Clinical Policy Bulletin: Orthognathic Surgery Policy Bulletin: ... Precertification requests or claims for orthognathic surgery are subject to review by Aetna's Oral and Maxillofacial

Orthognathic Surgery Page 1 of 14

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Aetna Better Health® 2000 Market Street, Suite 850 Philadelphia, PA 19103

AETNA BETTER HEALTH®

Clinical Policy Bulletin: Orthognathic Surgery

Revision: March 2015

Number: 0095

Policy

Certain jaw and cranio-facial deformities may cause significant functional

impairment. These deformities include apertognathia (either lateral or anterior not

correctable by orthodontics alone), significant asymmetry of the lower jaw,

significant class 2 and class 3 occlusal discrepancies, and cleft palate. Aetna

considers orthognathic surgery medically necessary for correction of the following

skeletal deformities of the maxilla or mandible when it is documented that these

skeletal deformities are contributing to significant dysfunction, and where the

severity of the deformities precludes adequate treatment through dental

therapeutics and orthodontics alone:

I. Maxillary and/or Mandibular Facial Skeletal Deformities Associated with

Masticatory Malocclusion

Aetna considers orthognathic surgery medically necessary for correction of

skeletal deformities of the maxilla or mandible when it is documented that

these skeletal deformities are contributing to significant masticatory

dysfunction, and where the severity of the deformities precludes adequate

treatment through dental therapeutics and orthodontics:

A. Antero-posterior discrepancies

1. Maxillary/mandibular incisor relationship: overjet of 5

millimeter (mm) or more, or a 0 to a negative value (norm 2

mm),

2. Maxillary/mandibular antero-posterior molar relationship

discrepancy of 4 mm or more (norm 0 to 1 mm).

Note: These values represent 2 or more standard deviations

(SDs) from published norms.

B. Vertical discrepancies

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1. Presence of a vertical facial skeletal deformity which is 2 or

more SDs from published norms for accepted skeletal

landmarks

2. Open Bite

a. No vertical overlap of anterior teeth greater than 2 mm

b. Unilateral or bilateral posterior open bite greater than 2

mm

3. Deep overbite with impingement or irritation of buccal or

lingual soft tissues of the opposing arch

4. Supraeruption of a dento-alveolar segment due to lack of

opposing occlusion creating dysfunction not amenable to

conventional prosthetics.

C. Transverse discrepancies

1. Presence of a transverse skeletal discrepancy which is 2 or

more SDs from published norms.

2. 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.

D. Asymmetries

1. Antero-posterior, transverse or lateral asymmetries greater

than 3 mm with concomitant occlusal asymmetry.

II. Facial Skeletal Discrepancies Associated with Documented Sleep Apnea,

Airway Defects, and Soft Tissue Discrepancies

Aetna considers orthognathic surgery medically necessary in cases where

it is documented that mandibular and maxillary deformities are contributing

to airway dysfunction, where such dysfunction is not amenable to non-

surgical treatments, and where it is shown that orthognathic surgery will

decrease airway resistance and improve breathing.

For example, studies demonstrate that persons with vertical hyperplasia of

the maxilla have an associated increase in nasal resistance, as do persons

with maxillary hypoplasia with or without clefts. Following orthognathic

surgery, such individuals routinely demonstrate decreases in nasal airway

resistance and improved respiration.

Aetna considers orthognathic surgery medically necessary for members

with underlying craniofacial skeletal deformities that are contributing to

obstructive sleep apnea. See CPB 0004 - Obstructive Sleep Apnea in

Adults. Before surgery, such individuals should be properly evaluated to

determine the cause and site of their disorder and appropriate non-surgical

treatments attempted when indicated.




III. Temporomandibular Joint Pathology

Aetna considers orthognathic surgery for correction of temporomandibular

joint disease or myofascial pain dysfunction experimental and

investigational because its effectiveness for these indications has not been

established. See CPB 0028 - Temporomandibular Disorders.

IV. Speech Impairments

Aetna considers orthognathic surgery medically necessary for treatment of

speech impairments accompanying severe cleft deformity. Orthognathic

surgery may help to reduce the flattening of the face that is characteristic of

severe cleft deformity. By using osteotomy techniques along with bone and

cartilage grafts, the upper and lower jaws and facial skeletal framework are

moved and appropriately reconstructed. Pre-surgical orthodontic treatment

is usually recommended.

