"extreme cases"

Here's the lowdown on extreme cases. I don't qualify, by the way.

"Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury. (1)

Note: This policy does not address surgical treatment of temporomandibular joint dysfunction or the surgical management of sleep apnea; discussion of these conditions may be found in Medical Policies, Surgery Nos. 49, 122 and 142.

Policy/Criteria
Orthognathic surgery for the treatment of obstructive sleep apnea may be considered medically necessary when the criteria in Surgery, Policy No. 49 are met.

Orthognathic surgery may be considered medically necessary to correct jaw and craniofacial deformities in the absence of obstructive sleep apnea when all of the following criteria (1-3) are met: Significant functional impairment is documented as a result of illness, injury, congenital anomaly, or developmental anomaly.

Significant functional impairment must be directly attributable to jaw and craniofacial deformities and must include one or more of the following:

• Chewing-induced trauma secondary to malocclusion
• Significantly impaired swallowing and/or choking due to inadequate mastication secondary to malocclusion
• Significant speech abnormalities (e.g., sibilant distortions or velopharyngeal distortion) which have not responded to speech therapy and are secondary to malocclusion
• Loss of masticatory or incisive function due to malocclusion or skeletal abnormality
• Airway restriction

Significant over- or underjet as documented by one of the following:

• In mandibular excess or maxillary deficiency, a reverse overjet of 3mm or greater
• In mandibular deficiency, an overjet of 5mm or greater
• Open bite of 4mm or greater
• Deep bite of 7mm or greater
• Less than six posterior teeth in functional opposition to other teeth secondary to a developmental or congenital growth abnormality (as opposed to a consequence of the loss of teeth)
• The functional impairment and over- or underjet are not correctable with non-surgical treatment modalities.

Orthognathic surgery in the absence of significant physical functional impairment is considered cosmetic, including but not limited to when used for altering or improving bite or for improvement of appearance.

The following documentation is required to determine medical necessity for orthognathic surgery:

• Current study models with the appropriate bite registration and/or the back of the models trimmed such that they represent the patient's current pre-surgical centric occlusion and/or centric relation bite
• Intra-oral and extra-oral photographs
• Cephalometric x-rays
• Diagnostic report
• Panorex x-ray