NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION …...Caries prevention for primary teeth in children...

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NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA

Revised: 7/1/2017

The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines.

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL

COVERAGE GUIDELINE

DIAGNOSTIC

Clinical Oral Evaluations D0120–D0191

Documentation in member record that includes all services performed for the code submitted

Pre-Diagnostic Services D0190 screening of a patient D0191 assessment of a patient

Documentation in member record that includes all services performed for the code submitted.

Diagnostic Imaging

Image capture with interpretation D0210–D0371

Image Capture only D0380–D0386

Interpretation and Report only D0391–D0395

CPT codes: 70486, 70487, 70488, 76376 and 76377

Documentation in the member record. Diagnostic, clear, readable images, dated with member name.

Criteria for codes D0364–D0368, D0380–D0386, D0391–D0395:

Cone beam computed tomography (CBCT) is unproven and not medically necessary for routine dental applications. There is insufficient evidence that CBCT is beneficial for use in routine dental applications. CBCT should not replace traditional dental x-rays as a preliminary diagnostic tool, or for routine dental procedures such as restorations, but be used as an adjunct when the level of detail CBCT is needed to safely render treatment for complex clinical conditions (e.g., oral surgery, implant placement and endodontics). These procedures may have a higher risk of complications without the level of detail CBCT imaging provides. CBCT imaging used for these reasons should be read and interpreted by an appropriately trained professional.

In addition, radiation exposure associated with CBCT needs to be weighed against possible benefits, which have not been supported in the published literature. Limited definitive conclusions regarding the clinical role of CBCT can be reached due to the lack of well-designed studies that systematically evaluate diagnostic accuracy and the impact of CBCT on clinical decision making and patient health outcomes. Additional studies are needed to verify that CBCT provides added diagnostic value beyond two-dimensional imaging such as panoramic radiography and conventional computed tomography and to

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COVERAGE GUIDELINE Diagnostic Imaging (continued)

determine whether CBCT improves treatment decision making and health outcomes.

Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP002.02)

Bacterial And Viral Testing D0414, D0415, D0416

Provider narrative including clinical reason/diagnosis for test and type of test performed.

Criteria for codes D0414, D0415, D0416

Collection of Microorganisms for Culture and Sensitivity

Collection of microorganisms for culture and sensitivity is indicated for the following:

For odontogenic infections that do not respond to rational antibiotic empiric therapy and/or incision and drainage in a timely manner

For odontogenic infections in patients with comorbidities including but not limited to impaired healing response, and compromised immune system

Collection of microorganisms for culture and sensitivity is not indicated for the following:

As a routine procedure for all infections (unless patient has multiple comorbidities or infection is resistant to conventional therapy)

If infection is small and limited to localized area

If infection is draining on its own with no evidence of spread of infection

For fungal infections

For viral culturing (this procedure has its own reporting code)

Viral Culture

Viral culturing is indicated for the presence of oral and perioral vesicles and ruptured vesicles resulting in lesions that may or may not be crusted over.

Viral culturing is not indicated for suspected cytomegalovirus (CMV) oral lesions (an incisional biopsy and testing is indicated).

Refer to coverage guideline: Bacterial And Viral Testing (DCG039.01)

Salivary Testing D0417, D0418


Criteria for codes D0417, D0418

Collection, Preparation and Analysis of Saliva Sample for Laboratory Diagnostic Testing

Collection, preparation and analysis of saliva sample for laboratory diagnostic testing may be indicated as part of oral disease risk assessment and management, including but not limited to caries, periodontal disease and xerostomia.

Refer to clinical policy: Salivary Testing (DCG037.01)

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COVERAGE GUIDELINE Genetic Testing for Oral Disease D0422, D0423



Collection and Preparation of Genetic Sample Material for Laboratory Analysis and Report

Genetic Test for Susceptibility to Diseases – Specimen Analysis

The collection, preparation and testing of genetic samples are indicated for patients who have known human papilloma virus (HPV) infection, or have other related risk factors, to identify if the strain of HPV known to be related to oral and oropharyngeal cancers is present.

The clinical utility of genetic testing for susceptibility to periodontal diseases has not been established. Additionally, there is a lack of objective, high quality clinical evidence to support these tests.

Refer to clinical policy: Genetic Testing for Oral Disease (DCP036.01)

Miscellaneous Diagnostic Procedures D0425, D0460, D0470


Caries Susceptibility Tests

There is a lack of objective, high quality clinical evidence to support or refute the efficacy or superiority of this specific testing method as a tool for caries risk assessment and management.

Pulp Vitality Tests

Pulp vitality tests are indicated for the following:

For traumatic injuries to teeth

Teeth with deep caries or defective restorations

Pulp vitality tests are not indicated for the following:

Sensitivity of exposed dentin without evidence of pulp pathosis

Teeth with no evidence of caries, resorption, defective restorations, or otherwise asymptomatic

As part of routine dental examinations

Diagnostic Casts

Combined with clinical and radiographic findings, diagnostic casts may be useful for select cases, as they can provide a further understanding of the overall dentition. They may be helpful in developing the treatment plan without the patient present, and can serve as an additional tool for educating the patient. They provide an opportunity for a more thorough evaluation of the following:

Tooth interdigitation

Functional occlusion, and any occlusal abnormalities

Wear facets and defective restorations, coronal contours, proximal contacts and embrasure spaces between teeth

Refer to coverage guideline: Miscellaneous Diagnostic Procedures (DCG040.01)

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COVERAGE GUIDELINE Non-Ionizing Diagnostic Procedures D0600


Criteria for code D0600

There is inadequate evidence demonstrating the efficacy of these devices, limiting their use as a principal diagnostic tool. A non-ionizing diagnostic procedure refers to a device specifically designed to identify, quantify, monitor, and record changes in structure of enamel, dentin and cementum. These devices may be used as an adjunctive tool by the dental provider to identify high caries risk areas, and create non-invasive treatment plans for remineralization before caries begins. Visual and radiographic examinations remain the standard diagnostic methods for diagnosing active caries.

Refer to clinical policy: Non-Ionizing Diagnostic Procedures (DCP041.01)

Tests and Examinations D0431

caries risk assessment D0601–D0603

Oral Pathology Laboratory D0472–D0502

Unspecified diagnostic procedure by report D0999


PREVENTIVE

Dental Prophylaxis D1110–D1120

Services performed must be documented in the member record.

Topical Fluoride Treatment D1206, D1208

CPT code: 99188

Documentation Age and medical necessity. An adult is generally defined as twelve years or older.


Topical Application of Fluoride – Excluding Varnish

Topical fluoride treatments in the form of gel, foam and rinses applied as a caries preventive agent in the dental office are benefitted twice per consecutive twelve months for children up to age 15. Patients at low risk of developing caries may not need additional topical fluorides other than over-the-counter fluoridated toothpaste and fluoridated water.

Topical Application of Fluoride Varnish

Fluoride varnish is indicated for the following:

As the preferred caries prevention agent for children under age 6

For head and neck radiation therapy patients

Sensitivity that does not resolve with an over-the-counter desensitizing dentifrice

For moderate to high caries risk patients with a medical or cognitive impairment that limits cooperation with a tray or rinse delivery method

Xerostomia due to systemic disease or medication

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COVERAGE GUIDELINE Topical Fluoride Treatment (continued)

For patients in active orthodontic treatment

For the remineralization of incipient or white spot enamel carious lesions

Refer to clinical policy: Topical Fluoride Treatment (DCP018.02)

Other Preventive Services D1310–D1330

Documentation/narrative in member record that service was performed and materials supplied to member.

Sealants D1351, D1352, D1353

Documentation Sealant: Tooth numbers.

Criteria for codes: D1351, D1352, D1353

Sealants

Dental caries is the most common pediatric disease. Dental sealants are recognized as an effective preventive approach to preventing pit and fissure caries in children and adolescents.

Sealants are indicated for the following:

Caries prevention in pit and fissures on permanent molars of children and adolescents

Non-cavitated carious lesions on permanent teeth in children and adolescents

Caries prevention for primary teeth in children with documented high caries risk with a reasonable prognosis for retention anticipated. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver have active caries o White spot lesions or enamel defects o Visible caries or previous restorations o Poor oral hygiene o Sub-optimal systemic fluoride intake o Frequent exposure to cavity-producing foods and drinks o Patients with special health care needs o Low socioeconomic status o Xerostomia o More than one interproximal lesion o Other factors identified by professional literature o Deep pits and fissures o Patients with special needs

Sealants are not generally indicated for the following:

Widespread cavitated carious lesions

Presence for interproximal or smooth surface lesions

Occlusal surfaces that are already carious with involvement of the dentin that requires restoration

Extrinsic staining of pits and fissures

For placement on premolars, buccal and lingual pits of molars and cingula of anterior teeth

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COVERAGE GUIDELINE Sealants (continued)

Preventive Resin Restoration (PRR)

Preventive resin restoration is done on an active cavitated lesion in a pit or fissure that does not extend into the dentin. This includes placement of a sealant in any radiating non-carious fissures or pits.

