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Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans

Number: 0082



Policy
  1. Coverage Statements:

    Dental services provided for the routine care, treatment, or replacement of teeth or structures (e.g., root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, and extensive dental restoration) or structures directly supporting the teeth are generally excluded from coverage under Aetna's medical plans, except under the limited circumstances outlined below.

    Treatment of Jaw and Contiguous Structures:

    Some Aetna medical plans provide coverage for some dental related services, and for certain "dental-in-nature" oral and maxillofacial surgery (OMS) services that are related to the jaw or facial bones.  Reduction of any facial bone fractures is covered under all Aetna medical plans.  Standard HMO and traditional plans cover the removal of tumors, treatment of dislocations, facial and oral wounds/lacerations, and removal of cysts or tumors of the jaws or facial bones, or other diseased tissues.  Members should refer to their plan documents for information regarding applicable terms and limitations of coverage.

    Medical Services Provided by a Dentist:

    Medically necessary medical services that could be performed by a physician (M.D. or D.O.) but are performed by a dentist are covered if performance of those services is within the scope of the dentist's license, according to state law.  These services may include, but are not limited to, the following:

    1. Dental examinations to detect infection prior to certain surgical procedures;
    2. Diagnostic x-rays in connection with services covered under the medical plan;
    3. Treatment of oral infections in connection with services covered under the medical plan.+

    Removal of Impacted Teeth:

    The removal of bone-impacted teeth may be covered under some Aetna medical plans.  HMO-based plans standardly exclude coverage of services related to the care, filling, removal or replacement of impacted teeth.  Standard HMO-based plans cover only the removal of partly or completely bone impacted teeth.  Standard traditional plans cover the surgical removal of erupted teeth, soft tissue impacted teeth and bone impacted teeth.  Members should refer to their plan documents for information regarding applicable terms and limitations of coverage.

    Note: In general, placement of bone grafts into extraction sites is considered not medically necessary.  See medical necessity statement regarding bone grafting of extraction sites below.

    Repair of Cleft Palate:

    Medical management of children with cleft palate may involve what might otherwise be considered dental care.  The following policies apply to the correction of this congenital defect.

    1. Alveolar ridge closure is covered under Aetna medical plans as part of the cleft palate repair.
    2. An appliance for palatal expansion in preparation for bone graft surgery of the alveolar cleft may be covered in the pre-surgical and post-surgical period for primary and mixed dentitions.  Later orthodontic care, including full braces for the permanent dentition, is not covered.
    3. Orthognathic surgery is covered for these members if the functional impairment to be corrected results from the cleft palate and/or its treatment.  For plans with precertification provisions, a proposed treatment plan must be submitted to Aetna for review.

    Dental Services that are Integral to Medical Procedures:

    A dental service that would otherwise be excluded from coverage under Aetna's medical plans may be a covered medical expense if the dental service is medically necessary and is incident to and an integral part of a service covered under the medical plan.  Coverage requires prior authorization by Aetna's Oral and Maxillofacial Surgery Unit in plans that have such provisions.

    Examples of dental services that are integral to medical procedures include the following:

    1. Extraction of teeth prior to radiation therapy of the head and neck.  Note: Dental reconstruction for the replacement of extracted teeth is not covered by the medical plan.
    2. Reconstruction of a dental ridge distorted as a result of removal of a tumor (including bone grafting and dental implants if necessary to stabilize a maxillofacial prosthesis such as an obturator).
    3. Removal of broken teeth necessary to reduce a jaw fracture.+

    In these examples, the dental or OMS service is either a part of the medical procedure or is done in conjunction with and made necessary solely because of the medical procedure and the dental or OMS service does not treat dental.

    Diagnostic Services:

    Whether ancillary services and procedures, such as diagnostic x-rays, are covered under the medical plan depends upon whether the primary procedure is covered under the medical plan.

    Dental Services Not Integral to Medical Services:

    Dental services and dental-in-nature OMS services do not become eligible for medical coverage merely by virtue of their being performed prior to a covered medical service for the treatment of systemic disease, even if the medical service makes the dental service medically necessary.  Removal of teeth at risk of infection, periodontal therapies, and subsequent oral rehabilitation reconstruction (i.e., the replacement of teeth) are not covered under medical plans even where these services are medically necessary prior to major surgical procedures such as open heart surgery, organ transplantation, joint reconstructive surgery or other types of surgery.  Members should refer to their plan documents for information regarding applicable terms and limitations of coverage.

