National Medical Policy

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1 National Medical Policy Subject: Policy Number: Orthognathic Surgery NMP109 Effective Date*: February 2004 Updated: March 2015 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other X None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Orthognathic Surgery Mar 15 1

2 VERY IMPORTANT NOTES 1. The Oral and Maxillofacial Surgeon must obtain precertification, providing Health Net, Inc. with a written explanation of the member's clinical course, including dates and nature of any previous treatment; physical evidence of a skeletal, facial or craniofacial deformity defined by study models and pre-orthodontic imaging; and a detailed description of the functional impairment considered to be the direct result of the skeletal abnormality. Please review state specific mandates and the member s Evidence of Coverage /Certificate of Insurance for specific coverage of reconstructive surgery including medical and dental services. Various states (such as California) require dental and orthodontia coverage under the member s medical benefits for craniofacial disorders such as cleft palate conditions when these services are considered an integral part of reconstructive surgery. Effective January 2013, Oregon (ORS ) mandates coverage for dental and orthodontic services to restore function. If this is not applicable, dental or orthodontic treatments are dental in nature and, as such, they are not covered under Health Net s medical plans. For plans that require precertification, orthognathic surgery must be precertified prior to presurgical orthodontic treatment. Failure to precertify the orthognathic surgical request prior to orthodontic care may result in the denial of benefits. Current Policy Statement Health Net, Inc. considers orthognathic surgery, 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) medically necessary for any of the following: A. For correction of facial skeletal deformities when it is documented that the skeletal deformities are contributing to significant dysfunction, and where the severity of the deformities precludes adequate treatment through dental therapeutics and orthodontics alone. Health Net, Inc. considers orthognathic surgical procedures medically necessary when they are related to functional improvement of: 1. 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: 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 Other causes of swallowing/choking problems have been ruled out, by history, physical, and/or other appropriate diagnostic studies, including: Allergies, post nasal drip (diagnostic studies, therapeutic trial of antihistamine and/or decongestant) Neurologic or metabolic diseases Hypothyroidism if enlarged tongue present on clinical exam Orthognathic Surgery Mar 15 2

3 Cephalometric analysis (i.e., quantitative measurements based on key anatomic landmarks) that verify significant facial skeletal deformities are as follows: Anteroposterior discrepancies when any of the following is met: a. Maxillary/mandibular incisor relationship: overjet * of 5 millimeter (mm) or more, or a 0 to a negative value (normal is 2 mm); or b. 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. ** Note: These values represent mandibular and maxillary relationships that vary by more than two standard deviations from published norms on cephalometric analysis. Vertical facial skeletal deformity when any of the following is met: a. Presence of a vertical skeletal discrepancy which is more than 2 standard deviations from published norms for accepted skeletal landmarks b. Open Bite: No vertical overlap of anterior teeth Unilateral or bilateral posterior open bite greater than 2 mm c. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch d. Supra-eruption of a dentoalveolar segment due to lack of opposing occlusion creating dysfunction not amenable to conventional prosthetics. Transverse discrepancies when any of the following is met: a. Presence of a transverse skeletal discrepancy which is more than two standard deviations from published norms for accepted skeletal landmarks b. 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. Asymmetries: a. 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. Orthognathic Surgery Mar 15 3

4 B. Restoration of function following significant accidental injury, infection or tumor. C. 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). 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. Note: 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 performed first and, if 6 month follow-up polysomnogram demonstrates unsuccessful surgery maxillary and mandibular advancement osteotomy (MMO) is usually offered. D. 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: Disorders of the eyes (eye muscle dysfunction, corneal exposure/corneal ulceration, globe herniation, visual acuity loss); or Respiratory problems (nasal airway obstruction, sleep apnea); or 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. Orthognathic Surgery Mar 15 4

