Anthem Blue Cross Blue Shield of Georgia policy
CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery is a public Anthem Blue Cross Blue Shield of Georgia policy (policy CG-SURG-84). It lists 45 CPT or HCPCS codes, 44 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-84
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| 00129 | Not listed | Policies naming 00129 | |
| 21120 | On the list | Genioplasty; augmentation (autograft, allograft, prosthetic material) | Policies naming 21120 |
| 21121 | On the list | Genioplasty; sliding osteotomy, single piece | Policies naming 21121 |
| 21122 | On the list | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) | Policies naming 21122 |
| 21123 | On the list | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) | Policies naming 21123 |
| 21125 | On the list | Augmentation, mandibular body or angle; prosthetic material | Policies naming 21125 |
| 21127 | On the list | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) | Policies naming 21127 |
| 21141 | On the list | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft | Policies naming 21141 |
| 21142 | On the list | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | Policies naming 21142 |
| 21143 | On the list | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | Policies naming 21143 |
| 21145 | On the list | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) | Policies naming 21145 |
| 21146 | On the list | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) | Policies naming 21146 |
| 21147 | On the list | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) | Policies naming 21147 |
| 21150 | On the list | Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) | Policies naming 21150 |
| 21151 | On the list | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) | Policies naming 21151 |
| 21154 | On the list | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I | Policies naming 21154 |
| 21155 | On the list | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I | Policies naming 21155 |
| 21188 | On the list | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) | Policies naming 21188 |
| 21193 | On the list | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft | Policies naming 21193 |
| 21194 | On the list | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) | Policies naming 21194 |
| 21195 | On the list | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation | Policies naming 21195 |
| 21196 | On the list | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation | Policies naming 21196 |
| 21198 | On the list | Osteotomy, mandible, segmental | Policies naming 21198 |
| 21199 | On the list | Osteotomy, mandible, segmental; with genioglossus advancement | Policies naming 21199 |
| 21206 | On the list | Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) | Policies naming 21206 |
| 21208 | On the list | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) | Policies naming 21208 |
| 21209 | On the list | Osteoplasty, facial bones; reduction | Policies naming 21209 |
| 21210 | On the list | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | Policies naming 21210 |
| 21215 | On the list | Graft, bone; mandible (includes obtaining graft) | Policies naming 21215 |
| 21244 | On the list | Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) | Policies naming 21244 |
| 21245 | On the list | Reconstruction of mandible or maxilla, subperiosteal implant; partial | Policies naming 21245 |
| 21246 | On the list | Reconstruction of mandible or maxilla, subperiosteal implant; complete | Policies naming 21246 |
| 21247 | On the list | Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) | Policies naming 21247 |
| D7940 | On the list | Osteoplasty - For Orthognathic Deformities | Policies naming D7940 |
| D7941 | On the list | Osteotomy - Mandibular Rami | Policies naming D7941 |
| D7943 | On the list | Osteotomy - Mandibular Rami With Bone Graft; Includes Obtaining The Graft | Policies naming D7943 |
| D7944 | On the list | OSTEOTOMY-SEGMENTED OR SUBAPICAL | Policies naming D7944 |
| D7945 | On the list | osteotomy - body of mandible | Policies naming D7945 |
| D7946 | On the list | LeFort I (maxilla - total) | Policies naming D7946 |
| D7947 | On the list | Lefort I (Maxilla - Segmented) | Policies naming D7947 |
| D7948 | On the list | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft | Policies naming D7948 |
| D7949 | On the list | Lefort II Or Lefort III - With Bone Graft | Policies naming D7949 |
| D7950 | On the list | Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report | Policies naming D7950 |
| D7995 | On the list | Synthetic Graft - Mandible Or Facial Bones, By Report | Policies naming D7995 |
| D7996 | On the list | Implant-Mandible For Augmentation Purposes (Excluding Alveolar Ridge), By Report | Policies naming D7996 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list