    Dental Services Accompanying Reconstructive Surgery:

    Dental services performed in conjunction with medically necessary reconstructive surgery (e.g., reconstructive surgery following ablative surgical procedures) are covered according to the guidelines below:

    The following dental services are covered in conjunction with medically necessary reconstructive surgery:

    1. Nasal, aural, orbital, and ocular prostheses;
    2. Radiation stents;
    3. Some medical plans include optional coverage for preventive or other dental services.  The Preventive Dental Care Benefit (for members under 12 years of age) is a standard benefit in many Aetna HMO-based plans.  In addition, some HMO-based medical plans include a dental services rider.  Refer to the individual plan documents for a description of covered services;
    4. Surgical, intermediate, and permanent obturators;
    5. Surgical splints.

    The following dental services are considered not covered under the medical plan regardless of whether they accompany medically necessary reconstructive surgery:

    1. Dental implants (except as specified in the certificate of coverage).  Most medical plans do not cover the routine replacement of teeth via surgical placement of a dental implant body.  In addition, any procedures (e.g., bone replacement graft,sinus lift surgery, soft tissue graft, and barrier membrane placement) considered as adjunctive procedures to the surgical placement of the dental implant body are also not covered.  For those medical plans that do cover routine replacement of teeth by dental implants, the only procedure covered by the medical plan related to the dental implant is the surgical placement of the dental implant body (replacement of the missing root).  The restorative procedure (replacement of the missing crown) is considered a dental expense;
    2. Fluoride carrier.

    Most of Aetna's traditional medical plans do cover replacement of teeth as a result of a non-biting injury.  These plans do cover the replacement of teeth whether accomplished by fixed or removable prostheses or by surgical placement of a dental implant body.  In situations where replacement of the tooth/teeth is accomplished by dental implants, the dental crown is also a covered medical expense.

    Special Coverage of Dental and OMS Services under Indemnity, PPO and Managed Choice Medical Plans:

    Aetna indemnity, PPO and Managed Choice medical plans generally provide medical coverage for the following dental and oral and maxillofacial surgery services; members should refer to their plan documents for information regarding applicable terms and limitations of coverage.

    1. Surgery needed:

      1. To alter the jaw, jaw joints or bite relationships by a cutting procedure when non-surgical management (including appliance, medical, physical and behavioral therapies) can not result in functional improvement;
      2. To remove cysts, tumors or other diseased tissues;
      3. To surgically remove teeth that will not erupt through the gum, teeth partly or completely impacted in the bone of the jaw, and teeth that can not be removed without cutting into bone; charges for routine tooth removal not needing cutting of bone is specifically excluded under standard traditional plans;
      4. To treat a fracture, dislocation or wound.
         
    2. Charges for repairing or replacing the first free-standing crown or abutment for fixed bridge prostheses, but only when accidental injury requires re-preparation of the natural tooth.  Note: Charges to remove, repair, replace, restore or reposition teeth lost or damaged in the course of biting or chewing are not covered medical expenses.  Sound natural teeth are defined as teeth that were stable, functional, free from decay and advanced periodontal disease, and in good repair at the time of the accident.
    3. Dental treatment needed to remove, repair, replace, restore or reposition natural teeth damaged, lost, or removed due to an injury occurring while the person is covered under the medical plan.  Standard traditional plans also cover dental work to restore, repair, remove, reposition or replace] other body tissues of the mouth fractured or cut.  Any such teeth must be free from decay, in good repair and firmly attached to the jawbone at the time of injury.  In general, most plans require restoration or replacement in the calendar year of the accident or the next calendar year.  Coverage requires prior authorization in plans that have such provisions.  The cost of installing the first denture, crown, in-mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury.  Orthodontic therapy used in the first course of treatment to correct a malocclusion caused by accidental injury (this does not include benefits for full mouth orthodontic therapy unless review by a dental director or OMS director authorizes coverage for these services).  Charges for repairing or replacing the first free-standing crown or abutment for fixed bridge prostheses, but only when accidental injury requires re-preparation of the natural tooth.  Note: Charges to remove, repair, replace, restore or reposition teeth lost or damaged in the course of biting or chewing are not covered medical expenses.  Sound natural teeth are defined as teeth that were stable, functional, free from decay and advanced periodontal disease, and in good repair at the time of the accident.
    4. Orthodontic therapy used in the first course of treatment to correct a malocclusion caused by accidental injury (this does not include benefits for full mouth orthodontic therapy unless review by a dental director or OMS director authorizes coverage for these services).
    5. The cost of installing the first denture, crown, in-mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury.

