Number: 020 
(Updated)

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

Reviewed: September 28, 2015

Important note

This Clinical Policy Bulletin explains how we determine 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 refer to 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.

See CPB here >

Resources

¹American 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/images/uploads/pdfs/bone_grafting.pdf. Accessed August 31, 2015.

²American Association of Oral and Maxillofacial Surgeons (AAOMS). White Paper on Third Molar Data. Rosemont, IL: AAOMS; March 2007. Available at: http://www.aaoms.org/images/uploads/pdfs/white_paper_third_molar_data.pdf. Accessed August 31, 2015.

Medical Clinical Policy Bulletin Number 0082, April 17, 2015: This CPB has been reviewed and maintained.

Dental Clinical Policy Bulletin 039 - Medically Necessary Orthodontia related to the Pediatric Dental Essential Benefit in the Affordable Care Act (ACA)   

Revision Dates

Original policy: November 4, 2004
Updated: September 25, 2006; November 16, 2009; January 20, 2011; June 5, 2012; September 23, 2013; September 28, 2015
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.