Craniomandibular Surgery AHM Clinical Indications

• Craniomandibular surgery is considered medically necessary to treat facial bone deformities (from trauma, tumor, infection, congenital) resulting in masticatory dysfunction, speech dysfunction, sleep apnea problems that are not amenable to non- surgical therapy. The patient must meet ALL of the following : • The patient has documentation of 1 or more of the following example diagnoses: . Hyperplasia . Hypoplasia . Macrognathism . Micrognathism . Macrogenia . Microgenia . Asymmetry of the jaw . Prognathism . Retrognathism . Crossbite . Disto-occlusion . Mesio-occlusion . Midline deviation . Open bite . Overbite . Overjet . Posterior lingual occlusion of mandibular teeth . Soft tissue impingement . Abnormal jaw closure . Malocclusion due to abnormal swallowing . Mouth breathing . Tongue, lip or finger habits • Cephalometric X-ray Study confirms 1 or more of the following : . Maxillary and/or mandibular skeletal deformities associated with masicatory malocclusion which results in 1 or more of the following • Anteroposterior Discrepancy

ActiveHealth Management Medical Management Guidelines

• Maxillary/Mandibular incisor relationship shows an overjet of 5mm or more, or a 0 to a negative value (normal 2mm) [A] • Maxillary/Mandibular anteroposterior molar relationship shows a discrepancy of 4mm or more (Normal is 0 to 1 mm) [B] • Vertical Discrepancies • Presence of vertical facial skeletal deformity that is 2 or more standard deviations from the published norms for accepted skeletal landmarks. • Open Bite . No vertical overlap of anterior teeth . Unilateral or bilateral posterior open bite greater than 2 mm . Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch . Supraeruption of a dentoalveolar segment due to lack of occlusion • Transverse Discrepancies • Presence of a transverse skeletal facial deformity that is 2 or more standard deviations from the published norms • 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 • Anteroposterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry. • REQUIRED DOCUMENTATION . Documentation is required for ALL of the following : • Documentation from the provider describing the patient history to include • Diagnosis and functional limitations such as sleep apnea, speech, masticating or swallowing problems, myofascial pain and psychosocial impairment • Dates and the status of the current orthodontic treatment to date. • Documentation from imaging supports the diagnosis • Cephalometric Study is required for all patients [C] [D] • Documentation of non-surgical treatments that have been tried and failed. • TYPES OF SURGERY- Can include 1 or more of the following : . Mandibular Surgery • Mandibular sagittal split osteotomy(with or without fixation) • Mandibular ramus osteotomy-with or without graft • Mandibular segmental osteotomy • Genioplasty- augmentation or reduction, sliding - Only if not cosmetic • Genioplasty is often requested as part of cosmetic surgery. [E]

ActiveHealth Management Medical Management Guidelines

. Maxillary Surgery • LeForte I Maxillary Osteotomy • LeForte I Maxillary Osteotomy- segmental • LeForte II - with or without graft • LeForte III- with or without graft . Facial Bone Surgery • Osteoplasty -augmentation or reduction Appendix

Reviewed by a Board Certified Internist Reviewed by David Evans, MD, Medical Director, Active Health Management- July 2016 Copyright 2016 ACTIVEHEALTH MANAGEMENT No part of this document may be reproduced without permission. Footnotes

[A] These values represent two or more standard deviation from published norms [ A in Context Link 1 ]

[B] These values represent two or more standard deviation from published norms [ B in Context Link 1 ]

[C] If the patient does not meet the criteria based on the Cephalometric study then documentation in the form of photographs and molds or other documentation must support the diagnosis [ C in Context Link 1 ]

[D] Additional studies such as the analysis from the orthodontist evaluating the current treatment of braces or banding is helpful in determining if the current treatment will not meet the current treatment plan of the patient. This analysis incorporates the angles and projections of the jaw and the bite. [ D in Context Link 1 ]

[E] Evidence must support that the surgery is to improve functional impairment and is not being done for cosmetic reasons [ E in Context Link 1 ] Codes

CPT® or HCPCS: 21120, 21121, 21141, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21193, 21194, 21195, 21196, 21198, 21208, 21209