5 E. 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 Documentation Requirements The Oral and Maxillofacial Surgeon must obtain precertification, providing us with all of the following: 1. A written explanation of the member's clinical course, including dates and nature of any previous treatment; and 2. Physical evidence of a skeletal, facial or craniofacial deformity defined by study models, photographs, orthodontic measurements and pre-orthodontic imaging / radiologic study reports; and 3. A detailed description of the functional impairment considered to be the direct result of the skeletal abnormality. Health Net, Inc. considers any of the following orthognathic procedures not medically necessary: 1. 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. 2. 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. 3. 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. 4. 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. 5. Orthognathic surgery for correction of distortions within the sibiliant sound class or for other distortions of speech quality (e.g., hypernasal or hyponasal speech). Note: While cosmetic improvement will typically occur with any orthognathic surgery, the primary intent and basis must be directed at achieving significant functional improvement in order to be eligible for coverage. Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or non- Orthognathic Surgery Mar 15 5

6 covered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2015 implementation date. ICD-9 Codes Neurofibromatosis/Von Recklinghausen s disease Acromegaly Thalassemia Mobius syndrome Amelogenesis imperfecta 524 Dentofacial anomalies Unspecified anomaly of jaw size Maxillary hyperplasia Mandibular hyperplasia Maxillary hypoplasia (Pfeiffer syndrome) Mandibular hypoplasia (Goldenhar syndrome/hemifacial Microsomia; Hallermann-Streiff syndrome; Robin Complex/Pierre-Robin syndrome) Macrogenia Microgenia Other specified anomaly of jaw size Anomalies of relationship of jaw to cranial base Unspecified anomaly of relationship of jaw to cranial base Maxillary asymmetry Other jaw asymmetry Other specified anomaly Anomalies of dental arch relationship Dentofacial anomalies, including malocclusion; Malocclusion, unspecified Dentofacial anomalies, including malocclusion; Dentofacial functional abnormalities: Abnormal jaw closure; Malocclusion due to: abnormal swallowing, mouth breathing, tongue, lip or finger habits Dentoalveolar anomalies Unspecified alveolar anomaly Alveolar maxillary hyperplasia Alveolar hyperplasia Alveolar maxillary hypoplasia Alveolar mandibular hypoplasia Other specified alveolar anomaly Unilateral condylar hyperplasia or hypoplasia of mandible Other acquired deformity of the head Unspecified acquired deformity of head Zygomatic hyperplasia Zygomatic hypoplasia (Treacher-Collins syndrome/mandibulofacial Dysostosis) Other specified acquired deformity of head Stewart-Morel syndrome Malunion of fracture Orthognathic Surgery Mar 15 6

7 Nonunion of fracture Other acquired deformity of the head Unspecified acquired deformity of head Zygomatic hyperplasia Zygomatic hypoplasia (Treacher-Collins syndrome/mandibulofacial Dysostosis) Other specified acquired deformity of head Congenital anomalies of ear, face, and neck; Unspecified anomalies of face and neck; Congenital: anomaly NOS, deformity NOS; of face (any part) or neck (any part) Congenital anomalies of respiratory system; Other anomalies of nose, Absent nose, Accessory nose, Cleft nose, Congenital: deformity of nose, Congenital: notching of tip of nose, Congenital: perforation of wall of nasal sinus, Deformity of wall of nasal sinus Hemifacial atrophy or hemifacial hypertrophy Apert s syndrome/acrocephalosyndactyly Cleidocranial Dysplasia/Cleidocranial Dysotosis Ehlers-Danlos syndrome Crouzon s syndrome/craniofacial Synostosis Achondroplasia Osteogenesis Imperfecta Osteopetrosis/Albers-Schonberg s disease Chondroectodermal Dysplasia/Ellis-Van Creveld syndrome Klinefelter syndrome Gorlin syndrome/basal Cell Nevus syndrome Marfan syndrome Hypersomnia with sleep apnea ICD-10 Codes E22.Ø Acromegaly and pituitary gigantism D56- D56.9 Thalassemia G47.3Ø Sleep apnea, unspecified 51- 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 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 Orthognathic Surgery Mar 15 7

