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36.3.8 Orthognathic Surgery
Orthognathic surgery is a benefit of the Texas Medicaid Program only when it is necessary for medical reasons, or when it is necessary as part of an approved plan of care in the Texas Medicaid Dental Program. Orthognathic surgery is administered and reimbursed as part of the medical/surgical benefit of the Texas Medicaid Program and not as part of the Texas Medicaid Dental Program.
Treatment of malocculsion is a benefit of the Texas Medicaid Dental Program. Orthognathic surgery is a benefit when it is necessary as part of the approved dental benefit.
Maxillary and/or mandibular facial skeletal deformities are associated with clearly abnormal masticatory malocclusion.
Orthognathic surgery may be considered medically necessary for the following client conditions:
• Producing signs or symptoms of masticatory dysfunction.
•Facial skeletal discrepancies associated with documented sleep apnea, airway defects, and soft tissue discrepancies.
•Facial skeletal discrepancies associated with documented speech impairments.
•Structural abnormalities of the jaws secondary to infection, trauma, neoplasia, or congenital anomalies.
Orthognathic surgery that is done primarily to improve appearance and not for reasons of medical necessity is considered cosmetic and is not a benefit of the Texas Medicaid Program.
Prior Authorization
The following orthognathic medical surgical services may be considered for reimbursement to oral and maxillofacial surgeons when mandatory prior authorization is received from the TMHP Medical Director or designee. A narrative explaining medical necessity must be provided with the authorization request.
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