Prior Authorization Review Panel MCO Policy Submission A ......CPB 0549 Distraction Osteogenesis for Craniofacial Defects . Clinical content was last revised on 09/05/2013. No additional

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date:10/01/2019

Policy Number: 0549 Effective Date: Revision Date: 09/05/2013

Policy Name: Distraction Osteogenesis for Craniofacial Defects

Type of Submission – Check all that apply:

New Policy Revised Policy* Annual Review – No Revisions Statewide PDL

*All revisions to the policy must be highlighted using track changes throughout the document.

Please provide any clarifying information for the policy below:

CPB 0549 Distraction Osteogenesis for Craniofacial Defects

Clinical content was last revised on 09/05/2013. No additional non-clinical updates were made byCorporate since the last PARP submission.

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

Revised July 22, 2019

http://www.aetna.com/cpb/medical/data/500_599/0549.html

Page 1 of 18

(https://www.aetna.com/)

Distraction Osteogenesis forCraniofacial Defects

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Pol icy History Last

Review

10/10/2018

Effective: 08/14/2000

Next Review:

05/23/2019

Review History

Definitions

Additional Information

Number: 0549

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

I. Aetna considers distraction osteogenesis (distraction histogenesis)

medically necessary for the correction of functional impairments

accompanying the following congenital craniofacial skeletal deformities:

Cleft lip and palate; or

Correction of hemifacial microsomia, in children with sufficient bone to

allow for a corticotomy and/or osteotomy and placement of pins for

external or internal distraction devices (i.e., Pruzansky Grade I and IIa

type mandibular deformity); or

Correction of severe congenital mandibular deficiency requiring

lengthening of the mandible of greater than 10 mm (orthognathic

surgery is able to correct smaller mandibular deformities); or

Correction of severe micrognathia (such as accompanying Pierre Robin

syndrome or Treacher Collins syndrome) in infants and children with

airway obstruction; or

Lengthening of a short mandibular ramus (stretching of

pterygomasseteric sling); or

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Non-syndromic craniosynostosis -- coronal (bilateral or unilateral) or

sagittal; or

Syndromic craniosynostosis -- Apert, Crouzon, and Pfeiffer syndromes;

or

Widening of a narrow mandible or maxilla.

Upon review by Aetna's Oral and Maxillofacial Surgery (OMS) Unit, distraction

osteogenesis may be considered medically necessary for correction of functional

impairments accompanying other congenital craniofacial anomalies where it is

determined that distraction osteogenesis can uniquely produce a degree of improvement

unavailable with other standard techniques.

II. Aetna considers distraction osteogenesis experimental and investigational

for acquired craniofacial defects (e.g., reconstruction of defects following

tumor (e.g., osteosarcoma) resection, or ablative head and neck surgery),

obstructive sleep apnea, and all other craniofacial indications because of

insufficient evidence regarding the clinical value of this approach for these

indications.

III. Aetna considers enhancement of bone formation by means of bone

morphogenetic proteins and local injection of bone marrow aspirate and

platelet gel at the osteotomy site during distraction osteogenesis

experimental and investigational because of insufficient evidence in the

peer-reviewed literature.

IV. Aetna does not cover distraction osteogenesis (distraction histogenesis) in

preparation for dental implants or orthodontic care under plans that

exclude dental implants or orthodontic care. Please check benefit plan

descriptions. See

CPB 0082 - Dental Services and Oral and Maxillofacial Surgery - Coverage

under Medical Plans (../1_99/0082.html)

V. Aetna considers distraction osteogenesis for the sole purpose of improving

individual appearance and profile cosmetic.

See also CPB 0004 - Obstructive Sleep Apnea in Adults (../1_99/0004.html),

CPB 0095 - Orthognathic Surgery (../1_99/0095.html)

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, CPB 0220 - Distraction Osteosynthesis (../200_299/0220.html),

CPB 0244 - Wound Care (../200_299/0244.html)

CPB 0411 - Bone and Tendon Graft Substitutes and Adjuncts

, (../400_499/0411.html)

, and CPB 0752 - Obstructive Sleep Apnea in Children (../700_799/0752.html).

