Is Maxillofacial Surgery Covered By Insurance?

Orthognathic surgery (jaw straightening) is not covered by dental insurance, however it may be covered by medical insurance. Although some medical plans specifically ban orthognathic surgery, most insurance policies allow orthognathic surgery to be authorized “when medically necessary.”

Is oral surgery covered by medical insurance?

Is dental care covered by medical insurance? Yes, many Indian health insurance policies cover treatment costs related to dental and surgical procedures.

Is jaw surgery medically necessary?

With the exception of orthognathic surgery for the treatment of temporomandibular disorders or obstructive sleep apnea, this document covers medically essential, reconstructive, and cosmetic operations involving the mandible, maxilla, or both. Temporomandibular disorders, obstructive sleep apnea, and orthodontia (braces) services are not covered by this agreement.

  • SURG.00129 Surgical Treatment for Obstructive Sleep Apnea or Snoring in the Oral, Pharyngeal, and Maxillofacial Areas

Procedures are considered medically necessary in this article if there is a severe functional impairment AND the procedure can be reasonably expected to improve that impairment.

Procedures are considered reconstructive in this article when they are designed to rectify a major deviation from normal due to an accident, disease, trauma, or treatment of a disease or congenital condition. Note: Benefits for reconstructive services as outlined by this document are not included in all benefit contracts/certificates. This document is superseded by benefit language.

Procedures are deemed cosmetic in this article when they are designed to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are sometimes defined as those whose primary goal is to maintain or improve one’s looks.

When the procedure may be reasonably expected to improve the functional impairment, mandibular/maxillary (orthognathic) surgery is considered medically required to treat a major functional impairment. Any of the following can cause significant functional impairment:

  • choking due to incomplete mastication, trouble swallowing chewed solid food, capacity to chew only soft food, or dependency on liquid meals are all symptoms of difficulties chewing.
  • Symptoms must be documented in the medical record, be severe, and last for at least four months; and
  • The history, physical exam, and relevant diagnostic studies have ruled out other causes of swallowing or choking issues.
  • Speech abnormalities determined by a speech pathologist or therapist to be caused by a malocclusion and not improved by orthodontics or at least six months of speech therapy.
  • Malocclusion-related intra-oral trauma while chewing (for example, loss of food through the lips during mastication, causing recurrent damage to the soft tissues of the mouth during mastication).
  • When requirements 1, 2, and 3 are present, masticatory dysfunction or malocclusion* occurs:
  • Completion of skeletal growth, as evidenced by a long bone x-ray or serial cephalometrics showing no change in facial bone connections over the previous 3- to 6-month period (Class II malocclusions and people over the age of 18 are exempt from this requirement); and
  • Malocclusion should be documented using intra-oral casts (if necessary), bilateral lateral x-rays, cephalometric radiographs with measurements, panoramic radiographs, or tomograms; and
  • The relationship between the maxillary and mandibular incisors (established norm = 2 mm) is defined as one of the following:
  • Overjet from zero to a negative number on the horizontal plane. (Note: Up to 5 mm of overjet may be treated with conventional orthodontic therapy.)
  • Anteroposterior molar relationship difference of 4 mm or greater between the maxillary and mandibular teeth (norm 0 to 1 mm).
  • A vertical facial skeletal malformation that is two or more standard deviations apart from published norms for recognised skeletal markers; or
  • Deep overbite with impingement or irritation of the opposing arch’s buccal or lingual soft tissues; or
  • Two or more standard deviations from established standards in the transverse skeletal discrepancy; or
  • Given normal axial inclination of the posterior teeth, a total bilateral maxillary palatal cusp to mandibular fossa disparity of 4 mm or larger, or a unilateral discrepancy of 3 mm or greater.
  • Anteroposterior, transverse, or lateral asymmetries of more than 3 mm with occlusal asymmetry

*When a skeletal deformity is being treated, a computed tomography (CT), magnetic resonance imaging (MRI), or x-ray must be used to document the abnormality.

