Prior Authorization for Orthognathic Surgery

Harvard Pilgrim will require prior authorization for orthognathic surgery for Commercial members, effective for dates of service beginning Oct. 1, 2022, and the following InterQual criteria subsets will be used for medical review:

  • Bone Augmentation, Mandible
  • Bone Augmentation, Maxilla
  • Osteotomy, Anterior Segment, Mandible
  • Osteotomy, LeFort I
  • Osteotomy, Sagittal Split, Mandible Ramus
  • Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy
  • Osteotomy, Anterior Segment, Maxilla

When submitting authorization requests to InterQual through HPHConnect, electronic authorization questionnaires will guide you through the criteria. You may view and print the applicable SmartSheet questionnaires by navigating to www.harvardpilgrim.org/providerportal and selecting Resources and then the Upcoming InterQual link.

For more information, including codes for which prior authorization will be required, please refer to Harvard Pilgrim’s Orthognathic Surgery for Severe Oral-Maxillofacial Functional Disorders Medical Policy. Codes listed on the policy include — but are not limited to — the following CPT codes, which have been removed from the Gender Affirming Services Medical Policy but will continue to require prior authorization under the Orthognathic policy:

  • 21141 – Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), without bone graft
  • 21142 – Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft
  • 21143 – Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft
  • 21145 – Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
  • 21146 – Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft)
  • 21147 – Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies)
  • 21188 – Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)
  • 21230 – Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
  • 21244 – Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)
  • 21245 – Reconstruction of mandible or maxilla, subperiosteal implant; partial

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