Background

Orthognathic surgery is the surgical correction of skeletal anomalies or

malformations involving the midface, mandible and maxilla. These malformations

may be present at birth, or may become evident as the patient grows and

develops. Jaw malformations can cause chewing and eating difficulties, abnormal

speech patterns, early loss of teeth, and disfigurement and dysfunction of the

maxilla and mandible. Mal-occlusion may be caused by a deficiency or excess of

bony tissue in one or both jaws, or by trauma to the facial bones.

In orthognathic surgery, an osteotomy is made in the affected jaw, and the bones

are repositioned in a more physiologic alignment. Generally, the bones are held in

their new positions with plates, screws and wires. The patient may also need arch

bars placed on both jaws to add stability (a procedure called intermaxillary

fixation). For patients with deformities affecting both jaws, either simultaneous or

staged osteotomies may be undertaken to achieve correction. Patients with

deficient bone tissue may require grafts from their ribs, hips or skull. Alloplastic

replacement of missing bone may also be required.

Indications for orthognathic surgery include: (i) mandibular prognathism; (ii)

mandibular retrognathia; (iii) maxillary excess; (iv) maxillary deficiency; and (v)

apertognathia (open bite deformity). In some cases, adjunctive procedures such

a reconstructive rhinoplasty, malar and chin osteoplasty, and bone grafting are

needed to correct deformities; however these procedures require evaluation by the

Oral and Maxillofacial Surgery Unit to determine coverage. These adjunctive

procedures are typically considered cosmetic in nature.

Distraction osteogenesis, initially developed by Ilizarov for limb lengthening has

recently been applied to the correction of severe congenital or acquired craniofacial

deformities as an early alternative to orthognathic surgery. Distraction

osteogenesis involves the lengthening and re-shaping of deformed bone by

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surgical fracture and gradual separation of bony segments. The surgeon lengthens

and re-shapes deformed bone by surgically fracturing the bone and slowly

separating (distracting) the resultant segments with specially fabricated hardware.

The bony fragments are held in place during the first week following surgical

fracture to allow callus to form between the fragments. During the next several

weeks, the fragments are gradually separated at a rate of 1 to 2 millimeters per

day, up to a pre-determined length (e.g., 20 days for 20 millimeters or 5/8 inches).

The bone segments are moved gradually to allow callus formation and adaptation

of fibromuscular attachments. Once the desired length and shape is achieved, the

hardware is left in place for an additional 6 weeks until the newly formed bone

calcifies.

The specially fabricated hardware used for the distraction process can be internal

or external. Advantages of external devices include ease of placement and

removal. In addition, some external devices allow multi-dimensional control.

External devices, however, are very conspicuous and are more likely to cause

traction scars than internal devices. Internal devices are less visible than external

devices, and directly transmit force to the bone. Internal devices, however, are only

uni-directional and require a subsequent surgical procedure for their removal.

The primary advantage claimed in connection with distraction osteogenesis is that it

allows major reshaping of the facial bones without bone grafts or jaw wiring.

Proponents claim that distraction osteogenesis may be safer than other methods of

facial reconstruction, since it can involve less blood loss and a lower risk of

infection. However, according to available literature, distraction osteogenesis has

several drawbacks. If the bone ends are moved apart too slowly, callus may calcify

too soon, preventing further distraction. If the bone ends are moved apart too

rapidly, callus may become too fibrous and fail to mature into solid bone.

Therefore, the rate and rhythm of distraction is important to the quality and quantity

of bone that is formed.

The published literature regarding the effectiveness of distraction osteogenesis for

craniofacial anomalies has focused on its use in repair of congenital conditions in

young children. The published clinical literature on distraction osteogenesis for

developmental and acquired craniofacial deformities is more limited, and consists

primarily of case series reporting on its technical feasibility, peri-operative morbidity,

and short-term outcomes. Orthognathic surgery is the established method of

correcting developmental mandibular deficiencies, maxillary deficiencies and other

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developmental and acquired craniofacial deformities. More investigation is

necessary to refine distraction osteogenesis technique, to help define its role in

craniofacial surgery, and to improve the design and reliability of distraction devices

in repairing developmental and acquired deformities in older children and adults

whose growth is at or near completion. Moreover, there are insufficient published

data on the long-term effectiveness of this procedure for these indications,

especiallyon the rate of skeletal relapse.