Preventive resin restorations are indicated for the restoration of pit and fissures carious lesions contained to enamel in moderate to high caries risk patients.

Preventive resin restorations are not indicated for the following:

When no caries is evident in pits and fissures

When a sealant is clinically indicated

For carious lesions that extend into dentin

Coverage Limitations

Sealants and PRRs are limited to one per tooth per 36 months. Refer to coverage guideline: Sealants (DCG026.02)

Space Maintenance D1510, D1515, D1520, D1525, D1550, D1555, D1575, D1999

Radiographs of the involved arch. Criteria for codes D1510, D1515, D1520, D1525, D1550, D1555, D1575, D1999

Space maintainers are indicated for the following:

Maintaining space due to premature loss of a primary tooth (teeth)

To regain space

Space maintainers are contraindicated for the following:

When tooth/teeth is/are close to eruption

Patient is not compliant or has poor oral hygiene

Severe crowing already exists

Space has already been lost

If sufficient amount of space already exists

Coverage Limitations and Exclusions

Limited to one per tooth per consecutive 60 months

Any space maintainer adjustments are inclusive for 6 months

Limited to persons under the age of 16

Refer to coverage guideline: Space Maintenance (DCG035.01)

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COVERAGE GUIDELINE

RESTORATIVE

Direct Restorations D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2941, D2990, D2999

Amalgam Restorations D2140–D2161

Resin-Based Composite Restorations – Direct D2330–D2394

Gold Foil Restorations D2410–D2430

Documentation Tooth number and surface. Caries removal documented in member record.

Criteria for codes D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2941, D2990, D2999

Direct Restorations

Direct restorations are indicated for the following:

To replace a tooth structure lost to caries or trauma

To replace restorative material lost in the course of accessing pulp chamber for endodontic therapy

To replace existing restorations that exhibit recurrent decay, fracture or marginal defects

In addition to the above, glass ionomer restorations are indicated for the following:

When teeth cannot be isolated properly to allow placement of resin restorations

As an alternative to resin sealants when the teeth cannot be properly isolated (patient cooperation, partially erupted teeth)

Class I,II, III and V restorations on primary teeth

Class III and V restorations on permanent teeth that cannot be isolated in high risk patients

As a caries control plan for high risk patients using atraumatic techniques

Direct restorations are not indicated for the following:

Teeth with a hopeless prognosis in which extraction is indicated

Incipient enamel only lesions extending less than halfway to the dentinoenamel junction (DEJ)

When there is sufficient loss of tooth structure that a crown or onlay is indicated

When used as part of comprehensive or interceptive orthodontics to maintain an open bite

For primary teeth that are near exfoliation or less than 50% of the tooth root remains

Composite resin restorations are not indicated for patients with heavy bruxism

Composite resin restorations are not indicated for patients with extensive active caries, or high caries risk

Amalgam restorations are not indicated for placement on teeth in which they will have contact with gold restorations

In addition to the above, glass ionomer restorations are not indicated for the following:

As a definitive, long term restoration in permanent teeth

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COVERAGE GUIDELINE Direct Restorations (continued)

When a sealant is indicated

Required Documentation

When a metal allergy is suspected, documentation from an allergist is required to support replacement of amalgam with composite.

Protective Restoration

Protective restoration is indicated for the following:

To relieve pain

To promote healing

To prevent further deterioration

To retain tissue form

Protective restoration is not indicated for the following:

As a liner or base for a definitive restoration

Not for endodontic access closure

Not for pulp capping

As a definitive restoration

Interim Therapeutic Restoration-Primary Dentition

Interim therapeutic restorations are indicated for the following:

For very young, uncooperative or special needs patients

When traditional tooth preparation for an amalgam or composite restoration is not feasible or must be postponed

As a caries control plan for high risk patients using atraumatic techniques

Resin Infiltration of Incipient Smooth Surface Lesions

Resin infiltration of incipient smooth surface lesions is typically used for aesthetic purposes. It is used to describe a proprietary product, and there is a lack of established objective evidence to support its use.


Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

Any dental procedure not directly associated with dental disease

Posterior composites may be alternately benefitted to amalgam coverage unless specified in member plan

Gold foil restorations are benefitted to amalgam unless specified in member plan, or used to replace material lost on a gold crown due to endodontic therapy

Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure

Refer to coverage guideline: Single Tooth Direct Restorations (DCG023.01)

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COVERAGE GUIDELINE Indirect Restorations:

Inlay/Onlay Restorations D2510–D2664 (Inlay/onlays)

Crowns – Single Restorations Only D2710–D2799

Documentation Pre-operative x-rays. If endodontic therapy has been performed, a periapical radiographic image clearly showing the apex of the completed treatment is required; otherwise, bitewing x-rays may be sufficient at the discretion of the reviewer. A narrative or photograph may provide additional information, especially for replacement of existing crowns. “Cracked tooth syndrome” requires adequate documentation of extent of fracture, location and how it was diagnosed. Tooth must be symptomatic. Restorations for members under age 15 require statement of medical necessity. Inclusive Local anesthesia; tooth preparation; temporary crown; fitting; cementation; post-op adjustments, impressions; bases.

Criteria for codes D2510, D2520 D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2799

Indications for Coverage

For indirect restorations, the following clinical parameters apply:

Five-year longevity should be evident, periodontium must be healthy or have documentation the member has periodontal disease under control for a period of at least 6 months, and no evidence of endodontic pathology or potential endodontic issues on the radiographic image.

Crowns

Crowns are indicated for the following:

Extensive caries on three or more surfaces or 50% loss of clinical crown

Large, >50% of the tooth, defective restoration that can be seen on the radiographic image

Fracture of cusps

Endodontically treated teeth, unless minimal access opening on anterior tooth

Documentation that a direct restoration is not possible

Crown/root ratio must be favorable

Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image

50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery

Anterior teeth: at least 50% involvement of incisal portion

Bicuspids and molars: 3 or more surfaces and one or more cusps involved

Symptomatic “cracked tooth syndrome” (not enamel “craze lines”)

Full coverage restoration of a primary tooth without a permanent successor

Crowns are not indicated for the following:

If a lesser means of restoration is acceptable

If root resorption is present

Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration)

For alteration of vertical dimension

For purposes of preventing future fracture, or to eliminate enamel craze lines (cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative; tooth must be symptomatic)

To treat non-pathologic wear/abrasion, or abfraction lesions in the absence of decay

For molars exhibiting bone loss with a class III furcation involvement

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COVERAGE GUIDELINE Indirect Restorations (continued)

Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable

Fracture of porcelain not involving the margin or a functional ridge is not sufficient for replacement

Onlays

Onlays are indicated for the following:

Extensive caries on three or more surfaces or 50% loss of clinical crown

Large, >50% of the tooth, defective restoration that can be seen on the radiographic image

Fracture of cusps

Endodontically treated teeth, unless minimal access opening on anterior tooth

Documentation that a direct restoration is not possible

Crown/root ratio must be favorable

Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image

50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery

Anterior teeth: at least 50% involvement of incisal portion


Benefitted for primary teeth without permanent successor


Symptomatic “cracked tooth syndrome”

Onlays are not indicated for the following:

If a lesser means of restoration is acceptable

If root resorption is present

Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration)

For alteration of vertical dimension

For purposes of preventing future fracture, or to eliminate enamel craze lines (cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative; tooth must be symptomatic)

To treat non-pathologic wear/abrasion, or abfraction lesions in the absence of decay

For molars exhibiting bone loss with a class III furcation involvement

Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable

Fracture of porcelain not involving the margin or a functional ridge is not sufficient for replacement

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COVERAGE GUIDELINE Indirect Restorations (continued)

Inlays

Inlays are unproven Inlays have not been proven superior over direct restorations and are alternative benefitted to amalgam restorations.


Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

Any Dental Procedure performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance).

Refer to coverage guideline: Single Tooth Indirect Restorations (DCG008.02)

Other Restorative Services D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2982, D2999

Repairs necessitated by restorative material failure D2980–D2999

Criteria for codes: D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2982, D2999

Recement and Rebond of Single Tooth Indirect Restorations

Recement and rebond of single tooth indirect restorations are subject to frequency limitations. Please refer to member specific benefit plan document for guidance.

