, LeFrt II; any 21151 directin, requiring bne grafts (includes btaining autgrafts) Recnstructin midface, LeFrt III 21154 (extracranial), any type, requiring bne grafts (includes btaining autgrafts); withut LeFrt I Recnstructin midface, LeFrt III 21155 (extracranial), any type, requiring bne grafts (includes btaining autgrafts); with LeFrt I Recnstructin f mandibular rami, hrizntal, 21193 vertical, C, r L stetmy; withut bne graft Recnstructin f mandibular rami, hrizntal, 21194 vertical, C, r L stetmy; with bne graft (includes btaining graft) Recnstructin f mandibular rami and/r bdy, 21195 sagittal split; withut internal rigid fixatin Recnstructin f mandibular rami and/r bdy, 21196 sagittal split; with internal rigid fixatin 21198 Ostetmy, mandible, segmental; Ostetmy, maxilla, segmental (eg, Wassmund 21206 r Schuchard) Osteplasty, facial bnes; augmentatin 21208 (autgraft, allgraft, r prsthetic implant) 21209 Osteplasty, facial bnes; reductin Graft, bne; nasal, maxillary r malar areas 21210 (includes btaining graft) 21215 Graft, bne; mandible (includes btaining graft) Recnstructin f mandibular cndyle with 21247 bne and cartilage autgrafts (includes btaining grafts) (eg, fr hemifacial micrsmia) ICD-9 Diagnsis 519.9 Unspecified disease f respiratry system 524.00 Unspecified anmaly 524.09 Other specified anmaly 524.10 Unspecified anmaly 524.19 Other specified anmaly 524.20 Unspecified anmaly f dental arch relatinship 524.29 Unspecified anmaly f dental arch relatinship 42 Memrial Drive Suite 1 Pinehurst, N.C. 28374 Phne (910) 715-8100 Fax (910) 715-8101 FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f
524.4 Malcclusin, unspecified 524.59 Other dentfacial functinal abnrmalities 526.89 Other specified diseases f the jaws 748.1 Other anmalies f nse 754.0 Of skull, face, and jaw V41.6 Prblems with swallwing and masticatin Index Orthgnathic 42 Memrial Drive Suite 1 Pinehurst, N.C. 28374 Phne (910) 715-8100 Fax (910) 715-8101 FirstCarlinaCare Insurance Cmpany, Inc. is a whlly-wned subsidiary f