8 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 Q85.0- Q85.09 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 CPT Codes Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, two or more osteotomies (e.g., Wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) Augmentation, mandibular body or angle; prosthetic material Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft LeForte I maxillary osteotomy; single piece (Code deleted) Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) Reconstruction midface, LeFortII; any direction, requiring bone grafts (includes obtaining autografts) Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I Mandibular ramus osteotomy (Horizontal, Vertical, C or L); without graft: right; left Mandibular ramus osteotomy (Horizontal, Vertical, C or L); with graft: right; left Mandibular sagittal split osteotomy; without rigid fixation: right; left Orthognathic Surgery Mar 15 8

9 21196 Mandibular sagittal split osteotomy; with rigid fixation: right; left Mandibular segmental osteotomy: Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) Osteoplasty (facial bones); augmentation Osteoplasty (facial bones); reduction Graft, bone; nasal, maxillary or malar areas (include obtaining graft) Cephalogram (cephalometric radiograph) Orthopantogram (panorex) Unlisted ultrasound procedure (image obtained by ultrasound) Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services (Code revised in 2013) HCPCS 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 Scientific Rationale Update January 2008 A modified condylotomy is a surgical procedure that may be utilized for select patients with persistent significant pain and dysfunction associated with internal derangement and/or osteoarthritis of the temporomandibular joint unresponsive to non-surgical therapy. Unlike orthognathic surgery, which is performed to correct malocclusion, a modified condylotomy helps to reduce pain and locking symptoms by creating an increase in the space within the temporomandibular joint thereby allowing for passive repositioning of the disc. The principle goal of this procedure is to allow pain free and unrestricted mandibular range of motion. Scientific Rationale The number of individuals with developmental dentofacial deformities in the United States who may benefit from orthognathic surgery is estimated at million. People who can benefit from orthognathic surgery include those with an improper bite or jaws that are positioned incorrectly. 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 Orthognathic Surgery Mar 15 9

10 instances, the upper and lower jaws may grow at different rates. The result can be a host of problems that can affect 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. However, of all the etiologies, developmental anomalies is by far the most common and extremes of population norms are the most common findings requiring orthognathic surgery. 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 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. In addition, dentoskeletal dysplasias can be classified further based on the position in space and on the volume or mass (whether deficient or in excess) of the individual elements. 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, labial-mental 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. Clinical frontal and profile photographs are essential for documentation and allow for photometric analysis. Skeletal evaluation typically includes radiographic evaluation with ortho Panorex and cephalometric x-rays. Ortho Panorex x-rays provide an overview of the stage of dental development, the mandibular anatomy, and gross pathology. Specific films such as occlusal and periapical views can be obtained to further assess the dentition, supporting bone, and interdental spaces. Cephalometric x-rays provide for standardized skull and/or facial views that allow for comparison over time to assess growth in an individual and for comparison of that individual against standardized population norms. Lateral cephalometric x-ray allows for assessment of the elements of the dentofacial skeleton from a sagittal perspective. The maxilla can be related to the mandible and each related to their position in the Orthognathic Surgery Mar 15 10