Repair of Single Tooth Indirect Restorations

Repair of single tooth indirect restorations is indicated to repair a fractured inlay, onlay, crown or veneer in which the functional area is involved due to restorative material failure.

Repair of single tooth indirect restorations is not indicated solely for cosmetic/aesthetic purposes.

Reattachment of Tooth Fragment

Reattachment of tooth fragment is indicated for a tooth fracture confined to enamel and dentin with loss of structure, but not exposing the pulp.

Reattachment of tooth fragment is not indicated for the following:

Tooth fractures involving pulpal exposure

Fractures involving roots

Coping

Coping is considered inclusive to the preparation of crowns and bridge

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COVERAGE GUIDELINE Other Restorative Services (continued)

abutments unless and indicated a separate procedure for the following:

If insufficient natural tooth structure remains to retain the crown

To allow a common path of insertion when retainer teeth are tipped or misaligned



Repairs are limited to those performed more than 12 months after the initial insertion.


Refer to coverage guideline: Other Restorative Services (DCG024.01)

Prefabricated Crowns Porcelain/Ceramic Crown D2929 Stainless Steel Crown D2930, D2931, D2932, D2933, D2934

Documentation Tooth number

Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934

Prefabricated Crowns are indicated for the following:

For the restoration of teeth with more than two surfaces affected with carious lesions, or where extensive one or two surface lesions are present.

For one and two surface carious lesions in documented high caries risk children. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver has active caries; o White spot lesions or enamel defects; o Visible caries or previous restorations; o Poor oral hygiene; o Sub-optimal systemic fluoride intake; o Frequent exposure to cavity-producing foods and drinks; o Patients with special health care needs; o Low socioeconomic status; o Xerostomia; o More than one interproximal lesion; o Other factors identified by professional literature;

Cervical decalcification, and/or developmental defects (hypoplasia, hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.).

Interproximal caries extending beyond line angles.

Following pulpotomy or pulpectomy.

For restoring a primary tooth that is to be used as an abutment for a space maintainer.

For the intermediate restoration of fractured teeth.

Restoration and protection of teeth exhibiting extensive tooth surface loss

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COVERAGE GUIDELINE Prefabricated Crowns (continued)

due to attrition, abrasion or erosion.

In patients with impaired oral hygiene in which the breakdown of intra-coronal restorations is likely.

When the tooth cannot be effectively isolated for amalgam or composite restorations.

Prefabricated Crowns are not indicated for the following:

A primary molar that is close to exfoliation, with more than half the roots resorbed.

Excessive tooth crown loss resulting in the inability for mechanical retention.

Loss of space due to tipping of neighboring teeth into carious defect interfering with the ability to attain proper fit.

As a definitive restoration on a permanent tooth.

For low and moderate caries risk patients, when a more conservative restoration is indicated.

Solely for cosmetic purposes.

As a prophylactic measure for teeth with no evidence of pathology.

Refer to clinical policy: Prefabricated Crowns (DCP012.02)

Protective restoration D2940

Documentation Recorded in member chart.

Criteria Direct placement of a restorative material to protect tooth and/or tissue form. Used to relieve pain, promote healing, or prevent further deterioration.

Covered as a separate procedure only if no other service other than radiographic images and exam were performed on the same tooth on the same day.

Not to be used for endodontic access closure, or as a base or liner under a restoration

Core Buildup, Post and Core and Pin Retention D2949

Core buildup: D2950

Pin retention per tooth: D2951

Post and Core: D2952, D2953, D2954, D2955, D2957 D2999

Documentation Bitewing unless tooth has had root canal therapy, then a periapical should be submitted.

Criteria for codes D2949, D2950, D2951, D2952, D2953, D2954, D2957, D2955, D2999

Restorative Foundation for an Indirect Restoration

Restorative foundation for an indirect restoration is indicated as a filler to eliminate undercuts, voids and other irregularities that have occurred during tooth preparation to create a more favorable tooth form for the retention of an indirect restoration.

Core Buildup (Including Any Pins When Required)

Core buildup is indicated for teeth with significant loss of coronal tooth structure (> 50%) due to caries or trauma to aid in retention of an indirect restoration.

Core buildup is not indicated for the following:

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COVERAGE GUIDELINE Core Buildup, Post and Core and Pin Retention (continued)

When adequate tooth structure remains to retain a crown

As a filler to correct irregularities in preparation

As a definitive composite or amalgam restoration

For retention of intracoronal restorations

Post and Core

Post and core are indicated for the following:

For teeth with significant loss of coronal tooth structure due to caries or trauma in endodontically treated teeth (> 50%) to aid in retention of an indirect restoration

Post and Core is not indicated for the following:

For vital teeth

For a post, when anatomic features are available to retain the core (e.g., for molars, as canals and pulp chamber can usually retain a core)

For teeth with short roots

Pin Retention

Pin retention is indicated for teeth with significant loss of coronal tooth structure due to caries or trauma, to allow retention of a direct restoration when preparation design alone is insufficient.

Pin retention is not indicated for the following:

For restoration of teeth with significant malocclusion

If the tooth cannot be properly restored with a direct restoration due to anatomic or functional considerations

Post Removal

Post removal is indicated for the following:

When there has been loss of adequate retention

In the case of fracture of tooth and/or post and core

When there is recurrent caries associated with post and core

When access is needed to root canal system for non-surgical endodontics

When the tooth has a reasonable long term prognosis for a new restoration



Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

Pin retention is limited to 2 pins per tooth; not covered in addition to cast restoration.

Post and core is covered only for teeth that have had root canal therapy.

Post removal is considered inclusive to retreatment procedure, and not

15


COVERAGE GUIDELINE Core Buildup, Post and Core and Pin Retention (continued)

covered

Restorative foundation for an Indirect Restoration is not covered


Refer to coverage guideline: Core Buildup, Post and Core and Pin Retention (DCG021.02)

Labial Veneer D2960, D2961, D2962

Documentation Radiographic image and narrative of medical necessity. Intraoral photo helpful.


A labial veneer is a thin layer of material placed over a tooth to protect it from further damage or for aesthetic reasons. For most plans, veneers are not covered, but for those plans that do have coverage, the following identify guidelines for placement.

Labial Veneers

Labial veneers are indicated for the following:

For coverage of enamel only fractures

Teeth with enamel defects including but not limited to enamel hypoplasia, severe decalcification, enamel hypocalcification and fluorosis

Labial veneers are not indicated for the coverage of fractures that extend into dentin.


The following are excluded from coverage: Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

Refer to coverage guideline: Labial Veneers (DCG025.01)

ENDODONTICS

Non-Surgical Endodontics

Endodontic codes: D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357

General documentation requirements Pre and post endodontic periapical radiographic images showing apex of tooth. For retreatment, surgical endodontics, cracked tooth syndrome and other procedures: pre and post-op images, taken within one year and narrative if the reason for treatment is not evident on films.

Diagnosis Diagnostic tests used to determine a diagnosis of irreversible pulpitis or periapical pathology must be documented in the record.

Criteria for codes D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357

Vital Pulp Therapy

Direct Pulp Cap

Direct pulp capping is indicated for the following:

Tooth has a vital pulp or been diagnosed with reversible pulpitis

All caries has been removed

Mechanical exposure of a clinically vital and asymptomatic pulp occurs

Bleeding is controlled at the exposure site

Exposure permits the capping material to make direct contact with the vital pulp tissue

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COVERAGE GUIDELINE Non-Surgical Endodontics (continued)

Exposure occurs when the tooth is under dental dam isolation

Adequate seal of the coronal restoration can be maintained

Patient has been fully informed that endodontic treatment may be indicated in the future

Direct Pulp capping is not indicated for a carious exposure in primary teeth

Indirect Pulp Cap

Indirect pulp capping is indicated for the following:

Tooth has a vital pulp or been diagnosed with reversible pulpitis

Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation

No history of subjective pretreatment symptoms

Pretreatment radiographs should not show periradicular pathosis

Therapeutic Pulpotomy

Therapeutic pulpotomy is indicated for the following:

Exposed vital pulps or irreversible pulpitis of primary teeth

Any bleeding was controlled within several minutes

As an emergency procedure in permanent teeth until root canal treatment can be accomplished

As an interim procedure for permanent teeth with immature root formation to allow continued root development

In primary teeth, where there is a reasonable period of retention expected (approximately one year)

Therapeutic pulpotomy is not indicated for the following:

Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor

As the first stage of complete root canal therapy

Removal of pulp apical to the dentinocemental junction

For primary teeth that are near exfoliation or less than 50% of the tooth root remains

Partial Pulpectomy for Apexogenesis

A partial pulpotomy for apexogenesis is indicated for the following:

In a young permanent tooth for a carious pulp exposure

When the pulpal bleeding is controlled within several minutes

A vital tooth, with a diagnosis of normal pulp or reversible pulpitis

Apexification/Recalcification

Apexification/recalcification is indicated for the following:

Incomplete apical closure in a permanent tooth root

External root resorption or when the possibility of external root resorption

17



exists.