    General Anesthesia Accompanying OMS and Dental Services:

    Aetna medical plans cover the use of general anesthesia for OMS and dental services if the member meets the selection criteria set forth in CPB 0124 - General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services and as specified in the plan documents.

  2. Medical Necessity Statements:

    Coverage of Orthodontics Under the Pediatric Oral Health Benefit

    Note: Some medical plans, including new plans and nongrandfathered plans subject to Patient Protection and Affordable Care Act requirements, cover medically necessary orthodontic services for children and adolescents under a pediatric oral health benefit. Please check benefit plan descriptions.

    Under these plans, comprehensive orthodontic services are considered medically necessary for children and adolescents who have a severe handicapping malocclusion related to a medical condition such as:

    1. Cleft palate or other congenital craniofacial or dentofacial malformations requiring reconstructive surgical correction in addition to orthodontic services; or
    2. Trauma involving the oral cavity and requiring surgical treatment in addition to orthodontic services; or
    3. Skeletal anomaly involving maxillary and/or mandibular structures.

    To be considered medically necessary, orthodontic services must be needed to treat, correct or ameliorate a medical defect or condition, and an essential part of an overall treatment plan developed by both the physician and the dentist in consultation with each other. 

    Orthodontic treatment is not considered medically necessary for dental conditions that are primarily cosmetic in nature or when self-esteem is the primary reason for treatment.

    Note on Documentation Requirements: Establishment of medical necessity of pediatric orthodontics requires documentation to support the severe handicapping malocclusion and the presence of a qualifying medical condition, and a score of 42 points or greater on the Modified Salzmann Index (see appendix). Documentation must include a completed Salzmann assessment form and a written report from the attending physician or pediatrician, or qualified medical specialist(s) treating the deformity/anomaly. Progress notes, photographs and other relevant supporting documentation may be included as appropriate.  

    Bone Grafting of Extraction Sites:

    In general, placement of bone grafts into extraction sites is considered not medically necessary.  Exception can be made for bone grafting of impacted third molar extraction sites when bony defects are clinically significant and the patient is 26 years of age or older (American Association of Oral and Maxillofacial Surgeons, 2006).

Background

In general, it is not necessary to place bone grafts into extraction sites.  When radiolucent lesions are associated with impacted teeth, enucleation of the radiolucent lesion and excision of the associated impacted tooth will leave a defect in the mandible.  Defects of this dimension usually refill with bone at variable rates dependant upon the age and health related factors.  Bone grafting is not required to maintain continuity since the risk of pathologic fracture is low or remote.

However, a bone graft may be necessary in situations where the radiolucent lesion (potentially cystic) has expanded to the point that there may be a risk for pathologic fracture, or when the lesion is located mesial (anterior), distal (posterior) or apical to the tooth where additional surgery will be required to access and remove the cyst, or when the cyst is so large (noted to be located outside the confines of the impacted tooth) and the patient is 26 years of age or older (American Association of Oral and Maxillofacial Surgeons, 2006).

Appendix

The Modified Salzmann Index is available at the following website:

https://www.dominiondental.com/files/Dentist_Forms/Other_Forms/salzmann_evaluation_index.pdf.

