Orthognathic Surgery

This policy covers orthognathic surgery (surgical correction of maxillary and/or mandibular skeletal deformities) for significant anteroposterior, vertical, transverse, or asymmetry discrepancies and associated functional conditions such as impaired mastication/swallowing, speech dysfunction, TMJ/myofascial pain refractory to conservative care, malnutrition/weight loss, congenital/developmental/post‑traumatic deformities, and obstructive sleep apnea when objective criteria are met. Procedures performed solely for cosmetic purposes or in patients still growing when less invasive orthodontic treatment could correct the problem are not medically necessary; coverage requires documented objective findings (e.g., measured discrepancies, polysomnogram with PAP failure/intolerance and failure/not candidate for less invasive surgery where applicable), adherence to conservativetreatment requirements, and is subject to member benefit limits and state Medicaid provisions.