When a considerable deviation from normal is caused by an accident, disease, trauma, or the treatment of a disease or congenital deformity, mandibular/maxillary (orthognathic) surgery is considered reconstructive.

When intended to change a physical look that would be deemed within normal human anatomic variation, mandibular/maxillary (orthognathic) surgery is considered aesthetic and not medically required.

When not coupled with masticatory malocclusion, a genioplasty (or anterior mandibular osteotomy) is considered cosmetic and not medically required.

The codes for treatments and procedures that apply to this document are listed below for your convenience. The inclusion or exclusion of a procedure, diagnosis, or device code(s) does not infer or imply that the member is covered or that the provider is reimbursed. To determine coverage or non-coverage of these services as it applies to an individual member, please refer to the member’s contract benefits in force at the time of service.

When conditions are met, services may be Medically Necessary or Reconstructive:

Mandibular body or angle augmentation; bone graft, onlay, or interpositional (includes obtaining autograft)

Midface reconstruction, osteotomies (not LeFort type), and bone grafts (includes obtaining autografts)

Facial bone augmentation and osteoplasty (autograft, allograft, or prosthetic implant)

Extraoral mandible reconstruction with transosteal bone plate (eg, mandibular staple bone plate)

Reconstruction of the mandibular condyle with autografts of bone and cartilage (including graft procurement) (eg, for hemifacial microsomia)

Without or with bone graft, LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion)

Autogenous or nonautogenous osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla, according to report

By report, implant – mandible for augmentation (excluding alveolar ridge).

Mandible excision, open approach [right or left; codes 0NBT0ZZ, 0NBV0ZZ]

When medically necessary or reconstructive criteria are not met for the surgery and diagnosis codes stated above.

The surgical treatment of skeletal defects or deformities involving the mandible (lower jaw) or the maxilla is known as orthognathic surgery (upper jaw). These abnormalities might be present at birth or develop over time as the person grows and develops. Orthognathic surgery can be used to repair malocclusions that have failed to improve with traditional orthodontic treatment and are causing functional problems. Treatment’s overall goal is to increase function by correcting the underlying bone abnormality.

When there is a relative insufficiency of the midface region, maxillary advancement is a type of orthognathic surgery that may be required to enhance facial contour and correct dental occlusion. This is accomplished by surgically repositioning the maxilla and securing it in place using advanced bone mobilization techniques.

Problems with the lower face may necessitate mandible surgery, depending on the soft tissue contour of the face or the severity of an occlusal disparity. This procedure can be done in conjunction with or independently of maxillary surgery. Bone grafts can be used to advance, set back, tilt, or increase the mandible. It’s possible that a mix of these operations will be required. Fixation can be done using mini-plates and screws or a combination of interosseous wires and intermaxillary fixation after any major surgical displacement of the mandible (IMF). The advantage of rigid fixation (screws and plates) is that it requires little or no IMF. When interosseous wire is employed, however, IMF is maintained for around 6 weeks.

There is compelling evidence of a link between face skeletal anomalies and malocclusions, such as Class II, Class III, asymmetry, and open bite deformities, including Class II, Class III, asymmetry, and open bite deformities. The state of an individual’s occlusion has been shown to have a substantial association with chewing efficiency, bite forces, and restricted mandibular excursions. Orthognathic surgery has improved chewing, breathing, and swallowing problems in cases where the severity of the deformity cannot be treated by dental therapies or orthodontics. Individuals with skeletal malocclusions experience a number of functional deficits, including reduced biting forces, restricted mandibular excursions, and aberrant chewing patterns, according to studies. Non-randomized controlled trials and case series studies are examples of evidence in the peer-reviewed literature that support this conclusion.