11 skull base. Simultaneously, the soft-tissue profile can be related to the facial skeleton. In addition, the dentition can be related to each other, and each can be related to its own skeletal base, the maxilla, and the mandible. Frontal cephalometric x-ray allows for assessment of the degree of facial asymmetry. Quantitative measurements based on key anatomic landmarks (cephalometric analysis) are also essential for the surgeon to construct a workable plan for repositioning of the skeletal elements. Using modern computer techniques and three dimensional models, the craniofacial surgeon can precisely plan how the surgery will be approached. Examples of conditions for which this surgery is used are mandibular prognathism, crossbite, open bite, overbite, underbite, mandibular deformity, and maxillary deformity. Prognathism is a protrusion of the mandible due to misalignment of teeth caused by malformations of the shape of the bones of the face; overjet is the horizontal distance between the incisal edges of the maxillary incisor to the mandibular incisor; overbite is the vertical distance between the incisal edge of the maxillary incisor and the mandibular incisor; crossbite is lingual-buccal malposition of the normal relationship between the upper and lower dentition (negative overjet); deep bite refers to excessive overbite; and open bite refers to a negative overbite (teeth do not meet). The following surgical procedures would be considered orthognathic surgery: reconstruction of the mandibular ramus, mandibular osteotomy, maxilla osteotomy, and reconstruction of the mandible/maxilla, which are related to function. Surgical movement of maxilla and mandible inherently alter the maxillarymandibular dental occlusion, and as such, careful analysis of the dental models with the orthodontist is essential. The maxillary dental and mandibular dental casts can be studied individually and hand manipulated with each other to assess how the arches are coordinated. Assessment of the models includes space analysis and arch length, transverse width discrepancies, position of the individual tooth within its own arch, and the relationship of the maxillary dentition to the mandibular dentition. There are a multitude of procedures available to correct these developmental or genetic disharmonies. Usually, pre-surgical orthodontics are necessary to straighten the teeth and align the arches so that a stable occlusion can be obtained postoperatively, while orthodontics following surgery are frequently required to revise minor occlusal discrepancies. Orthognathic surgery usually involves the maxilla and/or mandible, but other bony components may be involved as well. The patient may also need arch bars placed on both jaws to add stability, a procedure called intermaxillary fixation. Patients with deficient bone tissue may also require grafts from their ribs, hips or skull. Alloplastic replacement of missing bone may also be required. The elements of the facial skeleton can be repositioned, redefining the face through a variety of well-established osteotomies, including LeFort I-type osteotomy, LeFort IItype 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. 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 Orthognathic Surgery Mar 15 11

12 position, nasal tip and alar base region, and the columella labial angle without altering the orbitozygomatic region. 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. In addition to these abnormalities, there may be evidence of functional disorders such as respiratory problems (sleep apnea, airway obstruction), masticatory (chewing) and/or swallowing abnormalities, speech pathology, dental and or periodontal pathology, myofacial pain, and psychosocial impairment. Maxillary advancement may be necessary to normalize dental occlusion when there is a relative deficiency of the midface region. This is done by surgically moving the maxilla with sophisticated bone mobilization techniques and fixing it securely into place. For most patients, the use of screws and miniplates have replaced wiring of the bone and teeth required to hold the jaw stable. Inlay bone grafts can be utilized for space maintenance and secured with screw and plate fixation, while onlay bone grafting is used to augment the bony skeleton and improve facial soft tissue contour. 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. The chin can be augmented with alloplastic materials such as silicone, polyethylene or hydroxyapatite. However, most craniofacial surgeons prefer a sliding horizontal osteotomy genioplasty, which is a far more versatile procedure. The chin can be repositioned in multiple planes, allowing for correction of significant sagittal and vertical deformities of deficiency (microgenia) or excess (macrogenia) and asymmetric conditions. This procedure is purely cosmetic in nature as it tends to achieve facial harmony and give a more natural contour to the chin. Moreover, it avoids the risk of extrusion that goes along with alloplastic implants. Genioplasty is either performed as an isolated procedure or in conjunction with other orthognathic surgical procedures. Patients with deficient bone or soft tissues of the face may require distraction osteogenesis. Distraction osteogenesis involves the lengthening and reshaping of deformed bone by surgical fracture and gradual separation (distraction) of bony Orthognathic Surgery Mar 15 12