Necrotic pulp, irreversible pulpitis or periapical lesion

For prevention or arrest of resorption

Perforations or root fractures that do not communicate with oral cavity

Apexification/recalcification is not indicated for the following:

Tooth with a completely closed apex

If patient compliance or long term follow up may be questionable

Pulpal Regeneration

Pulpal regeneration is indicated for the following:

Permanent tooth with immature apex

Necrotic pulp

Pulp space not needed for post/core or final restoration

When tooth is not restorable

Pulpal regeneration is not indicated for the following:

Primary teeth

The pulp space would be needed for final restoration

Non-Vital Pulp Therapy

Pulpal Debridement (Pulpectomy)

Pulpal debridement (pulpectomy) is indicated for the following:

A restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified

The relief of acute pain prior to complete root canal therapy

A primary tooth, where there is a reasonable period of retention expected (approximately one year)

Pulpal debridement (pulpectomy) is not indicated for the following:

Complete root canal therapy of an infected or necrotic tooth

Primary teeth that are near exfoliation or less than 50% of the tooth root remains

Pulpal Therapy (Resorbable Filling) – Primary Teeth

Pulpal therapy for primary teeth is indicated for the following:

A restorable primary tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified

The prognosis for keeping the tooth is up to one year and the tooth root lies in at least 25% bone

Pulpal therapy is not indicated for the following:

Primary teeth that are near exfoliation or less than 50% of the tooth root remains

Permanent teeth

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Endodontic Therapy

Endodontic therapy is indicated for the following:

A restorable mature, completely developed permanent or primary tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure

Teeth with radiographic periapical pathology

Primary teeth without a permanent successor

Trauma

When needed for prosthetic rehabilitation

Endodontic therapy is not indicated for the following:

Teeth with a poor long term prognosis

Teeth that are considered non-restorable

Teeth with inadequate bone support or advanced or untreated periodontal disease

Teeth with incompletely formed root apices

Treatment of Root Canal Obstruction; Non-Surgical Access

Treatment of a root canal obstruction is indicated for the following:

When there is an obstruction of the root canal system, (biological, iatrogenic ledges or post removal) and endodontic retreatment is needed

Removal of obstruction is complex and/or requires significant time

Treatment of a root canal obstruction is not indicated when there is no obstruction evident.

Incomplete Endodontic Therapy: Inoperable, Unrestorable or Fractured Tooth

Incomplete endodontic therapy is indicated for the following:

During endodontic treatment of a tooth, it becomes apparent that the procedure cannot be successfully completed

The tooth will not be able to be restored, or the tooth fractures, necessitating discontinuation of treatment

Internal Root Repair of Perforation Defects

Internal root repair of perforation defects is indicated for the following:

There is a root perforation caused by pathology such as resorption or decay

A communication between the pulp space and external root surface as a result of internal root resorption.

Internal root repair of perforation defects is not indicated for the following:


Teeth with inadequate bone support or advanced untreated periodontal disease

Retreatment of Previous Root Canal Therapy

19



Retreatment of previous root canal therapy is indicated for the following:

Canal fill appears to extend to a point shorter than 2millimeters from the apex, or extends significantly beyond the apex

Fill appears to be incomplete

Tooth is sensitive to pressure and percussion or other subjective symptoms

The existing endodontics is poor

Placement of a post has the potential to compromise the existing obturation or apical seal of the canal system

The canal is accessible and allows for retreatment with a non-surgical procedure

Refer to coverage guideline: Non-Surgical Endodontics (DCG009.02)

Surgical Endodontics D3410, D3421, D3425, D3426, D3427, D3430, D3450, D3470, D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, D3999

Documentation Pre and post-operative radiograph image. Provider narrative may be requested if pathology is not visible. Date of last root canal treatment if needed.

Criteria for codes D3410, D3421, D3425, D3426, D3427, D3430, D3450, D3470, D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, D3999

Apicoectomy

Apicoectomy is indicated for the following:

Failed retreatment of endodontic therapy

When the apex of tooth cannot be accessed due to calcification or other anomaly

Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected

Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist

When individual patient considerations make prolonged non-surgical treatment not practical

A marked over extension of obturating materials interfering with healing

Apicoectomy is not indicated for the following:

Unusual bony or root configurations resulting in lack of surgical access

The possible involvement of neurovascular structures



When non-surgical endodontic treatment has not been attempted or was not indicated

Periradicular Surgery Without Apicoectomy (Includes Surgery and Periradicular Curettage)

Periradicular surgery without apicoectomy is indicated for the following:

Failed retreatment of endodontic therapy

When the apex of tooth cannot be accessed due to calcification or other anomaly

When a biopsy of periradicular tissue is necessary

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COVERAGE GUIDELINE Surgical Endodontics (continued)

Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected

Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist

When individual patient considerations make prolonged non-surgical treatment not practical

A marked overextension of obturating materials interfering with healing

Periradicular surgery without apicoectomy is not indicated for the following:

Unusual bony or root configurations resulting in lack of surgical access

The possible involvement of neurovascular structures



When non-surgical endodontic treatment has not been attempted or was not indicated

Retrograde Filling

Retrograde filling is indicated for the following:

Periradicular pathosis and a blockage of the root canal system that could not be obturated by nonsurgical root canal treatment

Persistent periradicular pathosis resulting from an inadequate apical seal that cannot be corrected nonsurgically.

Root perforations

Resorptive defects

Retrograde filling is not indicated for the following:

When canals are successfully obturated and no evidence of radiographic pathology or clinical symptoms persist

When a tooth has an overall poor prognosis with or without retrograde filling placement

Root Amputation

Root amputation is indicated for the following:

Class III furcation involvement

Untreatable bony defect (of one root)

Root fracture

Root caries

Root resorption

Persistent sinus tract or recurrent apical pathology

When there is greater than 75% bone supporting remaining root(s)

The tooth has had successful endodontic treatment on remaining root(s)

Root amputation is not indicated for the following:

Teeth with an overall poor prognosis with or without root amputation

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Vital teeth

Intentional Reimplantation

Intentional replantation is indicated when all of the following clinical conditions exist:

Persistent periradicular pathosis following endodontic treatment

Nonsurgical retreatment is not possible or has an unfavorable prognosis

Periradicular surgery is not possible or involves a high degree of risk to adjacent anatomical structures

The tooth presents a reasonable opportunity for removal without fracture

The tooth has an acceptable periodontal status prior to the replantation procedure

Intentional replantation is not indicated when any of the above criteria are not met.

Hemisection

Hemisection of multirooted teeth is indicated for the following:

Class III or Class IV periodontal furcation defect

Infrabony defect of one root of a multi-rooted tooth that cannot be successfully treated periodontally

Coronal fracture extending into the furcation

Vertical root fracture confined to the root to be separated and removed

Carious, resorptive root or perforation defects that are inoperable or cannot be corrected without root removal

Persistent periradicular pathosis where nonsurgical treatment or periradicular surgery is not possible and the problem is confined to one root

The tooth has had successful endodontic treatment on remaining portion of tooth

Hemisection of multirooted teeth is not indicated for the following:

Teeth with overall poor prognosis with or without hemisection

Vital teeth

Bone Graft in Conjunction with Periradicular Surgery

Bone graft in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate possible benefits of bone grafting in endodontic surgery.

Biologic Materials to Aid in Soft and Osseous Tissue Regeneration in Conjunction with Periradicular Surgery

Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery are unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate

22



possible benefits of biologic material to aid in tissue and osseous regeneration in endodontic surgery.

Guided Tissue Regeneration Resorbable Barrier in Conjunction with Periradicular Surgery

Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate possible benefits of guided tissue regeneration techniques in endodontic surgery.

Refer to coverage guideline: Surgical Endodontics (DCG010.02)

PERIODONTICS

Surgical Periodontics: Resective Procedures D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261, D4274

Documentation/Other for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261

Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films.

Tooth numbers or site designations.

Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.

Documentation for code D4274 Pre-surgical radiograph images.

Grafts:

One soft tissue graft per two contiguous teeth.

Bone graft and guided tissue regeneration: only one or the other allowed.