Aetna considers other orthognathic surgeries experimental and

investigational for correction of articulation disorders and other impairments

in the production of speech because there is inadequate evidence from

prospective clinical studies in the peer-reviewed published medical

literature of the effectiveness of orthognathic surgery for this indication.

Aetna considers orthognathic surgery for correction of distortions within the

sibilant sound class or for other distortions of speech quality (e.g., hyper-

nasal or hypo-nasal speech) not medically necessary as these distortions

do not cause functional impairment.

V. Unaesthetic Facial Features and Psychological Impairments

Orthognathic surgery is considered cosmetic for correction of unaesthetic

facial features.

Mentoplasty or genial osteotomies/ostectomies (chin surgeries) are always

considered cosmetic when performed as an isolated procedure to address

genial hypoplasia, hypertrophy, or asymmetry, and may be considered

cosmetic when performed with other surgical procedures.

No benefits are available for orthognathic surgery performed primarily for

cosmetic purposes. See Aetna CPB 0031 - Cosmetic Surgery.

VI. Aetna considers the use of condylar positioning devices in orthognathic

surgery experimental and investigational because their effectiveness in

orthognathic surgery has not been established.

VII. Aetna considers orthognathic surgery experimental and investigational for

all indications other than those listed above because their effectiveness for

indications other than the ones listed above has not been established.

VIII. Aetna considers three-dimensional virtual treatment planning of

orthognathic surgery experimental and investigational because its

effectiveness has not been established.




Note: Precertification requests or claims for orthognathic surgery are subject to

review by Aetna's Oral and Maxillofacial Surgery Unit.

Orthodontic Treatment Prior to Orthognathic Surgery

Note: Expenses associated with the orthodontic phase of care (both pre- and post-

surgical) are considered dental in nature and are not covered under Aetna's

medical plans. See CPB 0082 - Dental Services and Oral and Maxillofacial

Surgery: Coverage Under Medical Plans.

Orthodontic treatment may be needed prior to orthognathic surgery to position the

teeth in a manner that will provide for an adequate occlusion following surgical

repositioning of the jaws. For plans that require precertification, orthognathic

surgery must be precertified prior to pre-surgical orthodontic treatment. The

interim occlusion that is achieved by orthodontic treatment may be dysfunctional

prior to the completion of the orthognathic surgical phase of the treatment plan.

Therefore, all requests for orthognathic surgery must be reviewed/precertified by

an the Aetna Oral and Maxillofacial Surgery Unit prior to the initiation of pre-

surgical orthodontic care. Failure to obtain precertification of orthognathic surgery

prior to orthodontic care may result in the denial of benefits.

Documentation Requirements

Note: Orthognathic surgery may be subject to precertification review in plans that

include precertification requirements. The following documentation should be

forwarded to Aetna's Oral and Maxillofacial Surgery Unit for review: 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.

See also CPB 0082 - Dental Services and Oral and Maxillofacial Surgery:

Coverage Under Medical Plans.

Background

Orthognathic surgery is the revision by ostectomy, osteotomy or osteoplasty of the

upper jaw (maxilla) and/or the lower jaw (mandible) intended to alter the

relationship of the jaws and teeth. These surgical procedures are intended (i) to

correct skeletal jaw and cranio-facial deformities that may be associated with

significant functional impairment, and (ii) to reposition the jaws when conventional

orthodontic therapy alone is unable to provide a satisfactory, functional dental

occlusion within the limits of the available alveolar bone. Congenital or

developmental defects can interfere with the normal development of the face and

jaws. These birth defects may interfere with the ability to chew properly, and may

also affect speech and swallowing. In addition, trauma to the face and jaws may

create skeletal deformities that cause significant functional impairment. Functional

deficits addressed by this type of surgery are those that affect the skeletal




masticatory apparatus such that chewing, speaking and/or swallowing are

impaired.