The American Association of Oral and Maxillofacial Surgeons has released clinical practice guidelines on orthognathic surgery criteria (2020). The following is part of the advice:

In the following situations, orthognathic surgery may be necessary and considered medically appropriate:

  • Anteroposterior molar relationship difference of 4mm or greater between the maxillary and mandibular teeth (norm 0 to 1mm)
  • A vertical facial skeletal malformation that is two or more standard deviations from published norms for recognised skeletal landmarks is present.
  • Deep overbite with impingement or irritation of the opposing arch’s buccal or lingual soft tissues
  • A transverse skeletal disparity of two or more standard deviations from reported norms is seen.
  • Given proper axial inclination of the posterior teeth, a total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater or a unilateral discrepancy of 3mm or greater is required.
  • larger than 3mm anterior-posterior, transverse, or lateral asymmetries with occlusal asymmetry

These indicators link substantial facial abnormalities, maxillary and/or mandibular facial skeletal deformities, and masticatory malocclusion to verifiable clinical measurements. In addition to the aforementioned disorders, orthognathic surgery may be recommended in cases where particular indicators of dysfunction have been observed.

According to Franchi (1998), the cephalometric mean of the sella–nasion–A point angle (SNA) and sella–nasion–B point angle (SNB) using Steiner’s methodology was 82.98 and 80.37, with SDs of 3.46 and 3.21, respectively, in a sample of 100 North Americans. It’s worth noting that the average values for cephalometric measurements differ greatly across ethnic groups (Celebi, 2013; Connor, 1985; Flynn, 1989).

Cephalometrics is the science of interpreting lateral skull x-rays under controlled settings. The Steiner and McNamara analyses are two of the most widely utilized methods of analysis in orthodontics.

Class I occlusion: When the mesial-buccal cusp of the maxillary first permanent molar corresponds with the buccal groove of the mandibular first molar, the teeth are in a normal relationship.

When the mandibular teeth are distal or behind the normal relationship with the maxillary teeth, it is classified as a Class II malocclusion. This can be caused by a lower jaw shortage or an overabundance of the upper jaw, resulting in two types: (1) Division I occurs when the mandibular arch is behind the upper jaw, causing the top front teeth to protrude. (2) Division II occurs when the mandibular teeth are behind the upper teeth and the maxillary front teeth have retruded. Because of the uncontrolled migration of the lower front teeth upwards, both of these malocclusions show a propensity toward a deep bite. An overbite is a common term for this condition.

When the lower dental arch lies in front of (mesial to) the upper dental arch, it is classified as a Class III malocclusion. A strong or protruding chin is common in people with this type of occlusion, which can be caused by either horizontal mandibular excess or horizontal maxillary deficit. It’s also known as an under bite.

Dentoalveolar refers to the area of the alveolar bone directly surrounding a tooth.

Mastication is the process of chewing and grinding food in the mouth until it is soft enough to swallow.

The upper jaw is made up of two bones that constitute the skeletal base of the upper face, the roof of the mouth, the sides of the nasal cavity, and the floor of the orbit (which houses the eye).

McNamara analysis is one of the most widely used cephalometric procedures. It combines the anterior reference plane with information on the length of the individual’s jaw and their relationship.

Occlusion is the process of bringing the opposing surfaces of the teeth of the two jaws (mandible and maxilla) together.

Orthodontics is the branch of dentistry that deals with the prevention and treatment of crooked or misaligned teeth.

Panoramic radiograph: From the left to right glenoid fossa, a radiograph of the maxilla and mandible is taken. On a single film, an x-ray image of a curving body surface, such as the upper and lower jaws.

Skeletal discrepancies: A phrase used in orthodontics to characterize the nature of a malocclusion as a malrelationship of the bony basis rather than just the teeth; cephalometrics is typically used to analyze this.

One of the most widely utilized cephalometric analysis methods is the Steiner analysis. The SNA angle is used to determine the maxilla’s anteroposterior location in relation to the cranial base. The most crucial measures in Steiner’s analysis, according to him, were the ANB angle, which is created by the difference between the SNA and SNB angles.

Supraeruption: When the opposing tooth in the opposite jaw is gone, a tooth continues to grow out of the gum.

Tomography is the process of imaging by sections or sectioning using any type of penetrating wave.