Evidence of mobility, bruxism and/or hyperocclusion may contraindicate grafting

Criteria for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261, D4274

Gingivectomy/Gingivoplasty

Gingivectomy/Gingivoplasty is indicated for the following:

Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is fibrous and firm and there is an adequate zone of keratinized tissue;

Elimination of gingival enlargements/overgrowth due to medications, medical conditions or tooth position;

Elimination of suprabony periodontal abscesses;

For exposure of soft tissue impacted teeth to aid in eruption;

To reestablish gingival contour following an episode of acute necrotizing ulcerative gingivitis;

To allow restorative access, including root surface caries.

Gingivectomy/Gingivoplasty is not indicated for the following:

When bone surgery is required for infrabony defects, or for the purpose of examining bone shape and morphology;

Situations in which the bottom of the pocket is apical to the mucogingival junction;

Areas where aesthetics are a concern (particularly in the anterior maxilla);

In areas with a shallow palatal vault or prominent external oblique ridge;

Severely edematous or inflamed tissue;

Patients with poor plaque control or non-compliance with non-surgical procedures;

Patients with an uncontrolled underlying medical condition;

Solely for cosmetic/aesthetic purposes.

Anatomical Crown Exposure

Anatomical Crown exposure is indicated for the following:

In an otherwise periodontally healthy area to facilitate the restoration of

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COVERAGE GUIDELINE Surgical Periodontics: Resective Procedures (continued)

subgingival caries;

In an otherwise periodontally healthy area to allow proper contour of restoration;

In an otherwise periodontally healthy area to allow management of a fractured tooth in which the fracture extends subgingivally.

Anatomical Crown exposure is not indicated for the following:

Solely for cosmetic/aesthetic purposes;

Patients with an uncontrolled underlying medical condition.

Gingival Flap Procedure

Gingival flap procedure is indicated for the following (includes root planing):

The presence of moderate to deep probing depths;

Loss of attachment;

The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful;

The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods.

Gingival flap procedure is not indicated for the following:



Patients who have been non-compliant with previous periodontal therapies.

Apically Positioned Flap Procedure

Apically Positioned Flap Procedure is indicated for the following:

The presence of moderate to deep probing depths;

Loss of attachment;

The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful;

The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods;

To preserve keratinized tissue in conjunction with osseous surgery.

Apically Positioned Flap Procedure is not indicated for the following:




Clinical Crown Lengthening-Hard Tissue

Clinical Crown Lengthening-Hard Tissue is indicated for the following:

In an otherwise periodontally healthy area to allow a restorative procedure on a tooth with little to no crown exposure.



24


COVERAGE GUIDELINE Surgical Periodontics: Resective Procedures (continued)

Clinical Crown Lengthening-Hard Tissue is not indicated for the following:

As treatment for periodontal disease;


Patients with an uncontrolled underlying medical condition.

Osseous Surgery

Osseous surgery is indicated for the following:

Patients with a diagnosis of moderate to advanced periodontal disease;

For cases of refractory periodontal disease;

When less invasive therapy (i.e., non-surgical periodontal therapy, flap procedures) has failed to eliminate disease.

Osseous surgery is not indicated for the following:

Patients with a diagnosis of mild periodontal disease;

For teeth with a hopeless prognosis (more than 80% bone loss and Class 3 or higher mobility);



Distal or Proximal Wedge (When Not Performed in Conjunction with Surgical Procedures in the Same Anatomical Area)

Distal or Proximal Wedge procedure is indicated for the following:

The presence of moderate to deep probing depths (greater than 5mm) on a surface adjacent to an edentulous/terminal tooth area;

The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful on a surface adjacent to an edentulous/terminal tooth area;

The diagnosis of a cracked tooth, fractured root or external root resorption on a surface adjacent to an edentulous/terminal tooth area, when this cannot be accomplished by non-invasive methods.

Distal or Proximal Wedge procedure is not indicated for the following:



Patients who have been non-compliant with previous periodontal therapies;

In areas in which there are teeth with proximal contact.

Refer to clinical policy: Surgical Periodontics: Resective Procedures (DCP013.03)



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COVERAGE GUIDELINE Surgical Periodontics: Regenerative Procedures D4263, D4264, D4265, D4266, D4267, D4268, D4999

Codes D4265, D4266, D4267 and D4999 are each addressed in the Regenerative, Mucogingival and Resective Surgical Periodontics clinical policies.

Documentation Full radiographic images (panoramic image) with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.

Criteria for codes D4263, D4264, D4265, D4266, D4267, D4268, D4999

Bone Replacement Grafts

Bone Replacement Grafts are indicated for the following:

Infrabony/Intrabony vertical defects;

Class II furcation involvements.

Bone Replacement Grafts are not indicated for the following:

Class I furcation involvement;

Class III or higher furcation involvement;

Non-vertical defects;



Patients with poor oral hygiene;

Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility).

Biologic Materials to Aid in Soft and Osseous Tissue Regeneration

Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated for the following:

Intrabony/Infrabony vertical defects;


Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are not indicated for the following:

Class I and Class III or higher furcation involvement;





Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility).

Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier (includes Membrane Removal)

Guided Tissue Regeneration is indicated for the following:

Intrabony/infrabony vertical defects;


Guided Tissue Regeneration is not indicated for the following:

Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility);

Class I furcation involvement;

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COVERAGE GUIDELINE Surgical Periodontics: Regenerative Procedures (continued)

Class III or higher furcation involvement;

Horizontal bone loss;





Crater defects.

Surgical Revision Procedure (per Tooth)

Surgical Revision Procedure is indicated to correct an abnormal healing response that interferes with the therapeutic goals of the original regenerative surgical procedure.

Surgical Revision Procedure is not indicated solely for cosmetic/aesthetic purposes.

Refer to clinical policy: Surgical Periodontics: Regenerative Procedures (DCP014.03)

Surgical Periodontics: Mucogingival Procedures D4265, D4266, D4267, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4999

Codes D4265, D4266, D4267 and D4999 are each addressed in the Regenerative, Mucogingival and Resective Surgical Periodontics clinical policies.

Documentation/Other

Pedicle soft tissue graft (D4270) is not benefited at the same time with other periodontal surgery.

Soft tissue grafts are benefitted once per two contiguous teeth

Documentation (see Note) Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films.

Tooth numbers or site designations.

Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.

Note No radiographs required for the following codes: D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285

Criteria for codes D4265, D4266, D4267, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4999

Pedicle Soft Tissue Graft Procedure

Pedicle Soft Tissue Graft Procedure is indicated for the following:

Areas with less than 2 mm of attached gingiva;

Unresolved sensitivity in areas of recession;

Progressive recession or chronic inflammation;

For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control;

Ridge augmentation;

To increase vestibular depth for the correct fit of prosthesis;

To widen zone of attached gingiva for prosthetic abutment teeth;

To increase vestibular depth to allow proper oral hygiene techniques;

Gingival clefting.

Pedicle Soft Tissue Graft Procedure is not indicated for the following:

Roots covered with thin bony plates;

Patients with an untreated medical condition.

Autogenous Connective Tissue Graft

Autogenous connective tissue graft is indicated for the following:




For teeth with subgingival restorations where there is little or no attached

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COVERAGE GUIDELINE Surgical Periodontics: Mucogingival Procedures (continued)

gingiva to improve plaque control;

Ridge augmentation;




Gingival clefting.

Autogenous connective tissue graft is not indicated for the following:

Broad, shallow palatal donor site;

Excessively glandular or fatty submucosal tissue in donor site;

A donor site with roots covered with thin bony plates;


Non-Autogenous Connective Tissue Graft

Non-autogenous connective tissue graft is indicated for the following:





Ridge augmentation;




Gingival clefting.

Non-autogenous connective tissue graft is not indicated for the following:

When indications for connective tissue grafting are not met;


Combined Connective and Double Pedicle Graft

Combined Connective and Double Pedicle Graft is indicated for the following:





Ridge augmentation;




Gingival clefting.

Combined Connective and Double Pedicle Graft is not indicated for the following:



28


COVERAGE GUIDELINE Surgical Periodontics: Mucogingival Procedures (continued)

Roots covered with thin bony plates;


Free Soft Tissue Graft Procedure (including Donor Site Surgery)

Free Soft Tissue Graft Procedure is indicated for the following:







Gingival clefting.

Free Soft Tissue Graft Procedure is not indicated for the following:

Broad, shallow palatal donor site;

Excessively glandular or fatty submucosal tissue in donor site;

A donor site with roots covered with thin bony plates;


Biologic Materials to Aid in Soft and Osseous Tissue Regeneration

Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated for the following:

To enhance periodontal tissue regeneration and healing for mucogingival defects in conjunction with mucogingival surgeries with or without guided tissue regeneration.

Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier (includes Membrane Removal)

Guided Tissue Regeneration is indicated for the following:

For sensitivity in areas of recession;


Areas of bone dehiscence and fenestration’

Single tooth, wide and deep localized recession;

For areas associated with failed cervical restorations.

Guided Tissue Regeneration is not indicated for the following:

Multiple adjacent tooth sites of root coverage required;

Solely for cosmetic/aesthetic purposes.

Refer to clinical policy: Surgical Periodontics: Mucogingival Procedures (DCP015.02)



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COVERAGE GUIDELINE Provisional Splinting D4320, D4321

Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.


Provisional Splinting using these codes is indicated for the following:

Multiple teeth that have become mobile due to loss of alveolar bone loss and periodontium;

During surgical and healing phases of regenerative periodontal therapy.

Provisional Splinting using these codes is not indicated for the following:

Tooth transplantation;

Trauma resulting in the reimplantation of completely avulsed tooth/teeth;

Trauma resulting in displacement or fracture of tooth/teeth.


Limited to once per 36 months per same tooth/teeth.

Not to be billed on same day as any restoration, prostheses or implant for same tooth/teeth.

Refer to coverage guideline: Provisional Splinting (DCG011.02)

Non-Surgical Periodontal Therapy D4341, D4342, D4346, D4381, D4910, D4921

Documentation Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.

Criteria for codes D4341, D4342, D4346, D4381, D4910, D4921

Scaling and Root Planing

Scaling and root planing is indicated for any of the following:

Localized or generalized mild or moderate chronic periodontal disease which is the loss of clinical attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone, resulting in periodontal probing depths up to 6 mm with clinical attachment loss of up to 4 mm. Radiographic evidence of bone loss and tooth mobility are most likely present. In molars, furcation involvement should not to exceed Class 1

Localized or generalized severe periodontal disease which is the loss of clinical attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone, resulting in periodontal probing depths greater than 6 mm with attachment loss greater than 4 mm. Radiographic evidence of bone loss and tooth mobility are most likely present

Chronic refractory mild or moderate periodontal disease which is characterized by patients who demonstrate additional attachment loss despite being longitudinally monitored with periodontal maintenance

Periodontal abscess which is characterized by localized swelling and/or increased probing depth and loss of periodontal attachment

Scaling and root planing is not indicated for the following:

In the absence of diagnosed periodontal disease

For the removal of heavy deposits of calculus and plaque

Gingivitis defined as inflammation of the gingival tissue without loss of attachment (bone and tissue)

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COVERAGE GUIDELINE Non-Surgical Periodontal Therapy (continued)

As a sole treatment for chronic periodontitis with advanced loss of support demonstrated by pockets greater than 6 millimeters with CAL greater than 4 millimeters, and radiographic bone loss (mobility may or may not be present)

As a sole treatment for refractory chronic, aggressive or advanced periodontal diseases

Localized Delivery of Antimicrobial Agents

Localized delivery of antimicrobial agents is indicated as an adjunct to scaling and root planing in cases of refractory disease and/or residual probing depths greater than or equal to 5 millimeters with inflammation that are still present following conventional therapies.

Localized delivery of antimicrobial agents is unproven and not indicated in the absence of periodontal scaling and root planing (SRP) procedure.

Periodontal Maintenance

Periodontal maintenance is indicated for the following:

To maintain the results of non-surgical periodontal scaling and root planing therapy and prevent recurrent disease

As an extension of active periodontal therapy at selected intervals

Periodontal maintenance is not indicated for the following:

No history of scaling and root planing (SRP) or surgical procedures

Gingivitis-defined as inflammation of the gingival tissue without loss of attachment (bone and tissue)

Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation – Full Mouth

Scaling in presence of generalized moderate or severe gingival inflammation is indicated for the removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing.

Gingival Irrigation per Quadrant

Gingival irrigation per quadrant is unproven. There is limited evidence to support the efficacy of a single episode or multiple in office irrigation appointments. The available studies show the greatest problem with irrigation as an adjunctive therapy is that the antimicrobials are quickly eliminated.

Refer to clinical policy: Non-Surgical Periodontal Therapy (DCP004.03)

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COVERAGE GUIDELINE Full Mouth Debridement D4355

Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.

Criteria for codes D4355


Full Mouth Debridement is a covered dental service and indicated when the following criteria have been met:

Heavy calculus is present on teeth and usually visible on radiographs.

Due to the amount of calculus, plaque and debris, a comprehensive examination and diagnosis is not possible.


Limited to once every 36 months.

Not to be billed on same day as any exam code or non-surgical periodontal therapy code.

Not to be billed within 12 months of prophylaxis or periodontal maintenance.

Not to be used as a therapeutic or preventive procedure such as scaling and root planing or prophylaxis.

Refer to coverage guideline: Full Mouth Debridement (DCG001.02)

Unscheduled Dressing Change D4920

REMOVABLE PROSTHETICS

Removable Prosthodontics D5110–D5899 Complete dentures: D5110–D5140 Partial dentures: D5211–D5281 Adjustments to Dentures: D5410–D5422 Repair to Complete Dentures: D5510, D5520 Repair to Partial Dentures: D5610–D5671 Denture Rebase Procedures: D5710–D5721 Denture Reline Procedures: D5730–D5761 Interim partial dentures: D5810–D5821 Other Removable Prosthetic Services: D5850–D5875

Documentation Full mouth radiographic images.

Tooth numbers for missing teeth to be replaced, and other missing teeth.

Date of extractions if indicated.

Age of existing prosthesis. Immediate denture: X-rays showing at least one tooth present and severe periodontal disease or caries.

Criteria for codes D5110, D5120, D5130, D5140, D5211, D5212, D5213, D5214, D5221, D5222, D5223, D5224, D5225, D5226, D5281, D5410, D5411, D5421, D5422, D5510, D5520, D5610, D5620, D5630, D5640, D5650, D5660, D5670, D5671, D5710, D5711, D5720, D5721, D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761, D5810, D5811, D5820, D5821, D5850, D5851, D5862, D5863, D5864, D5865, D5866, D5867, D5875, D5899

Removable prosthodontic appliances are indicated for replacement of missing teeth loss to disease or injury. The following outlines indications and coverage guidelines for complete and partial removable prosthodontics.

Complete Dentures

Complete dentures are indicated for the following:

To replace teeth that are non-restorable due to gross caries and/or advanced periodontal disease

To replace teeth lost due to orofacial trauma

To replace teeth lost due to oral cancer surgery and subsequent reconstruction

Complete Dentures are not indicated for the following:

When there is no evidence of dental disease

When teeth appear to be restorable

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COVERAGE GUIDELINE Removable Prosthodontics (continued)

When there has been extensive bone atrophy resulting in an inadequate edentulous ridge for retention of appliance

Patient convenience


Limited to once per 60 months from initial or supplemental placement

Not allowed if within 60 months of an existing partial denture, interim partial denture, removable partial denture, pontic, retainer, inlay abutment, crown abutment, onlay abutment, or an interim retainer crown for same tooth

Not allowed if there is a history of an implant, implant abutment, denture, or interim partial for the same tooth

Partial Dentures

Partial Dentures are indicated for the following:

To replace teeth that are non-restorable due to gross caries and/or advanced periodontal disease

To replace teeth lost due to trauma or injury

When a fixed partial denture is contraindicated (e.g., immediately following extractions, for a long edentulous span, distal extension needs, a periodontally involved dentition, resorption and loss of edentulous ridge)

Partial Dentures are not indicated for the following:

Chronic poor oral hygiene

Severe periodontal disease with questionable ability to support a partial denture


Limited to once per 60 months

Not allowed if within 60 months of an existing partial denture, interim partial denture, removable partial denture, pontic, retainer, inlay abutment, crown abutment, onlay abutment, or an interim retainer crown for same tooth

Not allowed if there is a history of an implant, implant abutment, denture, or interim partial for the same tooth

Complete and Partial Denture Rebase Procedures

Rebasing of removable appliances is considered inclusive for the first 6 months, and then subject to frequency limitations. For immediate dentures, one rebase covered in the first six months; then additional rebasing subject to frequency limitations.

Denture Rebasing is indicated for the following:

When there is a space between base and residual ridge

When appliance has become mobile or unstable

When replacing or rearranging teeth on the appliance

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When the base has fractured or cracked

Denture Rebasing is not indicated for the following:

When the appliance is broken or worn to the extent that replacement is warranted

When the occlusion or structural integrity of the denture teeth are no longer functional

When reline is sufficient

Complete and Partial Denture Reline Procedures

Relining of removable appliances is considered inclusive for the first 6 months, and then subject to frequency limitations. For immediate dentures, one reline covered in the first six months; then additional relining subject to frequency limitations.