There is limited evidence of the effectiveness of orthognathic surgery on

temporomandibular disorders. Abrahamsson et al (2007) examined if orthognathic

surgery does affect the prevalence of signs and symptoms of temporomandibular

disorders (TMDs). A literature survey in the PubMed and Cochrane Library

electronic databases was performed and covered the period from January 1966 to

April 2006. The inclusion criteria were controlled, prospective or retrospective

studies comparing TMDs before and after orthognathic surgery in patients with

malocclusion. There were no language restrictions, and 3 reviewers selected and

extracted the data independently. The quality of the retrieved articles was

evaluated by 4 reviewers. The search strategy resulted in 467 articles, of which 3

met the inclusion criteria. Because of few studies with unambiguous results and

heterogeneity in study design, the scientific evidence was insufficient to evaluate

the effects that orthognathic surgery had on TMD. Moreover, the studies had

problems with inadequate selection description, confounding factors, and lack of

method error analysis. The authors concluded that to obtain reliable scientific

evidence, additional well-controlled and well-designed studies are needed to

determine how and if orthognathic surgery alters signs and symptoms of TMD.

Lindenmeyer et al (2010) performed a systematic review of the best available

research literature investigating the relation of oral and maxillofacial surgical

procedures to the onset or relief of chronic painful TMD. A comprehensive review

of the databases CINAHL, Cochrane Library, Embase, Medline, NHS Evidence--

Oral Health, PsycINFO, Web of Knowledge, and MetaLib was undertaken by 2

authors up to June 2009 using search terms appropriate to establishing a relation

between orofacial surgical procedures and TMD. The search was restricted to

English-language publications. Of the 1,777 titles reviewed, 35 articles were

critically appraised, but only 32 articles were considered eligible. These were

observational studies that fell into 2 groups; 9 were seeking to establish a surgical

cause for TMD. Of these, only 2 of a series of 3 claimed that there was a

significant link, but this claim was based on weak data (health insurance records)

and was abandoned in a subsequent report. Twenty-three studies were seeking

to achieve relief by orthognathic surgical intervention. These were also negative

overall, with 7 articles showing varying degrees of mostly non-significant

improvement, whereas 16 showed no change or a worse outcome. No published

report on the putative effect of implant insertion was found. The authors

concluded that these apparently contradictory approaches underline a belief that

oral surgical trauma or gross malocclusion has a causative role in the onset of

TMD. However, there was no overall evidence of a surgical causal etiology or

orthognathic therapeutic value. This review emphasized that it is in the patients'

best interest to carry out prospective appropriately controlled randomized trials to

clarify the situation.

In a Cochrane review, Luther et al (2010) examined the effectiveness of

orthodontic intervention in reducing symptoms in patients with TMD (compared

with any control group receiving no treatment, placebo treatment or reassurance)

and investigated if active orthodontic intervention leads to TMD. The Cochrane

Oral Health Group's Trials Register, CENTRAL, MEDLINE and EMBASE were

searched. Hand-searching of orthodontic journals and other related journals was




undertaken in keeping with the Cochrane Collaboration hand-searching program.

No language restrictions were applied. Authors of any studies were identified, as

were experts offering legal advice, and contacted to identify unpublished trials.

Most recent search was April 13, 2010. All randomized controlled trials (RCTs)

including quasi-randomized trials assessing orthodontic treatment for TMD were

included. Studies with adults aged equal to or above 18 years old with clinically

diagnosed TMD were included. There were no age restrictions for prevention

trials provided the follow-up period extended into adulthood. The inclusion criteria

required reports to state their diagnostic criteria for TMD at the start of treatment

and for participants to exhibit 2 or more of the signs and/or symptoms. The

treatment group included treatment with appliances that could induce stable

orthodontic tooth movement. Patients receiving splints for 8 to 12 weeks and

studies involving surgical intervention (direct exploration/surgery of the joint and/or

orthognathic surgery to correct an abnormality of the underlying skeletal pattern)

were excluded. The outcomes were: how well were the symptoms reduced,

adverse effects on oral health and quality of life. Screening of eligible studies,

assessment of the methodological quality of the trials and data extraction were

conducted in triplicate and independently by 3 review authors. As no 2 studies

compared the same treatment strategies (interventions) it was not possible to

combine the results of any studies. The searches identified 284 records from all

databases. Initial screening of the abstracts and titles by all review authors

identified 55 articles that related to orthodontic treatment and TMD. The full

articles were then retrieved and of these articles only 4 demonstrated any data

that might be of value with respect to TMD and orthodontics. After further analysis

of the full texts of the 4 studies identified, none of the retrieved studies met the

inclusion criteria and all were excluded from this review. The authors concluded

that there are insufficient research data on which to base clinical practice on the

relationship of active orthodontic intervention and TMD. There is an urgent need

for high quality RCTs in this area of orthodontic practice.