CPT Codes / HCPCS Codes/ ICD-9 Codes
CPT codes covered if selection criteria are met:
00100 - 00102 Anesthesia for procedure on salivary glands, including biopsy or anesthesia for procedures on plastic repair of cleft lip
00170 - 00192 Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery, or Anesthesia for procedures on facial bones or skull; not otherwise specified, or radical surgery (including prognathism)
21010 Arthrotomy, temporomandibular joint
21025 Excision of bone (e.g., osteomyelitis or bone abscess); mandible
21026     facial bone(s)
21030 Excision of benign tumor or cyst maxilla or zygoma by enucleation and curettage
21031 Excision of torus mandibularis
21032 Excision of maxillary torus palatinus
21034 Excision of malignant tumor of maxilla or zygoma
21040 Excision of benign tumor or cyst of mandible, by enucleation and curettage
21044 Excision of malignant tumor of mandible;
21045     radical resection
21046 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion(s))
21047     requiring extra-oral osteotomy and partial mandibulectomy (e.g., locally aggressive or destructive lesion(s))
21048 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion(s))
21049     requiring extra-oral osteotomy and partial maxillectomy (e.g., locally aggressive or destructive lesion(s))
21050 Condylectomy, temporomandibular joint (separate procedure)
21060 Meniscectomy, partial or complete, temporomandibular joint (separate Procedure)
21070 Coronoidectomy (separate procedure)
21076 Impression and custom preparation; surgical obturator prosthesis
21077     orbital prosthesis
21079     interim obturator prosthesis
21080     definitive obturator prosthesis
21081     mandibular resection prosthesis
21082     palatal augmentation prosthesis
21083     palatal lift prosthesis
21084     speech aid prosthesis
21085     oral surgical prosthesis
21086     auricular prosthesis
21087     nasal prosthesis
21088     facial prosthesis
21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)
21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21116 Injection procedure for temporomandibular joint arthrography
21141 Reconstruction midface, LeFort l; single piece, segment movement in any direction (e.g., for Long Face Syndrome),without bone graft
21142     two pieces, segment movement in any direction, without bone graft
21143     three or more pieces, segment movement in any direction, without bone graft
21145     single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
21146     two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft)
21147     three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies)
21150 Reconstruction midface, LeFort ll; anterior intrusion (e.g., Treacher-Collins Syndrome)
21151     Any direction, requiring bone grafts (includes obtaining autografts)
21154 Reconstruction midface, LeFort lll; (extracranial and intracranial) any type, requiring bone grafts (includes obtaining autografts); without Lefort l
21155     with Lefort l
21160     with Lefort l
21193 Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; without bone graft
21194     with bone graft (includes obtaining graft)
21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
21196     with internal rigid fixation
21198 Osteotomy, mandible, segmental;
21199     with genioglossus advancement
21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209     reduction
21210 Graft, bone, nasal, maxillary or malar areas (includes obtaining graft)
21215     mandible (includes obtaining graft)
21240 Arthroplasty, temporomandibular joint, with or without autograft includes obtaining grafts)
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement
21244 Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)
21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial
21246     complete
21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)
21248 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder): partial
21249     complete
21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)
21295 Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); extraoral approach
21296     intraoral approach
21421 Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint
21422 Open treatment of palatal or maxillary fracture (LeFort I type);
21423     complicated (comminuted or involving cranial nerve foramina), multiple approaches
21431 Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint
21432 Open treatment of craniofacial separation (LeFort III type) with wiring and/or internal fixation
21433     complicated (comminuted or involving cranial nerve foramina), multiple surgical approaches
21435     complicated, utilizing internal and/or external fixation techniques (e.g., head cap, halo device, and/or intermaxillary fixation)
21436     complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft)
21440 Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21445 Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21450 Closed treatment of mandibular fracture; without manipulation