Denture Relining is indicated for the following:

When appliance has become mobile or unstable

To reestablish a soft tissue base for a distal extension appliance when denture rotation is evident

When there has been loss of occlusal contact with opposing arch

Denture Relining is not indicated for the following:

When the appliance is broken or worn to the extent that replacing the appliance is warranted

When the occlusion or structural integrity of the denture teeth are no longer functional

Interim Prosthesis

Interim Prostheses are indicated for the following:

While tissue is healing following extractions

For the maintenance of a space for future permanent treatment such as an implant, bridge or definitive fixed appliance

To condition teeth and ridge tissue for optimum support of a definitive removable partial denture

To maintain established jaw relation until all restorative treatment has been completed and a definitive partial denture can be constructed

Interim Prostheses are not indicated for the following:

As a permanent, definitive prosthesis

Overdentures

Overdentures are indicated for the following:

To preserve the integrity of the edentulous ridge

When there are teeth available as abutments that have a good long term prognosis

Overdentures are not indicated for the following:

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When there has been significant deterioration of the edentulous ridge

When the teeth available as abutments do not have a good long term prognosis

For patients with poor oral hygiene and non-compliance

Tissue Conditioning

Tissue Conditioning is considered inclusive for the first 12 months, and is then subject to frequency limitations.

Tissue Conditioning is indicated for the following:

In the presence of inflammation and irritation of the mucosa covering den-ture-bearing areas

When there is distortion of normal anatomic structures, such as incisive papillae, rugae, and retromolar pads

A burning sensation in residual ridge areas, the tongue, and the cheeks and lips not related to a systemic medical condition

Subsequent to placement of immediate dentures to facilitate short term denture retention

Tissue Conditioning is not indicated for the following:

For long term appliance stability and/or comfort

Repairs and Adjustments

Repairs and adjustments of removable appliances are considered inclusive for the first 12 months, and are then subject to frequency limitations. Adding teeth to appliances is also subject to frequency limitations.

Maxillofacial Prosthetics

These are removable appliances for the loss of orofacial structures due to trauma, congenital deformity or destruction of structures due to cancer and resection. This code section also includes radiation shields, carriers for fluoride, radiation carriers, as well as specific medicaments. These removable prosthetics are considered to be medical in nature and are typically covered under the member’s medical plan. Please see appropriate medical policy.


The following are excluded from coverage:

Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.

Fixed or removable prosthodontic restoration procedures for complete oral

35



rehabilitation or reconstruction.

Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.

Clinical situations that can be effectively treated by a less costly dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure.

Refer to coverage guideline: Removable Prosthodontics (DCG020.02)

MAXILLOFACIAL PROSTHETICS

Maxillofacial Prosthetics D5900–D5999

Documentation Narrative Radiographic images if indicated

IMPLANTS

Implants D6010, D6011, D6012, D6013, D6040, D6050, D6051, D6052, D6055, D6056, D6057, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6080, D6081, D6085, D6090, D6091, D6092, D6093, D6094, D6095, D6100, D6101, D6102, D6103, D6104, D6110, D6111, D6112, D6113, D6114, D6115, D6116, D6117, D6190, D6194, D6199

Documentation

Single implant: periapical acceptable; request full mouth images or panoramic image if needed.

More than one implant: full mouth images or panoramic image required.

Bone graft at time of implant placement: periapical pre-op radiograph, request full mouth images or panoramic image if needed.

Criteria for codes D6010, D6011, D6012, D6013, D6040, D6050, D6051, D6052, D6055, D6056, D6057, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6080, D6081, D6085, D6090, D6091, D6092, D6093, D6094, D6095, D6100, D6101, D6102, D6103, D6104, D6110, D6111, D6112, D6113, D6114, D6115, D6116, D6117, D6190, D6194, D6199

A dental implant is an artificial tooth root that is placed into the jaw to hold a replacement tooth or bridge. Adequate bone in the jaw is needed to support the implant, and recipients should have healthy gum tissues that are free of periodontal disease. For most plans, implants are not covered, but for those plans that do have coverage, the following identify guidelines for implant placement, subsequent implant supported restorations, and any necessary treatment of peri-implant defects:

The implant site must be osseointegrated prior to loading.

Implant must have adequate crown/root ratio.

Must not have more than two threads above the alveolar crest.

Implant must not be closer than 1-1.5mm to adjacent roots.

Same day implant placement at time of extraction considered acceptable.

No direct loading of abutment and/or fixed prosthesis on date of implant

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COVERAGE GUIDELINE Implants (continued)

placement.

Periodontal health of existing dentition must be favorable.

Long term prognosis must be favorable.

Site is free of acute infection.

Factors to consider in treatment planning for implants:

Location of tooth/teeth;

Bone quality/quantity;

Periodontal status;

Restorability;

Patient cost;

Patient age (implants not appropriate for patients under age 15);

Patients undergoing strong chemotherapy;

Myocardial infarction: within 6 months of an attack;

Anticoagulant therapy;

Severe neuropsychiatric disease, mental disability, and narcotic drug addicts ;

Severe blood diseases;

Systemic Risk Factors: o Smoking o Diabetes o Hypertension o Decreased estrogen levels in postmenopausal women o Use of IV bisphosphonates

Refer to coverage guideline: Implants (DCG007.03)

FIXED PROSTHETICS

Fixed Prosthodontics D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6549, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6793, D6794, D6920, D6930, D6940, D6950, D6980, D6985, D6999

Documentation Radiographic images: full periapical set with bitewings. Panoramic with bitewings and PA of area (not preferable/panoramic needs to be high quality) of involved teeth, as well as contralateral and opposing sites. Pontic must be at least 2/3 the size of the tooth being replaced. Repair: Reviewer may request narrative if needed. Replacement: Reviewer may request narrative if needed.

Criteria for codes D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6549, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6793, D6794, D6920, D6930, D6940, D6950, D6980, D6985, D6999

Fixed Partial Dentures (FPD)

Fixed partial dentures are indicated for the following:

For the replacement of missing teeth in which the retainer teeth have a favorable long term prognosis

For the replacement of one to two missing posterior teeth in a tooth bounded space

In addition to the above, the following applies:

Resin bonded appliances are indicated for the replacement of one missing tooth and an unrestored abutment tooth with significant clinical crown

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COVERAGE GUIDELINE Fixed Prosthodontics (continued)

length

Fixed partial dentures are not indicated for the following:

Patients with rampant caries

Patients with poor oral hygiene

When retainer teeth have untreated endodontic pathology or periodontal disease or an unfavorable crown: root ratio

When teeth intended as retainers have inadequate remaining tooth structure

For the primary dentition

When an arch or dentition is deemed terminal

When tooth to be used as a retainer has tipped or drifted into edentulous space, rendering seating of retainer difficult or impractical

In addition to the above, the following applies:

Cantilever FPD is not indicated in an area with significant malocclusion, heavy occlusion or parafunctional habits (e.g., nail biting, bruxism, clenching)

Resin bonded FPD is not indicated when there is a pontic width discrepancy, in patients with parafunctional habits (e.g., nail biting, bruxism, clenching), in an area with significant malocclusion or heavy occlusion

Resin bonded FPD is not indicated as a temporary prosthesis

Provisional Fixed Partial Dentures

Provisional Fixed Partial Dentures are indicated for the following:

When the prognosis of a permanent fixed partial denture is questionable due to periodontal involvement, endodontic pathology or patient compliance

To replace a lost tooth in young patients to allow maturity of the dentition and jaws before constructing a definitive fixed prosthetic appliance

When a systemic medical condition prohibits the placement of a definitive fixed prosthetic appliance

Provisional Fixed Partial Dentures are not indicated for the following:

As a definitive fixed partial denture unless indicated by above criteria

Fixed Partial Denture Repair (Necessitated by Restorative Material Failure) Fixed partial denture repair is indicated for the following:

When the appliance to be repaired is functional and has a favorable long term prognosis

Fixed partial denture repair is not indicated for the following:

For porcelain fracture if margins are intact and functional area not involved

Precision Attachments

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Precision attachments are indicated for the following:

When aesthetics need to be considered

For the redistribution of occlusal forces

To minimize trauma to soft tissue

For the control of loading and rotational forces

When it is not possible to prepare two abutments with a common path of placement

When the prognosis of an abutment is uncertain

Connector Bar

Connector bars are indicated to brace individual abutment teeth with considerable coronal length for enhances stabilization of removable partial dentures, complete dentures and overdentures.

