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:

      • 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;
      • To remove cysts, tumors or other diseased tissues;
      • 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;
      • 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: Detailed Instructions for Completing the Salzmann Index Evaluation.

The above policy is based on the following references: