Subject: Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans
Reviewed: September 23, 2013
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:
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.
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:
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.
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:
In these examples, one of the following is true of the dental or OMS service:
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:
The following dental services are considered not covered under the medical plan regardless of whether they accompany medically necessary reconstructive surgery:
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.
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).
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*
|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 (for example, osteomyelitis or bone abscess); mandible|
|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;|
|21046||Excision of benign tumor or cyst of mandible; requiring intraoral osteotomy (for example, locally aggressive or destructive lesion(s))|
|21047||requiring extraoral osteotomy and partial mandibulectomy (for example, locally aggressive or destructive lesion(s))|
|21048||Excision of benign tumor or cyst of maxilla; requiring intraoral osteotomy (for example, locally aggressive or destructive lesion(s))|
|21049||requiring extraoral osteotomy and partial maxillectomy (for example, 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|
|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|
|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 I; single piece, segment movement in any direction (for example, 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) (for example, ungrafted unilateral alveolar cleft)|
|21147||three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (for example, ungrafted bilateral alveolar cleft or multiple osteotomies)|
|21150||Reconstruction midface, LeFort II; anterior intrusion (for example, Treacher-Collins Syndrome)|
|21151||Any direction, requiring bone grafts (includes obtaining autografts)|
|21154||Reconstruction midface, LeFort III; (extracranial and intracranial) any type, requiring bone grafts (includes obtaining autografts); without LeFort I|
|21155||with LeFort I|
|21160||with LeFort I|
|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 (for example, Wassmund or Schuchard)|
|21208||Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)|
|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 (for example, mandibular staple bone plate)|
|21245||Reconstruction of mandible or maxilla, subperiosteal implant; partial|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (for example, for hemifacial microsomia)|
|21248||Reconstruction of mandible or maxilla, endosteal implant (for example, blade, cylinder): partial|
|21255||Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)|
|21295||Reduction of masseter muscle and bone (for example, for treatment of benign masseteric hypertrophy); extraoral 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 (for example, 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|
|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 (for example, 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 - 77418||Radiation treatment delivery|
|HCPCS codes covered if selection criteria are met:|
|D4210 - D4261, D4268, D4274||Dental procedures, surgical services (including usual postoperative care)|
|D7210 - D7250||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|
|524.3||Anomalies of tooth position|
|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|
|996.5||Mechanical complications of other specified prosthetic device, implant, and graft|
|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|
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/images/uploads/pdfs/bone_grafting.pdf. Accessed August 31, 2015.
18 American Association of Oral and Maxillofacial Surgeons (AAOMS). White Paper on Third Molar Data. Rosemont, IL: AAOMS; March 2007. http://www.aaoms.org/images/uploads/pdfs/white_paper_third_molar_data.pdf. Accessed August 31, 2015.
Please reference other policy bulletins
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
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