Orthognathic Surgery Medical Necessity Criteria

Northwest Region Utilization

eview

UR 69: Orthognathic Surgery

Medical Necessity Criteria

Department: Non-Behavioral Health

Section: KPNW Region

Applies to: KPNW Region

Review Responsibility: Kelly Dezura, DMD;

Alexis Kleinman, DMD

Number: UR 69

Effective: 01/2017

Last Reviewed: 3/21, 3/22, 5/23, 5/21/24

Last Reviewed/Revised: 4/20

ORTHOGNATHIC SURGERY MEDICAL NECESSITY CRITERIA

Medical necessity criteria and policy are applied only after member eligibility and benefit coverage is determined.

Questions concerning member eligibility and benefit coverage need to be directed to Membership Services.

PURPOSE

The purpose of these criteria is to define KFHPNW coverage for orthognathic surgery to treat a limited

number of medical conditions, as mandated by WAC 284-43-5640.

DEFINITIONS

Orthognathic Surgery- the surgical correction of abnormalities of the mandible and/or maxilla. The

underlying abnormality may be present at birth or may become evident as the patient grows and develops

or may be the result of traumatic injuries.

Malocclusion- imperfect positioning of the teeth when the jaws are closed. The condition may also be

referred to as an irregular bite, crossbite, or overbite.

Congenital- a condition present at birth such as a cleft lip or cleft palate.

CRITERIA

For Medicare Members

Source Policy

CMS Coverage Manuals None

National Coverage Determinations

(NCD)

None

Local Coverage Determinations (LCD) None

Local Coverage Article None

Kaiser Permanente Medical Policy Due to the absence of an NCD or LCD, Kaiser

Permanente has chosen to use their own Clinical

Review Criteria, “Orthognathic Surgery” for medical

necessity determinations. Use the criteria below.

Orthognathic surgery and supplies are covered for any of the following:

1) conditions resulting from a skeletal malocclusion which resulted from TMJ arthritis, ankylosis,

trauma or tumor and is not amenable to orthodontic therapy alone.

2) sleep apnea with a referral from a Sleep Medicine specialist. Patient must have documented

severe OSA (obstructive sleep apnea) or the patient has documented mild-moderate OSA with

severe symptoms (based on Epworth Sleepiness Scale) with an identifiable dentofacial deformity

such as maxillary or mandibular hypoplasia. Patient is also either intolerant or unable to use

CPAP.

3) a congenital anomaly that is not amenable to orthodontic therapy alone with a referral from a

cranio-facial specialist (e.g. ENT, Cranio-facial Surgeon, Oromaxillo-facial Surgeon).

SPECIAL GROUP CONSIDERATIONS

Although this is a WA State mandate, the coverage criteria will be universally applied to all lines of

business beginning 1/1/17 except as follows:

Washington and Oregon Medicaid- these criteria do not apply to Medicaid.

Added Choice/POS: members may directly access non-KP providers under their Tier 2 and Tier 3 benefits,

without prior-authorization, for office visits that do not include a procedure. Procedures and levels of

care other than office visits require prior-authorization.

REFERENCES

WAC 284-43-5640; Essential health benefit categories, section (3)b,iii,B