According to a position statement from the American Association of Oral and

Maxillofacial Surgeons (AAOMS, 2003), “the indications for distraction involving the

jaws are limited to conditions in which this technique may be uniquely able to

produce significant improvement over more traditional therapy.” According to the

AAOMS (2003), examples of these situations are as follows:

Narrow mandible that must be widened. There has been little success in

widening the mandible with conventional surgery prior to the advent of

distraction. Distraction techniques offer a better way to address this problem

Need for lengthening of a short mandibular ramus. According to the AAOS, the

nature of distraction osteogenesis is well-suited for stretching of the

pterygomasseteric sling, which is not easily overcome by conventional

procedures.

Severe deficiency of either jaw with early correction indicated (e.g., an infant

with Pierre Robin with mandibular deficiency so severe that tracheostomy is

required and advancement of the mandible is the only way to correct an

obstructive situation).

Severe mandibular deficiency requiring lengthening of the mandible of greater

than 10 mm. Growth modification via orthodontics generally produces no more

than 5 mm differential growth and conventional orthognathic procedures

become more difficult and less predictable when greater than 8 to 10 mm

advancement is needed.

The AAOMS guidelines also list alveolar deficiency among examples of established

indications for distraction osteogenesis for craniofacial anomalies. However, there

is insufficient published evidence of the effectiveness of distraction osteogenesis for

vertical augmentation of the alveolar ridge in comparison with grafting techniques

for this indication.

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The AAOMS guidelines list “[w]idening of the maxilla in an adult” among

established indications for distraction osteogenesis. However, surgically assisted

palatal expansion, which is analogous to distraction osteogenesis, has been utilized

to overcome this problem for decades with very desirable and stable results".

AAOMS guidelines note that, “[a]s with any procedure, distraction osteogenesis

should be utilized primarily when superior results can be achieved com pared to

conventional techniques” (AAOMS, 2003).

Although the AAOMS guidelines do not distinguish between congenital and

developmental and acquired conditions, the published evidence to date has

focused on repair of congenital conditions. There is insufficient evidence of the

effectiveness of distraction osteogenesis for developmental and acquired

craniofacial anomalies.

Schreuder et al (2007) noted that bilateral sagittal split osteotomy (BSSO) and

distraction osteogenesis are the most common techniques currently applied to

surgically correct mandibular retrognathia. These investigators reviewed the

literature on BSSO and mandibular distraction osteogenesis with emphasis on the

influence of age and post-surgical growth, damage to the inferior alveolar nerve,

and post-surgical stability and relapse. Although randomized clinical trials are

lacking, some support was found in the literature for distraction osteogenesis

having advantages over BSSO in the surgical treatment of low and normal

mandibular plane angle patients needing greater advancement (greater than 7

mm). In all other mandibular retrognathia patients the treatment outcomes of

distraction osteogenesis and BSSO seemed to be comparable. Distraction

osteogenesis is accompanied by greater patient discomfort than BSSO during and

shortly after treatment, but it is unclear if this has any consequences in the long-

term. There is a need for randomized clinical trials comparing the 2 techniques in

all types of mandibular retrognathia, in order to provide evidence-based guidelines

for selecting which retrognathia cases are preferably treated by BSSO or distraction

osteogenesis.

Sacco and Chepeha (2007) stated that earlier work has reported encouraging

results regarding the translation of distraction osteogenesis from animal studies to

human uses, with particular success in the un-radiated setting. The major

challenge surrounding the use of this technology in head and neck oncological

reconstruction will be the effect of radiotherapy on the regenerate bone in patients

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who have received or will need radiotherapy as part of their treatment. Although

distraction osteogenesis provides an attractive option for reconstructing mandibular

defects, large human studies are needed to further evaluate the use of this

technology and its role in the treatment for mandibular neoplasms.

