Coverage Gaps and Inconsistencies: The Landscape of Insurance Coverage for Orthognathic Surgery in the United States

Abstract

Background:

Despite established indications for orthognathic surgery, insurance coverage is not guaranteed and obtaining coverage is often onerous. There is a paucity of literature regarding insurance coverage within the United States for orthognathic surgery.

Methods:

The top 50 health insurers in the US, and the top 3 per state, were selected using the National Association of Insurance Commissioners (NAIC) 2020 Market Share Report. Coverage policies were obtained online, or by phone when unavailable. Indications and criteria were compared to the American Association of Oral and Maxillofacial Surgeons (AAOMF) “Criteria for Orthognathic Surgery” recommendations.

Results:

Of the 65 insurance providers reviewed, 33 offered coverage with clear criteria, 24 offered coverage without listed criteria, and 8 explicitly excluded all orthognathic surgery. The 33 insurers with clear criteria were further reviewed. For malocclusion, 20 insurers used at least 75% of AAOMF measurements, while 4 used stricter criteria. Eleven insurers covered surgery for any congenital disorder; of the remaining, only 13 explicitly covered cleft-associated abnormalities. For the 25 with specified speech anomaly criteria, 21 offered coverage, and 4 excluded coverage. Sleep apnea coverage criteria were inconsistent, and temporomandibular joint disorder (TJMD) coverage was evenly split. No insurer covered orthognathic surgery for esthetic or psychological reasons. Among 66 identified unique criteria, only 6 significantly differed by US Census Region, with coverage for sleep apnea more prevalent in the South District.

Conclusions:

Access to insurer policies remains difficult. Insurers have inconsistent covered indications, strictness of coverage criteria, and exclusions, which frequently do not match standards of care. The authors present a list of the most commonly used criteria as a resource for insurance submissions, and encourage surgeons to advocate at the insurer and legislative levels for consistent coverage indications and criteria across insurance providers.