13 segments. A distraction device is applied. Bone osteotomies are performed. The bony fragments are held in place during the first week following surgical fracture to allow callus to form between the fragments. The distraction device is then used to slowly separate the bony fragments at a rate of 1 to 2 millimeters per day as new bone is being formed. Once the predetermined length is achieved, the device is left in place until the newly formed bone calcifies and the envelope of fibromuscular attachments has adapted to the increased length and then the device is removed. The primary advantage claimed in connection with distraction osteogenesis is that it allows major reshaping of the facial bones without bone grafts or jaw wiring. Since distraction osteogenesis involve less blood loss and a lower risk of infection, proponents claim that it may be safer than other methods of facial reconstruction. However, according to available literature, distraction osteogenesis has several drawbacks. If the bone ends are moved apart too slowly, callus may calcify too soon, preventing further elongation of the bone. If the bone ends are moved apart too rapidly, callus may become too fibrous and fail to mature into solid bone. Therefore, the timing of the distraction is extremely important to its final outcome. Cleft Palate (Please refer to the Health Net Cleft Palate and Other Craniofacial Abnormalities Medical Policy) A cleft palate occurs in early pregnancy when separate areas of the face have developed individually do not join together properly. The back of the palate is called the soft palate and the front is known as the hard palate. 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. The palate is very important in directing air out the mouth rather than the nose when speaking also acts to prevent food and liquids from going up into the nose when eating. 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 extra bone in the gum, called 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. There are many specific syndromes associated with cleft lip/palate. Apert syndrome is primarily characterized by specific malformations of the skull, midface, hands, and feet. The skull is prematurely fused and unable to grow normally; the midface (that area of the face from the middle of the eye socket to the upper jaw) appears retruded or sunken; and the fingers and toes are fused together in varying degrees. Crouzon syndrome is a congenital defect, which affect the skull and the upper facial bone. Parts of the skull s sutures become completely fused at birth (synostosis) which, cause severe deformities in the underdeveloped upper facial bone area. Common problems are breathing, eating, hearing, and eyesight difficulties. DiGeorge syndrome is characterized by injury to the development of pharyngeal pouches resulting in cardiac, facial, immune, and parathyroid anomalies. Pierre Robin syndrome is characterized by a combination of three features, possibly due to the underdevelopment of the lower jaw. The lower jaw is abnormally small (micrognathia), the tongue is displaced downwards (glossoptosis), and there is an Orthognathic Surgery Mar 15 13

14 abnormal opening in the roof of the mouth (cleft soft palate). In some infants, this combination may cause difficulties with normal breathing. 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. Review History February 2004 April 2006 January 2008 March 2010 March 2011 March 2012 Dec 2012 March 2013 March 2014 March 2015 Medical Advisory Council initial approval Update no changes Removed modified condylotomy from #3 listed under not medically necessary as this procedure is not considered orthognathic surgery. Added revision that some states may require coverage of dental and 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 Disorders Policy Update - no revisions Added reference to Oregon (ORS ) mandates for dates or service after Jan 2013 Update no revisions. Coding updates. Update no revisions Update no revisions. Codes Updated. This Policy is based on the following evidence-based guidelines: 1. Hayes. Search & Summary. Le Fort 1 Maxillary Osteotomy for Maxillary Retrognathia. February 13, Archived Mar 2013 References Update March Buchanan EP, Hollier LH. Syndromes with craniofacial abnormalities. UpToDate. October 21, References Update March 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 1. Orthognathic Surgery Mar 15 14

15 2. 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): References Update March 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 toothborne 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 ), References Update March 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. 2. Lopez PE, Guerrero CA, Mujica EV. Mandibular basal osteotomy: new designs and fixation techniques. J Oral Maxillofac Surg Mar;69(3): References - Update January American Society of Temporomandibular Joint Surgeons. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures. Available at: 2. Hall HD, Indresano AT, Kirk WS, Dietrich MS. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg Aug;63(8): Güven O. Inappropriate treatments in temporomandibular joint chronic recurrent dislocation: a literature review presenting three particular cases. J Craniofac Surg May;16(3): Choi YS, Yun KI, Kim SG. Long-term results of different condylotomy designs for the management of temporomandibular joint disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Feb;93(2): Hall HD, Navarro EZ, Gibbs SJ. One- and three-year prospective outcome study of modified condylotomy for treatment of reducing disc displacement. J Oral Maxillofac Surg Jan;58(1): Hall HD, Navarro EZ, Gibbs SJ. Prospective study of modified condylotomy for treatment of nonreducing disk displacement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Feb;89(2): Orthognathic Surgery Mar 15 15