21451     with manipulation
21452 Percutaneous treatment of mandibular fracture, with external fixation
21453 Closed treatment of mandibular fracture with interdental fixation
21454 Open treatment of mandibular fracture with external fixation
21461 Open treatment of mandibular fracture; without interdental fixation
21462     with interdental fixation
21465 Open treatment of mandibular condylar fracture
21470 Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints
21480 Closed treatment of temporomandibular dislocation; initial or subsequent
21485     complicated (e.g., recurrent requiring intermaxillary fixation or splinting) initial or subsequent
21490 Open treatment of temporomandibular dislocation
41825 Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair
41826     with simple repair
41827     with complex repair
41830 Alveolectomy, including curettage of osteitis or sequestrectomy
41850 Destruction of lesion (except excision), dentoalveolar structures
41874 Alveoplasty, each quadrant (specify)
42280 Maxillary impression for palatal prosthesis
42281 Insertion of pin-retained palatal prosthesis
70300 - 70320 Radiologic examination, teeth; single view, partial examination, less than full mouth, or complete, full mouth
Other CPT codes related to the CPB:
42200 - 42225 Palatoplasty
77401 - 77412 Radiation treatment delivery
HCPCS codes covered if selection criteria are met:
D4210 - D4261, D4268, D4274 Dental procedures, surgical services (including usual postoperative care)
D7210 - D7251 Dental procedures, surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)
D7410 - D7415 Surgical excision of reactive inflammatory lesions (scar tissue or localized congenital lesions
D7440 - D7465 Removal of tumors, cysts, and neoplasms
D7471 - D7490 Excision of bone tissue
D7510 - D7560 Surgical incision
D7610 - D7780 Treatment of fractures
D7810 - D7899 Reduction of dislocation and management of other temporomandibular joint dysfunctions
D7910 Suture of recent small wounds up to 5 cm
D7911 - D7912 Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure
D7920 - D7951, D7960 - D7998 Other repair procedures
D9220 Deep sedation/general anesthesia - first 30 minutes
D9221 Deep sedation/general anesthesia - additional 15 minutes
D9241 Intravenous conscious sedation/analgesia - first 30 minutes
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes
D9248 Non-intravenous conscious sedation
HCPCS codes not covered for indications listed in the CPB:
D4263 Bone replacement graft; first site in quadrant
D4264 Bone replacement graft - each additional site in quadrant (use if performed on same date of service as D4263)
D4265 Biologic materials to aid in soft and osseous tissue regeneration
D4266 Guided tissue regeneration; resorbable barrier, per site
D4267 Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal)
D4270 Pedicle soft tissue graft procedure
D4271 Free soft tissue graft procedure (including donor site surgery)
D4273 Subepithelial connective tissue graft procedures, per tooth
D4275 Soft tissue allograft
D4276 Combined connective tissue and double pedicle graft, per tooth
D5986 Fluoride gel carrier
D6010 - D6199 Implant services
D7292 - D7294 Surgical placement: temporary anchorage device
D7953 Bone replacement graft for ridge preservation - per site
D7955 Repair of maxillofacial soft and/or hard tissue defect
ICD-9 codes covered if selection criteria are met:
143.0 - 143.9 Malignant neoplasm of gum
170.0 - 170.1 Malignant neoplasm of bones of skull and face, except mandible, or malignant neoplasm of mandible
195.0 Malignant neoplasm of head, face, and neck
210.4 Benign neoplasm of other and unspecified parts of mouth
213.0 - 213.1 Benign neoplasm of bones of skull and face, or lower jaw bone
520.6 Disturbances in tooth eruption
522.4 - 522.8 Diseases of pulp and periapical tissues
524.30 - 524.39 Anomalies of tooth position
524.4 Malocclusion, unspecified
525.0 - 525.8 Other diseases and conditions of the teeth and supporting structures
526.0 - 526.89 Diseases of jaws
749.00 - 749.25 Cleft palate and cleft lip
802.20 - 802.5 Fracture of mandible or malar and maxillary bones, closed or open
830.0 - 830.1 Dislocation or jaw, closed, or open
873.40 - 873.9 Open wound of face, internal structures of mouth, or other and unspecified, without mention of complication, or complicated
905.0 Late effect of fracture of skull and face bones
906.0 Late effect of open wound of head, neck, and trunk
959.01 - 959.09 Injury to head, face, and neck
996.59 Mechanical complication of other specified prosthetic device, implant, and graft due to other implant and internal device, not elsewhere classified
996.69 Infection and inflammatory reaction due to other implant and internal device, not elsewhere classified
996.78 Other complications due to other internal orthopedic device, implant, and device
V72.2 Dental examination
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 "+":
ICD-10 codes will become effective as of October 1, 2015 :