  • SJ Ahn, JT Kim, and DS Nahm Cephalometric markers to consider while using the bionator to treat Class II Division 1 malocclusion. 2001; 119(6):578-586 in American Journal of Orthodontics and Dentofacial Orthopedics.
  • The long-term clinical morbidity of mandibular step osteotomy, Cheung LK, Lo J. Int J Adult Orthod Orthognath Surg, vol. 17, no. 4, pp. 283-290, 2002.
  • Am J Orthod. 1985; 87(2):119-134. Connor AM, Moshiri F. Orthognathic surgery norms for American black patients.
  • TR Flynn, RI Ambrogio, and SJ Zeichner. Orthognathic surgery cephalometric norms in black individuals in the United States. J Oral Maxillofac Surg, vol. 47, no. 1, pp. 30–39, 1989.
  • Han, H., and Davidson, W. M. HLD(Md) and HLD(Md) are two occlusal indexes that provide useful information (CalMod). Am J Orthod Dentofacial Orthop, vol. 120, no. 3, 2001, pp. 247-253.
  • CS Huang, SS Hsu, and YR Chen. In orthognathic surgery, a systematic review of the surgery-first method was conducted. Biomed J., vol. 37, no. 4, pp. 184-190, 2014.
  • The reliability and variability of the SN and PFH reference planes in cephalometric diagnosis and treatment planning of dentomaxillofacial abnormalities, Incisivo V, Silvestri A. J Craniofacial Surg, vol. 11, no. 1, pp. 31-38, 2000.
  • Long-term follow-up of Class II adults treated with orthodontic camouflage: a comparison with orthognathic surgery results, Mihalik CA, Profitt WR, Phillps C. 123(3):266-278 in American Journal of Orthodontics and Dentofacial Orthopedics, 2003.
  • Iwasaki LR, Nickel JC, Yao P, Spalding PM, Nickel JC. The benefits of combined orthodontic and orthognathic surgical treatment on TMJ loads and muscle forces have been numerically validated. 121(1):73-83 in American Journal of Orthodontics and Dentofacial Orthopedics, 2002.
  • MA Oomens, CR Verlinden, Y Goey, T Forouzanfar A systematic study of antimicrobial prophylaxis in orthognathic surgery. International Journal of Oral and Maxillofacial Surgery, 43(6), 725-731, 2014.
  • Angle Class III malocclusion classification and treatment techniques, Park JE, Baik SH. Int J Adult Orthod Orthognath Surg, vol. 16, no. 1, pp. 19-29, 2001.
  • Adult Class II Division 1 treatment: mandibular sagittal split osteotomy against Herbst appliance. Ruf S, Pancherz H. Orthognathic surgery and dentofacial orthopedics in adult Class II Division 1 treatment: mandibular sagittal split osteotomy versus Herbst appliance. 126(2):140-152 in American Journal of Orthodontics and Dentofacial Orthopedics, 2004.
  • A. Stellzig-Eisenhauser, C.J. Lux, and G. Schuster. Is orthodontic therapy or orthognathic surgery the best treatment option for adult patients with Class III malocclusion? 122(1):27-38 in American Journal of Orthodontics and Dentofacial Orthopedics, 2002.
  • Concomitant temporomandibular joint and orthognathic surgery: a preliminary report, Wolford LM, Karras S, Mehra P. J Oral Maxillofac Surg, 60(4), 356-362, 2002.
  • Consideration for orthognathic surgery throughout growth, part 1: mandibular abnormalities. Wolford LM, Karras SC, Mehra P. 119(2):95-101 in American Journal of Orthodontics and Dentofacial Orthopedics, 2001.
  • Consideration for orthognathic surgery throughout growth, part 2: maxillary abnormalities. Wolford LM, Karras SC, Mehra P. 2001; 119(2):102-105 in American Journal of Orthodontics and Dentofacial Orthopedics.
  • Condylar bony alteration, disk displacement, and signs and symptoms of TMJ issues in orthognathic surgery patients. Yamada K, Hanada K, Hayashi T, Ito J. 91(5):603-610 in Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

Review by the Medical Policy and Technology Assessment Committee (MPTAC). In the Clinical Indications section, the term “physical” was removed from the term “physical functional impairment.” Discussion and References sections have been updated. The Coding section has been redesigned, and examples of diagnosis codes have been added.

