CPT code and Description
21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)
21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)
21121 Genioplasty; sliding osteotomy, single piece
21122 Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin)
21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
21125 Augmentation, mandibular body or angle; prosthetic material
21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft
Description
Orthognathic surgery is the surgical correction of abnormalities of the mandible (lower jaw), the maxilla (upper jaw), or both. When orthognathic surgery is indicated, it is generally after orthodontic treatment (braces), which is done in order to move the teeth into their new position.
During the surgical procedure, the jawbones are repositioned to a more “normal” position; in some cases, bone may be added, removed, or reshaped. Surgical plates, screws, wires and rubber bands may be used to hold the jaws in their new position. The most common technique is known as the LeFort I (though there are variations of this technique that may be performed, depending on the exact indications for the surgery).
Orthognathic surgery is usually performed by both an oral and maxillofacial surgeon and an orthodontist. The orthodontist will work to position the teeth in proper alignment and the oral and maxillofacial surgeon does the surgery as needed on the jaw joints and/or other facial bones.
Coverage Limitations
Humana members may NOTbe eligible under the Plan for orthognathic surgeryfor any indications other than those listed above. This technology is considered experimental/investigational or NOT medically necessary if it is not utilized in accordance with nationally recognized standards of medical practice and/or identified as safe, widely used and generally accepted as effective for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
Humana members may NOTbe eligible under the Plan for 3-D Computerized Tomography (CT) scan, including in the pre-planning phase of treatment. This technology is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language
Criteria for a Coverage Determination as Reconstructive and Medically Necessary:
A requested procedure will be deemed reconstructive and medically necessary and therefore covered when:
1. There is a physical abnormality and/or physiological abnormality that is causing a functional impairment that requires correction;and
2. The proposed treatment is of proven efficacy; and is deemed likely to significantly improve or restore the patient’s physiological function
DOCUMENTATION REQUIREMENTS
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.
Medical notes documenting all of the following:
** Comprehensive history of the medical condition(s) requiring treatment or surgical intervention; including all of the following:
A well-defined physical and/or physiological abnormality (e.g., congenital abnormality, functional or skeletal impairments) resulting in a medical condition that has required or requires treatment; The physical and/or physiological abnormality has resulted in a functional deficit; The functional deficit is recurrent or persistent in nature
** Appropriate clinical studies/tests including cephalometric tracings and analysis addressing the physical and/or physiological abnormality that confirm its presence and the degree to which it is causing impairment, with appropriate measurements, when applicable Radiologic film interpretations including lateral cephalometric radiograph, AP radiograph and panoramic radiograph
** Clinical photographs of the member’s occlusion Diagnostic Polysomnography for obstructive sleep apnea surgery
** Treating physician’s plan of care including surgical treatment objectives, which must include the expected outcome for the improvement of the functional deficit
** History of previous non-surgical and surgical treatment (e.g.,obstructive sleep apnea
DEFINITIONS
The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable definitions.
Cancer Sequela: An aftereffect resulting from a cancer
Functional/Physical Impairment: A Physical/Functional or Physiological Impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.
Jaw Surgery: Surgical procedures to address facial trauma, neoplasms, facial clefts, surgical resection and iatrogenic radiation.
Orthognathic Surgery: The surgical correction of skeletal anomalies or malformations involving the mandible (lower jaw) or maxilla (upper jaw). These malformations may be present at birth or may become evident as the individual grows and develops. Causesinclude congenital or developmental anomalies.
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