16 7. Hall HD, Werther JR. Results of reoperation after failed modified condylotomy. J Oral Maxillofac Surg Nov;55(11) 8. Albury CD Jr. Modified condylotomy for chronic nonreducing disk dislocations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Sep;84(3): Hall HD. Modification of the modified condylotomy. J Oral Maxillofac Surg May;54(5): McKenna SJ, Cornella F, Gibbs SJ. Long-term follow-up of modified condylotomy for internal derangement of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod May;81(5): Werther JR, Hall HD, Gibbs SJ. Disk position before and after modified condylotomy in 80 symptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Jun;79(6): References 1. 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): Kindelan J, Tobin M, Roberts-Harry D, Loukota RA. Orthodontic and orthognathic management of a patient with osteogenesis imperfecta and dentinogenesis imperfecta: a case report. J Orthod Dec;30(4): 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): Noguchi N, Goto M. Computer simulation system for orthognathic surgery. Orthod Craniofac Res. 2003;6 Suppl 1: Stavropoulos F, Dolwick MF. Simultaneous temporomandibular joint and orthognathic surgery: the case against. J Oral Maxillofac Surg Oct;61(10): Wolford LM. Concomitant temporomandibular joint and orthognathic surgery. J Oral Maxillofac Surg Oct;61(10): Kahn JL, Bourjat P, Barriere P. Imaging of mandibular malformations and deformities. J Radiol Sep;84(9): Hynes PJ, Earley MJ. Assessment of secondary alveolar bone grafting using a modification of the Bergland grading system. Br J Plast Surg Oct;56(7): Corvo G, Tartaro G, Giudice A, Diomajuta A. Distribution of craniomandibular disorders, occlusal factors and oral parafunctions in a paediatric population. Eur J Paediatr Dent Jun;4(2): Burford D, Noar JH. The causes, diagnosis and treatment of anterior open bite. Dent Update Jun;30(5): Cousley RR, Grant E, Kindelan JD. The validity of computerized orthognathic predictions. J Orthod Jun;30(2):149-54; discussion Israel HA, Ward JD, Horrell B, Scrivani SJ. Oral and maxillofacial surgery in patients with chronic orofacial pain. J Oral Maxillofac Surg Jun;61(6): Ellis PE, Benson PE. Does articulating study casts make a difference to treatment planning? J Orthod Mar;30(1):45-9; discussion Lu CH, Ko EW, Huang CS. The accuracy of video imaging prediction in soft tissue outcome after bimaxillary orthognathic surgery. J Oral Maxillofac Surg Mar;61(3): Orthognathic Surgery Mar 15 16

