Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (020)

Number: 020 
(Updated)

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

Reviewed: September 23, 2013

Important note

This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:

• Clinical outcome studies in the peer-reviewed published medical and dental literature
• Regulatory status of the technology
• Evidence-based guidelines of public health and health research agencies
• Evidence-based guidelines and positions of leading national health professional organizations
• Views of physicians and dentists practicing in relevant clinical areas
• Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy:

1. Coverage Statements:

Dental services provided for the routine care, treatment, or replacement of teeth or structures (for example, 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. Treatment of oral infections in connection with services covered under the medical plan
3. Diagnostic x-rays 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. In general, HMO-based plans 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.

4. Alveolar ridge closure is covered under Aetna medical plans as part of the cleft palate repair.
5. 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.
6. An appliance for palatal expansion in preparation for bone graft surgery of the alveolar cleft may be covered in the presurgical and post-surgical period for primary and mixed dentitions. Later orthodontic care, including full braces for the permanent dentition, is not covered.

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 incidental to and an integral part of a service covered under the medical plan. Coverage requires medical 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:

7. Removal of broken teeth necessary to reduce a jaw fracture.
8. 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)
9. 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.
    

In these examples, one of the following is true of the dental or OMS service:

• It is part of the medical procedure.
• It is done in conjunction with and made necessary solely because of the medical procedure and the dental.
• The 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 being performed before 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 (that is, the replacement of teeth) are not covered under medical plans even if 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 (for example, 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:

10.  Surgical, intermediate, and permanent obturators
11.  Nasal, aural, orbital, and ocular prostheses
12.  Surgical splints
13.  Radiation stents
14.  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
     

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

15.  Fluoride carrier
16.  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 (for example, 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.
     

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.

17.  Surgery needed:
    
    
    1. To treat a fracture, dislocation or wound
    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 cannot 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 alter the jaw, jaw joints or bite relationships by a cutting procedure when nonsurgical management (including appliance, medical, physical and behavioral therapies) cannot result in functional improvement


18.  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


19.  The cost of installing the first denture, crown, in-mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury


20.  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)


21.  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

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 124 - General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services, http://www.aetna.com/cpb/medical/data/100_199/0124.html and as specified in the plan documents.

2. Medical Necessity Statements:

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 dependent upon 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).

CPT Codes / HCPCS Codes/ ICD-9 Codes*

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.

Please reference other policy bulletins

• Medical Clinical Policy Bulletin Number 0082: March 15, 2013
  This CPB has been reviewed and maintained.

Revision Dates

Original policy: November 4, 2004
Updated: September 25, 2006; November 16, 2009; January 20, 2011; June 5, 2012; September 23, 2013
Revised: August 26, 2008

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.

*Current Procedural Terminology (CPT^®) 2010 copyright
2010 American Medical Association. All Rights Reserved.