Orthognathic Surgery (Jaw Surgery) & Insurance Coverage

Orthognathic (jaw straightening) surgery is not a dental insurance matter, but may be a covered benefit on the medical insurance. 

Although there are some medical plans that specifically exclude orthognathic surgery, most insurance plans permit the authorization of orthognathic surgery “when medically necessary”. Please check whether it is a covered benefit on your insurance plan. The typical diagnosis codes (ICD-10) used are: M26.00-06, M26.10-12, M26.212, M26.213, M26.220, and M26.221. The typical procedure codes (CPT) used are as follows: 21120-21123, 21141-21147, 21193-21198.

The issue for the insurance carrier is usually to identify the medical necessity. This is the decision of the insurance company based on criteria set by them, not Fantuzzo – Oral, Maxillofacial & Dental Implant Surgery, PLLC.

For your initial consultation visit, please bring any radiographs and models that you may have with you, including those from your orthodontist, and give some thought to the issue of “medical necessity.”

Most patients require many months of orthodontic treatment prior to surgery. It is virtually impossible to receive any kind of insurance authorization prior to commencement of orthodontic treatment. Most insurance companies will not authorize a procedure that will not be carried out for several months. Therefore, authorization is only requested as the patient approaches “orthodontic readiness” for surgery. In fact most insurance authorizations are only valid for 90 days from the time they are issued. This means that most potential patients must commence orthodontic treatment prior to knowing whether their surgery will be authorized. Your insurance company may have a different policy.

Requests sent to the insurance carrier for prior authorization before orthognathic surgery often take 4-8 weeks for a response. Please be patient during this process.

Your surgery cannot be scheduled with the operating room until we have a valid insurance authorization to cover the proposed surgery date and associated global period.