21497
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
4.52
Facility
$561.80
Non-Facility
$717.12
Documentation Required
- Medical history and physical examination with reference to symptoms related to the orthognathic deformity.
- Description of the specific anatomic deformity present (documentation of skeletal measurements and deformity type).
- Lateral and anterior-posterior (posteroanterior) cephalometric radiographs.
- Cephalometric tracings and documentation of all key anatomical landmarks and measurements used to demonstrate deviation from norms (e.g., overjet, molar relationship discrepancy, vertical/transverse asymmetry measurements).
Key Coverage Criteria
- Orthognathic surgery is considered medically necessary when BOTH of the following criteria are met: (A) presence of a facial skeletal deformity (see specific deformities below) AND (B) presence of a functional impairment (see specific impairments below).
- Anteroposterior skeletal discrepancies: maxillary/mandibular incisor relationship with horizontal overjet of 5 millimeters (mm) or more, or a zero to negative value (norm = 2 mm).
- Anteroposterior skeletal discrepancies: maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more (norm = 0-1 mm).
- Vertical discrepancies: presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks.
- Vertical discrepancies: open bite with no vertical overlap of anterior teeth or unilateral or bilateral posterior open bite greater than 2 mm.
- Vertical discrepancies: deep overbite with impingement of palatal soft tissue (impingement or irritation of buccal or lingual soft tissues of the opposing arch).
1 Active Policy
CIGNA-0209 — Orthognathic Surgery - (0209)
Related Codes
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