CPT codes covered if selection criteria are met:
00100 - 00102 Anesthesia for procedure on salivary glands, including biopsy or anesthesia for procedures on plastic repair of cleft lip
00170 - 00192 Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery, or Anesthesia for procedures on facial bones or skull; not otherwise specified, or radical surgery (including prognathism)
21010 Arthrotomy, temporomandibular joint
21025 Excision of bone (e.g., osteomyelitis or bone abscess); mandible
21026     facial bone(s)
21030 Excision of benign tumor or cyst maxilla or zygoma by enucleation and curettage
21031 Excision of torus mandibularis
21032 Excision of maxillary torus palatinus
21034 Excision of malignant tumor of maxilla or zygoma
21040 Excision of benign tumor or cyst of mandible, by enucleation and curettage
21044 Excision of malignant tumor of mandible;
21045     radical resection
21046 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion(s))
21047     requiring extra-oral osteotomy and partial mandibulectomy (e.g., locally aggressive or destructive lesion(s))
21048 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion(s))
21049     requiring extra-oral osteotomy and partial maxillectomy (e.g., locally aggressive or destructive lesion(s))
21050 Condylectomy, temporomandibular joint (separate procedure)
21060 Meniscectomy, partial or complete, temporomandibular joint (separate Procedure)
21070 Coronoidectomy (separate procedure)
21076 Impression and custom preparation; surgical obturator prosthesis
21077     orbital prosthesis
21079     interim obturator prosthesis
21080     definitive obturator prosthesis
21081     mandibular resection prosthesis
21082     palatal augmentation prosthesis
21083     palatal lift prosthesis
21084     speech aid prosthesis
21085     oral surgical prosthesis
21086     auricular prosthesis
21087     nasal prosthesis
21088     facial prosthesis
21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)
21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21116 Injection procedure for temporomandibular joint arthrography
21141 Reconstruction midface, LeFort l; single piece, segment movement in any direction (e.g., for Long Face Syndrome),without bone graft
21142     two pieces, segment movement in any direction, without bone graft
21143     three or more pieces, segment movement in any direction, without bone graft
21145     single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
21146     two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft)
21147     three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies)
21150 Reconstruction midface, LeFort ll; anterior intrusion (e.g., Treacher-Collins Syndrome)
21151     Any direction, requiring bone grafts (includes obtaining autografts)
21154 Reconstruction midface, LeFort lll; (extracranial and intracranial) any type, requiring bone grafts (includes obtaining autografts); without Lefort l
21155     with Lefort l
21160     with Lefort l
21193 Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; without bone graft
21194     with bone graft (includes obtaining graft)
21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
21196     with internal rigid fixation
21198 Osteotomy, mandible, segmental;
21199     with genioglossus advancement
21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209     reduction
21210 Graft, bone, nasal, maxillary or malar areas (includes obtaining graft)
21215     mandible (includes obtaining graft)
21240 Arthroplasty, temporomandibular joint, with or without autograft includes obtaining grafts)
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement
21244 Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)
21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial
21246     complete
21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)
21248 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder): partial
21249     complete
21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)
21295 Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); extraoral approach
21296     intraoral approach
21421 Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint
21422 Open treatment of palatal or maxillary fracture (LeFort I type);
21423     complicated (comminuted or involving cranial nerve foramina), multiple approaches
21431 Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint
21432 Open treatment of craniofacial separation (LeFort III type) with wiring and/or internal fixation
21433     complicated (comminuted or involving cranial nerve foramina), multiple surgical approaches
21435     complicated, utilizing internal and/or external fixation techniques (e.g., head cap, halo device, and/or intermaxillary fixation)
21436     complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft)
21440 Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21445 Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21450 Closed treatment of mandibular fracture; without manipulation
21451     with manipulation