Ow and Cheung (2008) stated that mandibular distraction osteogenesis has been

used effectively to treat syndromic craniofacial deformities. In recent years, its

scope of application has widened to include treatment of airway obstruction in

adults and children as well as non-syndromic class II mandibular hypoplasia. So

far, there has been no evidence-based review of mandibular distraction

osteogenesis for mandibular lengthening. These investigators carried out a meta-

analysis of mandibular distraction osteogenesis. Two rounds of searches were

performed by 2 independent assessors. The first-round PubMed search used the

keywords "mandible" and "distraction osteogenesis". In the second-round search,

the reference lists of the articles were retrieved. For both rounds, abstracts and

then full articles were reviewed and selected on the basis of a set of inclusion and

exclusion criteria. The 178 retrieved articles yielded 1,185 mandibular distraction

osteogenesis patients: 539 received unilateral mandibular distraction osteogenesis

and 646 received bilateral mandibular distraction osteogenesis. Mandibular

distraction osteogenesis was reported to improve facial asymmetry and

retrognathia (50.1 %), correct the slanted lip commissure (24.7 %), and improve or

level the mandibular occlusal plane (11.1 %) in unilateral asymmetry cases,

whereas bilateral mandibular distraction osteogenesis was shown to be effective in

preventing tracheostomies for 91.3 % of neonates or infants with respiratory

distress, and in relieving symptoms of obstructive sleep apnea for 97.0 % of

children and 100 % of adult patients. The authors concluded that mandibular

distraction osteogenesis is effective in treating craniofacial deformities, but further

clinical trials are needed to evaluate the long-term stability and to compare the

treatment with conventional treatment methods, especially in cases of obstructive

sleep apnea or class II mandibular hypoplasia.

In a retrospective medical review spanning a 9-year period, Kolstad and colleagues

(2011) examined if there is a difference in mandibular distraction osteogenesis

(MDO) treatment success rates and adverse outcomes in newborns, early infants,

and older pediatric patients. Ten newborn (less than or equal to 35 days old), 5

early infant (36 days to 5 months) and 8 older pediatric (greater than 5 months)

patients underwent MDO for treatment of micrognathia with a severe tongue-based

obstruction. Success was defined as avoidance of tracheostomy or continuous

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positive airway pressure, and de-cannulation of patients with tracheotomies. Post-

operative complications were grouped into minor and major. MDO successfully

treated 90 % of newborns, 100 % of early infants and 100 % of older pediatric

patients. There was no difference in the rates of success (p = 0.48), minor (p =

1.00) and major (p = 1.00) post-operative complications between newborns and

early infants. Older pediatric patients had no treatment failures, tended to have

fewer minor (p = 0.18) and significantly fewer major (p = 0.04) post-operative

complications compared to younger patients. The distractor pin mobility (9 %) and

scar revisions (13 %) were uncommon. The authors concluded that MDO is a

reliable method for relieving severe tongue-based obstructions in pediatric

patients. When comparing newborns and early infant patients, treatment success

rates and the occurrence of complications were not found to be different. Older

pediatric patients had no treatment failures, and tended to have fewer post-

operative complications compared to younger patients.

Pluijmers et al (2014) provided an overview of the surgical correction of the

mandible in unilateral craniofacial microsomia (UCM) performed i n the growing

patient, and its long-term outcome and stability. The following databases were

searched: PubMed, Embase, Cochrane, and Web of Science. Articles reporting

prospective and retrospective studies of patients not older than 16 years (n ≥ 4)

who had undergone surgical correction of a craniofacial microsomia spectrum

condition using gr afts, osteotomies, distraction, or combinations of these, were

reviewed. The period of follow-up was selected to be greater than or equal to 1

year. After inclusion, the articles were evaluated on short- and long-term

outcomes, relapse, and any increase in asymmetry following t reatment; 30 of 1,611

articles were included in the qualitative synthesis. Analysis of the surgical

mandibular correction of UCM showed that the outcome is not so much treatment-

dependent, but patient-dependent, i.e., deformity gradation-dependent. The type I

and type IIa Pruzansky-Kaban patient had the best results with regard to minimal

relapse and/or minimal increase i n asymmetry. Single-stage correction of the

asymmetry should be pos tponed until the permanent dentition stage. The authors

concluded that in the treatment of the severely hypoplastic mandible, the patient will

benefit from a multi-stage treatment protocol if indicated for functional or

psychological problems.