There is a lack of evidence to support the use of condylar positioning devices in

orthognathic surgery. Costa et al (2008) stated that in the past few years, many

devices have been proposed for preserving the pre-operative position of the

mandibular condyle during bilateral sagittal split osteotomy. The authors stated

that accurate mandibular condyle re-positioning is considered important to obtain a

stable skeletal and occlusal result, and to prevent the onset of TMD. Condylar

positioning devices (CPDs) have led to longer operating times, the need to keep

inter-maxillary fixation as stable as possible during their application, and the need

for precision in the construction of the splint or intra-operative wax bite. The

authors reviewed the literature concerning the use of CPDs in orthognathic

surgery since 1990 and their application to prevent skeletal instability and contain

TMD since 1995. They concluded that there is no scientific evidence to support

the routine use of CPDs in orthognathic surgery.

Stokbro et al (2014) stated that numerous publications regarding virtual surgical

planning protocols have been published, most reporting only 1 or 2 case reports to

emphasize the hands-on planning. None had systematically reviewed the data

published from clinical trials. This systematic review analyzed the precision and

accuracy of three-dimensional (3D) virtual surgical planning of orthognathic

procedures compared with the actual surgical outcome following orthognathic

surgery reported in clinical trials. These researchers performed a systematic




search of the current literature to identify clinical trials with a sample size of more

than 5 patients, comparing the virtual surgical plan with the actual surgical

outcome. Search terms revealed a total of 428 titles, out of which only 7 articles

were included, with a combined sample size of 149 patients. Data were presented

in 3 different ways: intra-class correlation coefficient, 3D surface area with a

difference less than 2mm, and linear and angular differences in 3D. Success

criteria were set at 2 mm mean difference in 6 articles; 125 of the 133 patients

included in these articles were regarded as having had a successful outcome.

Due to differences in the presentation of data, meta-analysis was not possible. The

authors concluded that virtual planning appears to be an accurate and reproducible

method for orthognathic treatment planning; a more uniform presentation of the

data is necessary to allow the performance of a meta-analysis. Moreover, they

stated that currently the software system most often used for 3D virtual planning in

clinical trials is SimPlant (Materialise); more independent clinical

trials are needed to further validate the precision of virtual planning.

Adolphs et al (2014) stated that within the domain of craniomaxillofacial surgery,

orthognathic surgery is a special field dedicated to the correction of dentofacial

anomalies resulting from skeletal malocclusion. Generally, in such cases, an inter-

disciplinary orthodontic and surgical treatment approach is needed. After initial

orthodontic alignment of the dental arches, skeletal discrepancies of the jaws can

be corrected by distinct surgical strategies and procedures in order to achieve

correct occlusal relations, as well as facial balance and harmony within

individualized treatment concepts. To transfer the pre-operative surgical planning

and re-position the mobilized dental arches with optimal occlusal relations, surgical

splints are typically used. For this purpose, different strategies have been

described which use 1 or more splints. Traditionally, these splints are

manufactured by a dental technician based on patient-specific dental casts;

however, computer-assisted technologies have gained increasing importance with

respect to pre-operative planning and its subsequent surgical transfer. In a pilot

study of 10 patients undergoing orthognathic corrections by a 1-splint strategy, 2

final occlusal splints were produced for each patient and compared with respect to

their clinical usability. One splint was manufactured in the traditional way by a

dental technician according to the preoperative surgical planning. After performing

a CBCT scan of the patient's dental casts, a second splint was designed virtually

by an engineer and surgeon working together, according to the desired final

occlusion. For this purpose, RapidSplint, a custom-made software platform, was

used. After post-processing and conversion of the datasets into .stl files, the

splints were fabricated by the PolyJet procedure using photo polymerization.

During surgery, both splints were inserted after mobilization of the dental arches

then compared with respect to their clinical usability according to the occlusal

fitting. Using the workflow described above, virtual splints could be designed and

manufactured for all patients in this pilot study. Eight of 10 virtual splints could be

used clinically to achieve and maintain final occlusion after orthognathic surgery.

