CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery

This policy addresses mandibular/maxillary (orthognathic) surgery to correct jaw deformities and malocclusion. It is covered when used to treat a significant functional impairment and is expected to improve that impairment—for example, dysphagia related to chewing difficulties with symptoms that are significant, documented for at least 4 months, and after other causes have been ruled out. It is not covered when performed for cosmetic reasons within normal anatomic variation; standalone genioplasty is considered cosmetic and not medically necessary unless associated with masticatory malocclusion.

"Mandibular/Maxillary (orthognathic) surgery is consideredmedically necessaryto treat a significant functional impairment when the procedure can be reasonably expected to improve the functional impa..."

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