Review of the MPTAC. The first draft of the document. SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery’s content has been moved to a new clinical utilization management guideline paper with the same name.

Is facial asymmetry surgery covered by insurance?

Because each facial asymmetry surgery is tailored to the patient’s personal requirements, prices vary. When your insurance company deems that the operations are medically necessary to correct deformities or functional difficulties, coverage may be provided.

We will be able to discuss prices in greater detail with you during your consultation appointment. Our team will also go over the various financing alternatives and assist with insurance approval questions.

Why is orthognathic surgery not covered by insurance?

Although orthognathic surgery for malocclusion or other jaw asymmetry may be recommended from a dental standpoint, it is not a covered benefit unless there is convincing documentation, based on medical records maintained over time by treating physicians, that (1) the malocclusion is affecting the patient’s PHYSICAL health.

Can I claim insurance for root canal treatment?

Dental insurance covers dental procedures that are deemed necessary by a medical practitioner but do not include aesthetic dentistry. Procedures are divided into two categories: preventative and diagnostic. Filling cavities, tooth extractions, dentures, root canal procedures, and other procedures are all covered by dental insurance.

What does medical cover for dental work?

Medi-Cal Dental Benefits Program Tooth extractions; fillings; anterior/posterior root canal treatments; crowns (prefabricated/laboratory);

What’s the difference between a dentist and an oral surgeon?

Patients have a wide range of dental professionals to choose from, and determining which type of dental expert is appropriate for your present needs can be difficult. Understanding the distinctions between regular dentists and oral surgeons, such as Dr. Matthew Hilmi, can assist you in making an informed dental care decision.

After earning a bachelor’s degree, both general dentists and oral surgeons must attend dental school. Students study anatomy, physiology, pharmacology, pathology, and oral surgery in dental school, which normally takes four years of full-time study. Dental students also participate in clinical practicums, where they learn how to identify and treat dental disorders firsthand.

A general dentist must pass a license exam to practice in a specific region after graduating from dental school with a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) degree. Oral surgeons (also known as oral and maxillofacial surgeons) go through a four- to six-year surgical residency. The Commission on Dental Accreditation must approve the residency program, ensuring that each resident receives the necessary training in oral pathology, anesthesia, oral surgery, and other areas. After completing a surgical residency, a person must pass a board certification exam.

General dentists are the primary care providers in the field of dentistry. You will receive teeth cleaning, X-rays, and a thorough dental screening at a regular dentist’s practice. Gum care, dental fillings, root canals, veneers, bridges, and crowns are the most common services provided by general dentists. They also offer suggestions on how to avoid frequent dental issues. Although a general dentist can do simple tooth extractions, more complex surgeries may be beyond his or her scope of practice.

Oral and maxillofacial surgeons are trained to treat a wide range of problems that affect the face, mouth, and jaw. When an issue is beyond the area of a general dentist’s skill, patients are usually referred to an oral surgeon. Simple and sophisticated tooth extractions, including wisdom tooth extraction, are performed by oral surgeons. They also assist accident victims who require reconstructive dentistry. Soft tissue biopsies, tumor excision, jaw realignment surgery, soft tissue repair, and implant placing are all procedures that oral surgeons can undertake.

It can be challenging to figure out which dental expert is best for you. Please contact our office to see if an oral surgeon is the right option for you.

Who qualifies for jaw surgery?

The following are some examples of situations that necessitate corrective jaw surgery: Your chin is retreating. You’ve had a face injury or have birth abnormalities that have caused your jaw to misalign. You have an elongated jaw.

Is malocclusion covered by insurance?

2. Minor malocclusion adjustments are considered cosmetic. NOTE: A group can specify which dental services are covered under their dental or medical plan, as well as which services are subject to dollar constraints or other limitations.