In 2 cases virtual splints were not usable due to insufficient occlusal fitting, and

even two of the traditional splints were not clinically usable. In five patients where

both types of splints were available, their occlusal fitting was assessed as being

equivalent, and in one case the virtual splint showed even better occlusal fitting

than the traditional splint. In 1 case where no traditional splint was available, the

virtual splint proved to be helpful in achieving the final occlusion. The authors




concluded that the findings of this pilot study demonstrated that clinically usable

splints for orthognathic surgery can be produced by computer-assisted

technology. Virtual splint design was realized by RapidSplint®, an in-house

software platform which might contribute in future to shorten pre-operative

workflows for the production of orthognathic surgical splints. The preliminary

findings from this pilot study need to be validated by well-designed studies.

Swennen (2014) evaluated the timing for 3D virtual treatment planning of

orthognathic surgery in the daily clinical routine. A total of 350 consecutive patients

were included in this study. All patients were scanned following the standardized

"Triple CBCT Scan Protocol" in centric relation. Integrated 3D virtual planning and

actual surgery were performed by the same surgeon in all patients. The authors

concluded that although clinically acceptable, still software improvements

especially toward 3D virtual occlusal definition are mandatory to make 3D virtual

planning of orthognathic surgery less time-consuming and more user-friendly to the

clinician.

CPT Codes / HCPCS Codes / ICD-9 Codes

CPT codes covered if selection criteria are met:

21083 Impression and custom preparation; palatal lift prosthesis

21084 speech aid prosthesis

21085 oral surgical splint

21088 facial prosthesis

21141 Reconstruction midface, Lefort I; single piece, segment

movement in any direction (e.g., for Long Face Syndrome),

without bone graft

21142 2 pieces, segment movement in any direction, without bone

graft

21143 3 or more pieces, segment movement in any direction,

without bone graft

21145 single piece, segment movement in any direction, requiring

bone grafts (includes obtaining graft)

21146 2 pieces, segment movement in any direction, requiring

bone grafts (includes obtaining autografts) (e.g., ungrafted

unilateral alveolar cleft)

21147 3 or more pieces, segment movement in any direction,

requiring bone grafts (includes obtaining autografts) (e.g.,

ungrafted bilateral alveolar cleft or multiple osteotomies)

21150 Reconstruction midface, Lefort II; anterior intrusion (e.g.,

Treacher-Collins Syndrome)




21151 any direction, requiring bone grafts (includes obtaining

autografts)

21154 Reconstruction midface, Lefort III (extracranial), any type,

requiring bone grafts (includes obtaining autografts); without

Lefort I

21155 with Lefort I

21159 Reconstruction midface, Lefort III (extra and intracranial) with

forehead advancement (e.g., mono bloc), requiring bone grafts

(includes obtaining autografts): without Lefort I

21160 with Lefort I

21181 Reconstruction by contouring of benign tumor of cranial bones

(e.g., fibrous dysplasia), extracranial

21182 Reconstruction of orbital walls, rims, forehead, nasoethmoid

complex following intra- and extracranial excision of benign

tumor of cranial bone (e.g., fibrous dysplasia) with multiple

autografts (includes obtaining grafts); total area of bone

grafting less than 40 sq cm

21183 total area of bone grafting greater than 40 sq cm but less

than 80 sq cm

21184 total area of bone grafting greater than 80 sq cm

21188 Reconstruction midface, osteotomies (other than Lefort type)

and bone grafts (includes obtaining autografts)

21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L

osteotomy; without bone graft

21194 with bone graft (includes obtaining graft)

21195 Reconstruction of mandibular rami and/or body, sagittal split;

without internal rigid fixation

21196 with internal rigid fixation

21198 Osteotomy, mandible, segmental;

21199 with genioglossus advancement

21206 Osteotomy, maxilla, segmental (e.g., Wassmund or

Schuchard)

21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or

prosthetic implant)

21209 reduction




21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining

graft)

21215 mandible (includes obtaining graft)

21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear

(includes obtaining graft)

21235 ear cartilage, autogenous, to nose or ear (includes obtaining

graft)

21240 Arthroplasty, temporomandibular joint, with or without autograft

(includes obtaining graft)

21242 Arthroplasty, temporomandibular joint, with allograft

21243 Arthroplasty, temporomandibular joint, with prosthetic joint

replacement

21247 Reconstruction of mandibular condyle with bone and cartilage

autografts (includes obtaining grafts) (e.g., for hemifacial

microsomia)

21255 Reconstruction of zygomatic arch and glenoid fossa with bone

and cartilage (includes obtaining autografts)