Tahiri et al (2014) stated that distraction osteogenesis is an effective technique for

elongating the deficient mandible. These investigators evaluated its effectiveness

in the treatmentof airway obstruction in pediatric patients with mandibular

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hypoplasia. A comprehensive literature review of the National Library of Medicine

(PubMed) database was performed. English-language studies involving isolated

distraction of the pediatric mandible (younger than 18 years) with descriptive

reporting of airway changes were included. Extracted data included demographics,

initial diagnosis, distractor type, distraction protocol, pre-distraction and post-

distraction airway status, and complications. A total of 74 articles met the inclusion

criteria, resulting in 711 patients with craniofacial abnormalities who underwent

mandibular distraction osteogenesis. Mean age at the time of distraction was 18.1

months. The most common diagnoses were isolated Pierre Robin sequence (52.9

%), syndromic Pierre Robin sequence (7 %), and Treacher Collins syndrome (6.8

%). Mandibular distraction osteogenesis successfully treated airway obstruction in

89.3 % of cases. Success was defined as either de-cannulation of tracheostomy,

avoidance of tracheostomy or continuous positive airway pressure, or alleviation or

significant improvement of obstructive sleep apnea (OSA) symptoms. A total of

171 (84.2 %) of the 203 tracheostomy-dependent patients were successfully de-

cannulated. Among the 181 patients with OSA, mandibular distraction

osteogenesis successfully allowed for either complete resolution or significant

improvement of symptoms in 95.6 %. A 23.8 % overall complication rate was

noted. The mean follow-up time was 28.7 months. The authors concluded that in

addition to its positive effect on facial appearance, mandibular distraction

osteogenesis is an effective procedure for the treatment of airway obstruction

associated with congenital craniofacial defects involving mandibular hypoplasia in

appropriately selected patients.

Bone Morphogenetic Proteins

Sabharwal and colleagues (2011) notd that delayed bone healing during distraction

osteogenesis negatively affects clinical outcome. In addition to autologous bone

grafting, several mechanical, chemical, biologic, and external treatment modalities

may be employed to promote bone growth during distraction osteogenesis in the

pediatric patient. Mechanical approaches include compressive loading of the

distraction regenerate, increased frequency of small increments of distraction, and

compression-distraction. Intra-medullary nailing and sub-muscular plating can

reduce the time in external fixation; however, these techniques are associated with

technical difficulties and complications. Exogenous application of low-intensity

pulsed ultrasound or pulsed electromagnetic fields may shorten the duration of

external fixation. Other promising modalities include diphosphonates,physician-

directed use (off-label use) of bone morphogenetic proteins, and local injection of

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bone marrow aspirate and platelet gel at the osteotomy site. The author concluded

that well-designed clinical studies are needed to establish safe and effective

guidelines for various modalities to enhance new bone formation during distraction

osteogenesis in children.

Terbish and colleagues (2015) evaluated the effect of recombinant human bone

morphogenetic protein-2 (rhBMP-2) on the quality and quantity of regenerated bone

when injected into distracted alveolar bone. A total of 16 adult beagle dogs were

assigned to either the control or rhBMP-2 group. After distraction was completed,

an rhBMP-2 dose of330 μg in 0.33 ml was injected slowlyinto the distracted

alveolar crest of the mesial, middle, and distal parts of the alveolar bone in the

experimental group. Histologic and micro-computed tomographyanalyses of

regenerated bone were done after 2 and 6 weeks of consolidation. After 6 weeks

of consolidation, the vertical defect height in the middle of the regenerated bone

was significantly lower in the rhBMP-2 group (2.2 mm) than in the control group (3.4

mm) (p < 0.05). Additionally, the width of the regenerated bone was significantly

greater in the rhBMP-2 group (4.3 mm) than in the control group (2.8 mm) (p <

0.05). The bone density and volume of regenerated bone in the rhBMP-2 group

were greater than in the control group after 6 weeks of consolidation (p < 0.001).

The authors concluded that injection of rhBMP-2 into regenerated bone after a

distraction osteogenesis procedure significantly increased bone volume in the

dento-alveolar distraction site and improved both the width and height of the

alveolar ridge and increased the bone density. These preliminary findings from a

canine model need to be examined in human subjects.