21452 Percutaneous treatment of mandibular fracture, with external fixation
21453 Closed treatment of mandibular fracture with interdental fixation
21454 Open treatment of mandibular fracture with external fixation
21461 Open treatment of mandibular fracture; without interdental fixation
21462     with interdental fixation
21465 Open treatment of mandibular condylar fracture
21470 Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints
21480 Closed treatment of temporomandibular dislocation; initial or subsequent
21485     complicated (e.g., recurrent requiring intermaxillary fixation or splinting) initial or subsequent
21490 Open treatment of temporomandibular dislocation
41825 Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair
41826     with simple repair
41827     with complex repair
41830 Alveolectomy, including curettage of osteitis or sequestrectomy
41850 Destruction of lesion (except excision), dentoalveolar structures
41874 Alveoplasty, each quadrant (specify)
42280 Maxillary impression for palatal prosthesis
42281 Insertion of pin-retained palatal prosthesis
70300 - 70320 Radiologic examination, teeth; single view, partial examination, less than full mouth, or complete, full mouth
Other CPT codes related to the CPB:
42200 - 42225 Palatoplasty
77401 - 77412 Radiation treatment delivery
HCPCS codes covered if selection criteria are met:
D4210 - D4261, D4268, D4274 Dental procedures, surgical services (including usual postoperative care)
D7210 - D7251 Dental procedures, surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)
D7410 - D7415 Surgical excision of reactive inflammatory lesions (scar tissue or localized congenital lesions
D7440 - D7465 Removal of tumors, cysts, and neoplasms
D7471 - D7490 Excision of bone tissue
D7510 - D7560 Surgical incision
D7610 - D7780 Treatment of fractures
D7810 - D7899 Reduction of dislocation and management of other temporomandibular joint dysfunctions
D7910 Suture of recent small wounds up to 5 cm
D7911 - D7912 Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure
D7920 - D7951, D7960 - D7998 Other repair procedures
D9220 Deep sedation/general anesthesia - first 30 minutes
D9221 Deep sedation/general anesthesia - additional 15 minutes
D9241 Intravenous conscious sedation/analgesia - first 30 minutes
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes
D9248 Non-intravenous conscious sedation
HCPCS codes not covered for indications listed in the CPB:
D4263 Bone replacement graft; first site in quadrant
D4264 Bone replacement graft - each additional site in quadrant (use if performed on same date of service as D4263)
D4265 Biologic materials to aid in soft and osseous tissue regeneration
D4266 Guided tissue regeneration; resorbable barrier, per site
D4267 Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal)
D4270 Pedicle soft tissue graft procedure
D4271 Free soft tissue graft procedure (including donor site surgery)
D4273 Subepithelial connective tissue graft procedures, per tooth
D4275 Soft tissue allograft
D4276 Combined connective tissue and double pedicle graft, per tooth
D5986 Fluoride gel carrier
D6010 - D6199 Implant services
D7292 - D7294 Surgical placement: temporary anchorage device
D7953 Bone replacement graft for ridge preservation - per site
D7955 Repair of maxillofacial soft and/or hard tissue defect
ICD-10 codes covered if selection criteria are met:
C03.0 - C03.9 Malignant neoplasm of gum
C41.0 - C41.1 Malignant neoplasm of bones of skull and face and mandible
C76.0 Malignant neoplasm of head, face, and neck
D10.30 - D10.39 Benign neoplasm of other and unspecified parts of mouth
D16.4 - D16.5 Benign neoplasm of bones of skull and face and lower jaw bone
K00.6 Disturbances in tooth eruption
K04.0 - K04.8 Diseases of pulp and periapical tissues
K08.0 - K08.9 Other disorders of teeth and supporting structures
K09.0 - K09.1
M27.0 - M27.9
Diseases of jaws
M26.211 - M26.29 Anomalies of dental arch relationship
M26.30 - M26.39 Anomalies of tooth position of fully erupted tooth or teeth
Numerous options Open wound of head, neck, and trunk, sequela
Q35.1 - Q36.9 Cleft palate and cleft lip
S01.401+ - S01.95x+ Open wound of face, internal structures of mouth, or other and unspecified, without mention of complication, or complicated
S02.0xxS - S02.92xS Fracture of skull and face bones, sequela
S02.400+ - S02.42x+
S02.600 - S02.69x+
Fracture of malar, maxillary, zygoma nad mandibular bones, closed or open
S03.0xx+ Dislocation or jaw
S09.10x+ - S09.19x+
S09.8xx+, S09.90x+ - S09.93x+
Injury to head, face, and neck
T84.81x+ - T84.89x+ Other specified complications of internal orthopedic prosthetic devices, implant, and grafts
T85.21x+ - T85.318
T85.390 - T85.398
T85.618
Mechanical complication of other specified prosthetic device, implant, and graft due to other implant and internal device, not elsewhere classified
T85.79x+ Infection and inflammatory reaction due to other internal devices, implants and grafts
Z01.20 - Z01.21 Encounter for dental examination and cleaning