21270 Malar augmentation, prosthetic material

21275 Secondary revision of orbitocraniofacial reconstruction

21295 Reduction of masseter muscle and bone (e.g., for treatment of

benign masseteric hypertrophy); extraoral approach

21296 intraoral approach

42200 -

42281

Repair of palate

CPT codes not covered for indications listed in the CPB:

21125 Augmentation, mandibular body or angle; prosthetic material

21127 with bone graft, onlay or interpositional (includes obtaining

autograft)

Other CPT codes related to the CPB:

21110 Application of interdental fixation device for conditions other

than fracture or dislocation, includes removal

21120 -

21123

Genioplasty

HCPCS codes covered if selection criteria are met:




D5954 -

D5959

Palatal augmentation and lift prosthesis

D7940 -

D7955

Other repair procedures

Other HCPCS codes related to the CPB:

D8010 -

D8999

Orthodontics

ICD-9 codes covered if selection criteria are met:

524.00 -

524.29

Major anomalies of jaw size and dental arch relationship

524.4 -

524.59

Malocclusion and dentofacial functional abnormalities

749.00 -

749.04

Cleft palate

749.20 -

749.25

Cleft palate with cleft lip

327.23 Obstructive sleep apnea (adult) (pediatric) [associated with

facial skeletal deformities]

ICD-9 codes not covered for indications listed in the CPB:

524.60 -

524.69

Temporomandibular joint disorders

V50.1 Other plastic surgery for unacceptable cosmetic appearance

Other ICD-9 related to the CPB:

784.5 Other speech disturbance

786.00 -

786.09

Dyspnea and respiratory abnormalities [associated with

obstructive airway defects]

The above policy is based on the following references:

1. McCarthy JG, Stelnicki EJ, Grayson BH. Distraction osteogenesis of the

mandible: A ten-year experience. Semin Orthod. 1999;5(1):3-8.

2. 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):90-93.

3. 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):65-75.




4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Cope JB, Samchukov ML, Cherkashin AM. Mandibular distraction

osteogenesis: A historic perspective and future directions. Am J Orthod

Dentofacial Orthop. 1999;115(4):448-460.

Drew SJ, Schwartz MH, Sachs SA. Distraction osteogenesis. N Y State

Dent J. 1999;65(1):26-29.

Buttke TM, Proffit WR. Referring adult patients for orthodontic treatment. J

Am Dent Assoc. 1999;130(1):73-79.

Davies J, Turner S, Sandy JR. Distraction osteogenesis--a review. Br Dent

J. 1998;185(9):462-467.

American Society of Plastic and Reconstructive Surgeons (ASPRS).

Orthognathic Surgery: Recommended Criteria for Third-Party Payer

Coverage. Arlington Heights, IL: ASPRS; September 1997.

Barkate HE. Orthognathic surgery by distraction osteogenesis: A literature

review. Dentistry. 1997;17(3):14, 16-18.

Lupori JP, Van Sickels JE, Holmgreen WC. Outpatient orthognathic surgery:

Review of 205 cases. J Oral Maxillofac Surg. 1997;55(6):558-563. Tompach

PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in orthognathic

surgery. Int J Adult Orthodon Orthognath Surg. 1995;10(2):97-

107.

Ruhl CM, Bellian KT, Van Meter BH, et al. Diagnosis, complications, and

treatment of dentoskeletal malocclusion. Am J Emerg Med. 1994;12(1):98-

104.

Sinn DP, Ghali GE. Advances in orthognathic surgery. Curr Opin Dent.

1992;2:38-41.

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):490-497.

Koh H, Robinson PG. Occlusal adjustment for treating and preventing

temporomandibular joint disorders. Cochrane Database Syst Rev. 2003;

(1):CD003812.

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;

2002. Available at: http://www.aaoms.org/allied/allied_template.asp?

content_type_id=126&entity_id=122. Accessed April 15, 2003.

Tulloch JF, Proffit WR, Phillips C. Outcomes in a 2-phase randomized

clinical trial of early Class II treatment. Am J Orthod Dentofacial Orthop.

2004;125(6):657-667.

Van Lierde KM, Schepers S, Timmermans L, et al. The impact of

mandibular advancement on articulation, resonance and voice

characteristics in Flemish speaking adults: A pilot study. Int J Oral

Maxillofac Surg. 2006;35(2):137-144.

Chanchareonsook N, Samman N, Whitehill TL. The effect of cranio-

maxillofacial osteotomies and distraction osteogenesis on speech and

velopharyngeal status: A critical review. Cleft Palate Craniofac J. 2006;43

(4):477-487.