Distraction Osteogenesis of the Irradiated Craniofacial Skeleton

Momeni and colleagues (2017) stated that craniofacial DO is a common treatment

modality today. Despite its numerous advantages, however, concerns have been

expressed regarding the use of DO in the irradiated setting. A systematic review

was performed to identify all published reports of patients who underwent DO of the

irradiated craniofacial skeleton. The following parameters were of particular

interest: post-operative complications, specifically, insufficient bone formation,

fracture, and hardware exposure (intra-oral and cutaneous), as well as the need for

additional bone grafting. The initial search retrieved a total of 183 articles of which

20 articles (38 patients) met pre-determined inclusion criteria. The most common

site of distraction was the mandible (76.3 %). The median radiation dose was 50.7

Gy (range of 30 to 70 Gy). Bone defects ranged from 30 to 80 mm (median of42.5

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mm). Complications were encountered in 19 patients (50 %), with insufficient bone

formation being most common (9 patients; 23 %). The overall incidence of

complications was not significantly associated with radiation dosage (p =0.79). The

remaining procedural and demographic variables also failed to meet statistical

significance when compared against the overall complication rate (p =0.27 to

0.97). The authors concluded that the complication rate associated with

craniofacial DO of the irradiated skeleton did not appear to be substantially higher

than what was reported for DO in the non-irradiated setting. As such, patients

should be offered this treatment modality, particularly in light of the fact, that it

offers the option to decrease patient morbidity as well as treatment complexity.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:

CPT codes not covered for indications listed in the CPB:

Other CPT codes related to the CPB:

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Code

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Code Description

20939 Bone marrow aspiration for bone grafting, spine surgery only, through

separate skin or fascial incision (List separately in addition to code for

primary procedure)

21110 Application of interdental f ixation device for conditions other than

fracture or dislocation, includes removal

21120 - 21196 Repair, revision, and/or reconstruction bones of face

21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

21247 Reconstruction of mandibular condyle w ith bone and cartilage autografts

(includes obtaining grafts) (eg, for hemifacial microsomia)

30400 - 30462 Rhinoplasty

42200 - 42225 Palatoplasty

HCPCS codes not covered for indicationslisted in the CPB:

S9055 Procuren or other grow th factor preparation to promote w ound healing

Other HCPCS codes related to the CPB:

D6010 - D6199 Implant services

D7946 - D7949 LeFort procedures I, II, or III

D8010 - D8999 Orthodontic dental procedures

ICD-10 codes covered if selection criteria are met:

M26.00 -

M26.59

Dentofacial anomalies [including malocclusion]

Q35.1 - Q35.9 Cleft palate

Q37.0 - Q37.9 Cleft palate w ith cleft lip

Q67.0 - Q67.4 Congenital deformities of skull, face and jaw

Q75.0 - Q75.9 Congenital malformation of skull and face bones [includes hemifacial

microstomia]

Q87.0 Congenital malformation syndromes predominantly affecting facial

appearance

ICD-10 codes not covered for indications listed in the CPB:

G47.33 Obstructive sleep apnea (adult) (pediatric)

M95.2 Other acquired deformity of head [acquired craniofacial defects]

Z41.1 Encounter for cosmetic surgery

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Z46.3

Z46.4

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The above policy is base d on the following re fe re nces:

1. Van Sickels JE. Distraction osteogenesis versus orthognathic surgery. Am J

Orthod Dentofacial Orthop. 2000;118(5):482-484.

2. Rachmiel A, Aizenbud D, Eleftheriou S, et al. Extraoral vs. intraoral

distraction osteogenesis in the treatment of hemifacial microsomia. Ann

Plast Surg. 2000;45(4):386-394.

3. Gateno J, Teichgraeber JF, Aguilar E. Distraction osteogenesis: A new

surgical technique for use with the multiplanar mandibular distractor.

Plast Reconstr Surg. 2000;105(3):883-888.

4. Oda T, Sawaki Y, Ueda M. Experimental alveolar ridge augmentation by

distraction osteogenesis using a simple device that permits secondary

implant placement. Int J Oral Maxillofac Implants. 2000;15(1):95-102.

5. Marquez IM, Fish LC, Stella JP. Two-year follow-up of distraction

osteogenesis: Its effect on mandibular ramus height in hemifacial

microsomia. Am J Orthod Dentofacial Orthop. 2000;117(2):130-139.

6. van Strijen PJ, Perdijk FB, Becking AG, et al. Distraction osteogenesis for

mandibular advancement. Int J Oral Maxillofac Surg. 2000;29(2):81-85.