The above policy is based on the following references:
    1. UK National Health Service (NHS), Centre for Reviews and Dissemination (CRD). Prophylactic removal of impacted third molars: Is it justified? Effectiveness Matters. 1998; 3(2):1-4.
    2. Toljanic JA, Bedard JF, Larson RA, Fox JP. A prospective pilot study to evaluate a new dental assessment and treatment paradigm for patients scheduled to undergo intensive chemotherapy for cancer. Cancer. 1999;85(8):1843-1848.
    3. Glassman P, Wong C, Gish R. A review of liver transplantation for the dentist and guidelines for dental management. Spec Care Dentist. 1993;13(2):74-80.
    4. Heimdahl A. Prevention and management of oral infections in cancer patients. Support Care Cancer. 1999;7(4):224-228.
    5. Torres JH. Benefits and risk of the extraction of wisdom teeth. Rev Stomatol Chir Maxillofac. 1997;98(3):173-178.
    6. Muzaffar AR, Adams WP Jr, Hartog JM, et al. Maxillary reconstruction: Functional and aesthetic considerations. Plast Reconstr Surg. 1999;104(7):2172-2183.
    7. Carl W, Ikner C. Dental extractions after radiation therapy in the head and neck area and hard tissue replacement (HTR) therapy: A preliminary study. J Prosthet Dent. 1998;79(3):317-322.
    8. Oikarinen KS. Clinical management of injuries to the maxilla, mandible, and alveolus. Dent Clin North Am. 1995;39(1):113-131.
    9. National Institute for Clinical Excellence. Guidance on the extraction of wisdom teeth. Technology Appraisal No. 1. London, UK: NICE; March 2000.
    10. Song F, O'Meara S, Wilson P, Golder S, Kleijnen J. The effectiveness and cost-effectiveness of prophylactic removal of wisdom teeth. Health Technology Assess. 2000;4(15):1-55.
    11. Percinoto C, Vieira AE, Barbieri CM, et al. Use of dental implants in children: A literature review. Quintessence Int. 2001;32(5):381-383.
    12. Kuitert RB. Orthodontic treatment for adults. Ned Tijdschr Tandheelkd. 2000;107(4):160-168.
    13. Minnesota Department of Health, Health Technology Advisory Committee. Dental implants. Technology Assessment. St. Paul, MN: Minnesota Department of Health; February 2000.
    14. Norwegian Knowledge Centre for the Health Services (NOKC). Prophylactic removal of wisdom teeth [summary]. SMM-Report 10/2003. Oslo, Norway: Norwegian Knowledge Centre for the Health Services (NOKC); 2003.
    15. American Dental Association, Council on Scientific Affairs. Dental endosseous implants. An update. J Am Dental Assoc. 2004;135:92-97.
    16. Mettes DTG, Nienhuijs MMEL, van der Sanden WJM, et al. Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. Cochrane Database Syst Rev. 2005;(2):CD003879.
    17. American Association of Oral and Maxillofacial Surgeons (AAOMS). Bone grafting after removal of impacted third molars. Statement of the American Association of Oral and Maxillofacial Surgeons concerning the management of selected clinical conditions and associated clinical procedures. AAOMS Condition Statements. Rosemont, IL: AAOMS; March 2006. Available at: http://www.aaoms.org/docs/practice_mgmt/condition_statements/
      bone_grafting.pdf
      . Accessed January 25, 2007.
    18. American Association of Oral and Maxillofacial Surgeons (AAOMS). White Paper on Third Molar Data. Rosemont, IL: AAOMS; March 2007. http://www.aaoms.org/docs/third_molar_white_paper.pdf. Accessed July 19, 2007.
    19. Salzmann JA. Handicapping malocclusion assessment to establish treatment priority. Am J Orthod. 1968;54(10):749-765.


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