17 16. Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders (Cochrane Review). In: The Cochrane Library, Issue 1, Oxford: Update Software. 17. American Academy of Oral and Maxillofacial Surgeons (AAOMS). Criteria for orthognathic surgery. Reimbursement and Appeal Resources. Health Policy and Third Party Payor Relations Resources. Rosemont, IL: AAOMS; Accessed at: d= Jones RH. Orthognathic surgery and implants. Ann R Australas Coll Dent Surg Oct;16: Gilon Y, Raskin S, Heymans O, Poirrier R. The role of maxillofacial surgery in obstructive sleep hypopnea and apnea syndrome. Rev Belge Med Dent. 2002;57(2): Lemaitre A. Surgical technics in orthognathic surgery. Rev Belge Med Dent. 2002;57(1): Bousaba S, Delatte M, Barbarin V, et al. Pre- and post-surgical orthodontic objectives and orthodontic preparation. Rev Belge Med Dent. 2002;57(1): Glineur R, Balon-Perin A. A multidisciplinary approach to orthognathic surgery. Rev Belge Med Dent. 2002;57(1): Bousaba S, Siciliano S, Delatte M, et al. Indications for orthognathic surgery, the limitations of orthodontics and of surgery. Rev Belge Med Dent. 2002;57(1): Loh S, Yow M. Computer prediction of hard tissue profiles in orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 2002;17(4): Khambay B, Nebel JC, Bowman J, et al. 3D stereophotogrammetric image superimposition onto 3D CT scan images: the future of orthognathic surgery. A pilot study. Int J Adult Orthodon Orthognath Surg. 2002;17(4): Hajeer MY, Ayoub AF, Millett DT, et al. Three-dimensional imaging in orthognathic surgery: the clinical application of a new method. Int J Adult Orthodon Orthognath Surg. 2002;17(4): Tucker MR. Management of severe mandibular retrognathia in the adult patient using traditional orthognathic surgery. J Oral Maxillofac Surg Nov;60(11): Hunt OT, Johnston CD, Hepper PG, et al. The psychosocial impact of orthognathic surgery: A systematic review. Am J Orthod Dentofacial Orthop. 2001;120(5): Aghabeigi B, Hiranaka D, Keith DA, Kelly JP, Crean SJ. Effect of orthognathic surgery on the temporomandibular joint in patients with anterior open bite. Int J Adult Orthodon Orthognath Surg. 2001;16(2): Bailey LJ, Haltiwanger LH, Blakey GH, Proffit WR. Who seeks surgical-orthodontic treatment: a current review. Int J Adult Orthodon Orthognath Surg Winter;16(4): Bettega, G., Pepin, J. L., Veale, D., Deschaux, D., Raphael, B., Levy, P. Obstructive sleep apnea syndrome. Fifty-one consecutive patients treated by maxillofacial surgery. American Journal of Respiratory and Critical Care Medicine, 2000;162 (2 Pt 1), McCarthy JG, Stelnicki EJ, Grayson BH. Distraction osteogenesis of the mandible: A ten-year experience. Semin Orthod. 1999;5(1): Baker NJ, David S, Barnard DW, et al. Occlusal outcome in patients undergoing orthognathic surgery with internal fixation. Br J Oral Maxillofac Surg. 1999;37(2): Bennett ME, Phillips CL. Assessment of health-related quality of life for patients with severe skeletal disharmony: A review of the issues. Int J Adult Orthodon Orthognath Surg. 1999;14(1): Orthognathic Surgery Mar 15 17

