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Clinical Policy Bulletin:
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
00170 - 00192
21010
21025
21026
21030
21031
21032
21034
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
21100
21110
21116
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21160
21193
21194
21195
21196
21198
21199
21206
21208
21209
21210
21215
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21295
21296
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
21470
21480
21485
21490
41825
41826
41827
41830
41850
41874
42280
42281
70300 - 70320
Other CPT codes related to the CPB:
42200 - 42225
77401 - 77418
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


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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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering 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 affiliates. 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.
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