Fedorowicz Z, Nasser M, Newton T, Oliver R. Resorbable versus titanium

plates for orthognathic surgery. Cochrane Database Syst Rev. 2007;

(2):CD006204.


http://www.aaoms.org/allied/allied_template.asp



21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

Hassan T, Naini FB, Gill DS. The effects of orthognathic surgery on speech:

A review. J Oral Maxillofac Surg. 2007;65(12):2536-2543.

Abrahamsson C, Ekberg E, Henrikson T, Bondemark L. Alterations of

temporomandibular disorders before and after orthognathic surgery: A

systematic review. Angle Orthod. 2007;77(4):729-734.

Lye KW. Effect of orthognathic surgery on the posterior airway space

(PAS). Ann Acad Med Singapore. 2008;37(8):677-682.

Won CH, Li KK, Guilleminault C. Surgical treatment of obstructive sleep

apnea: Upper airway and maxillomandibular surgery. Proc Am Thorac Soc.

2008;5(2):193-199.

Costa F, Robiony M, Toro C, et al. Condylar positioning devices for

orthognathic surgery: A literature review. Oral Surg Oral Med Oral Pathol

Oral Radiol Endod. 2008;106(2):179-190.

Kang SH, Yoo JH, Yi CK. The efficacy of postoperative prophylactic

antibiotics in orthognathic surgery: A prospective study in Le Fort I

osteotomy and bilateral intraoral vertical ramus osteotomy. Yonsei Med J.

2009;50(1):55-59.

Danda AK, Wahab A, Narayanan V, Siddareddi A. Single-dose versus

single-day antibiotic prophylaxis for orthognathic surgery: A prospective,

randomized, double-blind clinical study. J Oral Maxillofac Surg. 2010;68

(2):344-346.

Dan AE, Thygesen TH, Pinholt EM. Corticosteroid administration in oral

and orthognathic surgery: A systematic review of the literature and meta-

analysis. J Oral Maxillofac Surg. 2010;68(9):2207-2220.

Garg M, Cascarini L, Coombes DM, et al. Multicentre study of operating

time and inpatient stay for orthognathic surgery. Br J Oral Maxillofac Surg.

2010;48(5):360-363.

Lindenmeyer A, Sutcliffe P, Eghtessad M, et al. Oral and maxillofacial

surgery and chronic painful temporomandibular disorders -- a systematic

review. J Oral Maxillofac Surg. 2010;68(11):2755-2764.

Luther F, Layton S, McDonald F. Orthodontics for treating

temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev.

2010;(7):CD006541.

Pineiro-Aguilar A, Somoza-Martín M, Gandara-Rey JM, Garcia-Garcia A.

Blood loss in orthognathic surgery: A systematic review. J Oral Maxillofac

Surg. 2011;69(3):885-892.

Danda AK, Ravi P. Effectiveness of postoperative antibiotics in orthognathic

surgery: A meta-analysis. J Oral Maxillofac Surg. 2011;69(10):2650-2656.

Mattos CT, Vilani GN, Sant'Anna EF, et al. Effects of orthognathic surgery

on oropharyngeal airway: A meta-analysis. Int J Oral Maxillofac Surg.

2011;40(12):1347-1356.

Stokbro K, Aagaard E, Torkov P, et al. Virtual planning in orthognathic

surgery. Int J Oral Maxillofac Surg. 2014;43(8):957-965.

Adolphs N, Liu W, Keeve E, Hoffmeister B. RapidSplint: Virtual splint

generation for orthognathic surgery - results of a pilot series. Comput Aided

Surg. 2014;19(1-3):20-28.

Swennen GR. Timing of three-dimensional virtual treatment planning of

orthognathic surgery: A prospective single-surgeon evaluation on 350

consecutive cases. Oral Maxillofac Surg Clin North Am. 2014;26(4):475-

485.




Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in

administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy

Bulletin contains only a partial, general description of plan or program benefits and does not constitute a

contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or

outcomes. Participating providers are independent contractors in private practice and are neither

employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice

and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

CPT only copyright 2008 American Medical Association. All Rights Reserved.


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Clinical Policy Bulletin: Orthognathic Surgery Policy Bulletin: ... Precertification requests or claims for orthognathic surgery are subject to review by Aetna's Oral and Maxillofacial