18 35. Cope JB, Samchukov ML, Cherkashin AM. Mandibular distraction osteogenesis: A historic perspective and future directions. Am J Orthod Dentofacial Orthop. 1999;115(4): Buttke TM, Proffit WR. Referring adult patients for orthodontic treatment. J Am Dent Assoc. 1999;130(1): Throckmorton, G. S., Buschang, P. H., Ellis, E. 3rd. Morphologic and biomechanical determinants in the selection of orthognathic surgery procedures. Journal of Oral and Maxillofacial Surgery. 1999; 57 (9), Coleman, J. Oral and maxillofacial surgery for the management of obstructive sleep apnea syndrome. Otolaryngologic Clinics of North America. 1999; 32 (2), Li, K. K., Riley, R. W., Powell, N. B., Troell, R., Guillemkinault, C. Overview of phase II surgery for obstructive sleep apnea syndrome. Ear Nose and Throat Journal. 1999; 78 (11), 851, Drew SJ, Schwartz MH, Sachs SA. Distraction osteogenesis. N Y State Dent J. 1999;65(1): Davies J, Turner S, Sandy JR. Distraction osteogenesis--a review. Br Dent J. 1998;185(9): Luther, F. Orthodontics and the temporomandibular joint: Where are we now? Part 2. Functional occlusion, malocclusion, and TMD. The Angle Orthodontist. 1998; 68 (4), Alanen P, Varrela J. The occlusal theory further complicated. Med Hypotheses Nov;49(5): Barkate HE. Orthognathic surgery by distraction osteogenesis: A literature review. Dentistry. 1997;17(3):14, Lupori JP, Van Sickels JE, Holmgreen WC. Outpatient orthognathic surgery: Review of 205 cases. J Oral Maxillofac Surg. 1997;55(6): American Society of Plastic Surgeons. (1997, September). Orthognathic Surgery: Recommended Criteria for Third-Party Payer Coverage. Accessed at: McNeil, C. Management of temporomandibular disorders: concepts and controversies. The Journal of Prosthetic Dentistry. 1997; 77 (5), Clark, G. T., Tsukiyama, Y., Baba, K., Simmons. The validity and utility of disease detection methods and of occlusal therapy for temporomandibular disorders. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics. 1997; 83 (1), Dawson, P. E. Why NIH is wrong about 'TMD'. The Journal of Craniomandibular Practice. 1997; 5 (1), Management of Temporomandibular Disorders. NIH Technol Statement Online 1996 Apr 29-May. Accessed at: Van Sickels, J. Stability of orthognathic surgery: a review of rigid fixation. Br. J. Oral Maxillofac. Surg. 1996; 34: Ishii, K., Kaloust, S., Ousterhout, D. K. Airway changes after Le Fort III osteotomy in craniosynostosis syndromes. Journal of Craniofacial Surgery. 1996; 7 (5), Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 1995;10(2): Ruhl CM, Bellian KT, Van Meter BH, et al. Diagnosis, complications, and treatment of dentoskeletal malocclusion. Am J Emerg Med. 1994;12(1): American Society of Plastic and Reconstructive Surgeons, Inc. (1994, September). Maxillary Retrognathia (Hypoplasia) and Maxillary Protrusion (Hyperplasia) and Orthognathic Surgery Mar 15 18

19 Vertical Deficiency or Excess. Clinical Practice Guidelines for Plastic and Maxillofacial Surgery. (p. 1-6). 56. Riley, R. W., Powell, N.B., Guilleminault. Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients. Otolaryngology and Head and Neck Surgery. 1993; 108 (2), Sinn DP, Ghali GE. Advances in orthognathic surgery. Curr Opin Dent. 1992;2: Riley, R. W., Powell, N. B., Guilleminault, C. Maxillofacial surgery and nasal CPAP. A comparison of treatment for obstructive sleep apnea syndrome. Chest. 1990; 98 (6), Riley, R. W., Powell, N., Guilleminault, C. Current surgical concepts for treating obstructive sleep apnea syndrome. Journal of Oral and Maxillofacial Surgery. 1987; 45 (2), Schendel, S. And Williamson, L. W. Surgical maxillary superior repositioning and the facial muscles. Jrnl. Oral Maxillofac.Surg. 1983;41: Speissel, B. The sagittal splitting osteotomy for correction of mandibular prognathism. Clin. Plast. Surg. 1982; 9: Lindorf, H. H., and Steinhauser, E.W. Correction of jaw deformity involving simultaneous osteotomy of the mandible and maxilla. Jrnl. Maxillofac. Surg. 1980; 8: Bell, W. H. Lefort I. Osteotomy for correction of maxillary deformities. Jrnl. Oral Surg., 1975; 33:412. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective. Orthognathic Surgery Mar 15 19

20 No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member s contract shall govern. The Policies do not replace or amend the Member s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code requires health care service plans to cover reconstructive surgery. Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation. Orthognathic Surgery Mar 15 20