7. Jensen OT. Distraction osteogenesis and its use with dental implants. Dent

Implantol Update. 1999;10(5):33-36.

8. Tillery DE Jr. Advances in orthognathic surgery. Dent Today. 1998;17(8):90

92.

9. Gaggl A, Schultes G, Karcher H. Distraction implants: A new operative

technique for alveolar ridge augmentation. J Craniomaxillofac Surg.

1999;27(4):214-221.

10. Cohen SR, Burstein FD, Williams JK. The role of distraction osteogenesis in

the management of craniofacial disorders. Ann Acad Med Singapore.

1999;28(5):728-738.

11. Diner PA, Tomat C, Soupre V, et al. Intraoral mandibular distraction:

Indications, technique and long-term results. Ann Acad Med Singapore.

1999;28(5):634-641.

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12. Mehrara BJ, Longaker MT. New developments in craniofacial surgery

research. Cleft Palate Craniofac J. 1999;36(5):377-387.

13. Figueroa AA, Polley JW. Management of severe cleft maxillary deficiency

with distraction osteogenesis: Procedures and results. Am J Orthod

Dentofac Orthop. 1999;115:1-12.

14. Guerrero CA, Bell WH, Contasti GI, et al. Mandibular widening by intraoral

distraction osteogenesis. Br J Oral Maxillofac Surg. 1997;35:383-392.

15. Liou EJ, Huang CS. Rapid canine retraction through distraction of the

periodontal ligament. Am J Orthod Dentofac Orthop. 1998;114:372-382.

16. Samchukov ML, Cope JB, Harper RP, et al. Biomechanical considerations of

mandibular lengthening and widening by gradual distraction using a

computer model. J Oral Maxillofac Surg. 1998;56(1):51-59.

17. Mommaerts MY. Reliability and validity of a backlighted digitizer when

used for craniofacial measurements. J Craniofac Surg. 1997;8:222-228.

18. Klein C, Howaldt HP. Correction of mandibular hypoplasia by means of

bidirectional callus distraction. J Craniofac Surg. 1996;7:258-266.

19. Swennen G, Schliephake H, Dempf R, et al. Craniofacial distraction

osteogenesis: A review of the literature: Part 1: Clinical studies. Int J Oral

Maxillofac Surg. 2001;30(2):89-103.

20. Swennen G, Dempf R, Schliephake H. Cranio-facial distraction

osteogenesis: A review of the literature. Part II: Experimental studies. Int J

Oral Maxillofac Surg. 2002;31(2):123-135.

21. Imola MJ, Hamlar DD, Thatcher G, et al. The versatility of distraction

osteogenesis in craniofacial surgery. Arch Facial Plast Surg. 2002;4(1):8-19.

22. Patel PK, Han H. Craniofacial, distraction osteogenesis. eMedicine Plastic

Surgery, Topic 459. Omaha, NE: eMedicine.com; updated February 1, 2002.

23. Imola MJ. Craniofacial distraction osteogenesis. eMedicine Otolaryngology

and Facial Plastic Surgery, Topic 702. Omaha, NE: eMedicine.com; updated

May 14, 2002.

24. American Association of Oral and Maxillofacial Surgeons (AAOMS).

Distraction osteogenesis. Statements by the American Association of Oral

and Maxillofacial Surgeons Concerning the Management of Selected

Clinical Conditions and Associated Clinical Procedures. Rosemont, IL:

AAOMS; July 2003. Available at:

http://www.aaoms.org/allied/pdfs/distraction.pdf. Accessed October 16,

2003.

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http://www.aaoms.org/allied/pdfs/distraction.pdf

http://eMedicine.com

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administer ing plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in

private practice and are neither employees nor agents of Aetna or its aff iliates. Treating providers are solely responsible

for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to

change.

Copyright © 2001-2019 Aetna Inc.

http://www.aetna.com/cpb/medical/data/500_599/0549.html 09/23/2019


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0549 Distraction

Osteogenesis for Craniofacial Defects

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania annual 10/01/2019

http://www.aetnabetterhealth.com/pennsylvania

Documents

Prior Authorization Review Panel MCO Policy Submission A ......CPB 0549 Distraction Osteogenesis for Craniofacial Defects . Clinical content was last revised on 09/05/2013. No additional