Stress Breaker (a Non-Rigid Connector)

Stress Breakers are indicated for the following:

When it is not possible to prepare two abutments with a common path of placement

When the prognosis of an abutment is uncertain

Control of loading and rotational forces

For the redistribution of occlusal forces


Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement

Limited to repairs or adjustments performed more than 12 months after the initial insertion; limited to 1 per consecutive 6 months

Limited to 1 time per tooth per consecutive 60 months

Stress breakers, and connector bars are not covered

Clinical situations that can be effectively treated by a less costly alternative procedure will be assigned a benefit based on the least costly procedure

Any Dental Procedure performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance)

Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error (this type of replacement is the responsibility of the Dentist; if replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement)

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction

Attachments to conventional removable prostheses or fixed bridgework

39



(this includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature)

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO)

Placement of fixed partial dentures solely for the purpose of achieving periodontal stability

Refer to coverage guideline: Fixed Prosthodontics (DCG017.02)

ORAL SURGERY

Non-Surgical Extractions D7111, D7140

Documentation Pre-operative radiographic images


Non-Surgical Extractions

Non-surgical extractions are indicated for the following:

For non-restorable teeth

For teeth in which previous restorative, endodontic or periodontal treatment has failed

Teeth with periapical pathology evident

Supernumerary teeth

Crowding/nonfunctional teeth

Orthodontic considerations

For primary teeth with roots retained in bone or soft tissue that is interfering with eruption of permanent teeth

For primary canines to correct eruption pattern of a permanent canine that is palatally displaced

Interference with prosthodontic needs

Non-surgical extractions are not indicated when the clinical condition requires a surgical procedure (e.g., tooth impaction). Please refer to the Surgical Extraction of Impacted Teeth and Surgical Extraction of Erupted Teeth and Retained Roots dental policies.

Coverage Limitations

Limited to one extraction per tooth, per lifetime

Refer to coverage guideline: Non-Surgical Extractions (DCG022.02)

Surgical Extraction of Erupted Teeth and Retained Roots D7210, D7250

Documentation Dated and labeled radiographic images including panoramic image or periapicals usually taken within one year and appropriate to document the case. Panoramic, periapicals, or tomography for third molar extractions is


Surgical Extraction of an Erupted Tooth

Surgical extraction of an erupted tooth is indicated for any of the following:

No clinical crown is visible in the mouth;

There is insufficient remaining clinical crown to allow a non-surgical

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COVERAGE GUIDELINE Surgical Extraction of Erupted Teeth and Retained Roots (continued)

indicated by the clinical presentation. Treatment notes if radiographic information not conclusive.

extraction;

The fracture of a tooth or roots during a non-surgical extraction procedure;

Erupted teeth with unusual root morphology (dilacerations, cementosis);

Erupted teeth with developmental abnormalities that would make non-surgical extraction unsafe or cause harm;

When fused to an adjacent tooth;

In the presence of periapical lesions;

For maxillary posterior teeth whose roots extend into the maxillary sinus;

When severe crowding or ectopic position of the tooth is present;

When tooth has been crowned or been treated endodontically;

Other conditions as deemed necessary by a licensed dentist.

Surgical extraction is not proven or indicated for the following:

When a conservative non-surgical procedure is possible;

When the Indications for Coverage criteria above are not met.

Surgical Removal of Residual Tooth Roots

Surgical removal of residual tooth roots is indicated for the following:

When tooth roots, or fragments of tooth roots remain in the bone following a previous incomplete tooth extraction;

Extreme tooth decay resulting in the destruction of the dentition to the extent that only root tips remain.

Refer to coverage guideline: Surgical Extraction of Erupted Teeth and Retained Roots (DCG005.02)

Surgical Extraction of Impacted Teeth D7220, D7230, D7240, D7241, D7251

Documentation Dated and labeled radiographic images including panoramic image or periapicals usually taken within one year and appropriate to document the case.

Panoramic, periapicals, or tomography for third molar extractions is indicated by the clinical presentation.

Narrative:

If reason for extraction is not apparent

For bicuspid with no apparent pathology, to determine if orthodontic extractions

D7241, full bony impaction with complications

Cyst removal (D7450, 7451, 7460, 7461): Documentation of special services; size greater than 1.25mm and/or unrelated to tooth removal; operative notes and pathology report.

Treatment notes if radiographic information not conclusive.

Criteria for codes D7220, D7230, D7240, D7241, D7251

The prophylactic extraction of impacted third molars that are asymptomatic and disease free remains highly controversial. In the absence of strong clinical evidence to support or refute prophylactic extractions of asymptomatic and disease free third molars, the following coverage rationale has been adopted.

Surgical Extraction of Soft Tissue Impacted Teeth

Surgical extraction of soft tissue impacted teeth is indicated for the following:

Extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted;

For a tooth/teeth in the line of a jaw fracture or complicating fracture management;

As part of comprehensive treatment in orthognathic surgery;

Moderate to severe or acute pain, or recurrent episodes that do not respond to conservative treatment (i.e. pain medication or antibiotics);

Non-restorable caries;

Management of, or limiting the progression of periodontal disease;

In the case of acute/chronic infection (abscess, cellulitis, pericoronitis);

Pulpal exposure;





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COVERAGE GUIDELINE Surgical Extraction of Impacted Teeth (continued)

Non-restorable pulpal or periapical lesion;

Internal resorption;

As a prophylactic procedure for an underlying medical or surgical condition (e.g., organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer );

Tumor resection;

Ectopic position;

For purposes of prosthetic rehabilitation (partial dentures and complete dentures).

Surgical extraction of soft tissue impacted teeth is not indicated for the following:

For prophylactic reasons other than an underlying medical condition;

When a more conservative procedure can be performed;

For pain or discomfort related to normal tooth eruption.

Surgical Extraction of Partially Bony Impacted Teeth

Surgical extraction of partially bony impacted teeth is indicated for the following:

Extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted;

Tooth/teeth in the line of a jaw fracture or complicating fracture management;




Management of, or limiting the progression of periodontal disease;


Pulpal exposure;

Non-restorable pulpal or periapical lesion;


As a prophylactic procedure for an underlying medical or surgical condition (e.g., organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer );

Tumor resection;

Ectopic position;

For purposes of prosthetic rehabilitation (partial dentures and complete dentures).

Surgical extraction of partially bony impacted teeth is not indicated for the following:





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Surgical Extraction of Completely Bony Impacted Teeth

Surgical extraction of completely bony impacted teeth is indicated for the following:

For extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted;

Tooth/teeth in the line of a jaw fracture or complicating fracture management;




Management of, or limiting progression of periodontal disease;


Pulpal exposure or periapical lesion;

Resorption of adjacent tooth;

As a prophylactic procedure for an underlying medical or surgical condition(e.g., organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer);

Tumor resection

Ectopic position

For purposes of prosthetic rehabilitation (partial dentures an complete dentures);

Pathology associated with tooth follicle (e.g., cysts and tumors) or other related pathology (e.g., dentigerous cyst).

Surgical extraction of completely bony impacted teeth not indicated for the following:




Surgical Extraction of Completely Bony Impacted Teeth with Unusual Surgical Complications

Surgical extraction of completely bony impacted teeth with unusual surgical complications is indicated for the following:

For extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted;

Tooth/teeth in the line of a jaw fracture


Moderate to severe or acute pain, or recurrent episodes that do not



43



respond to conservative treatment (i.e. pain medication or antibiotics);


Management of, or limiting progression of periodontal disease;


Pulpal exposure;

Periapical lesion;


As a prophylactic procedure for an underlying medical condition (e.g., organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer);

Tumor resection;

Ectopic position;

For purposes of prosthetic rehabilitation (partial dentures an complete dentures);

When complicated procedures are anticipated such as nerve dissection, sinus closure, aberrant tooth position or anatomy, or are unanticipated and arise during surgical extraction.

Surgical extraction of completely bony impacted teeth with unusual surgical complications is not indicated for the following:




Coronectomy

Coronectomy is indicated for the following:

When clinical criteria for extraction of impacted teeth is met.

When the removal of complete tooth would likely result in damage to the neurovascular bundle.

Coronectomy is not indicated for the following:

For routine extractions;

When clinical criteria for extraction of impacted teeth is not met;

For prophylactic reasons.

Refer to clinical policy: Surgical Extraction of Impacted Teeth (DCP006.02)

Oral Surgery: Alveoloplasty and Vestibuloplasty D7310, D7311, D7320, D7321, D7340, D7350 CPT codes: 40840, 40842, 40843, 40844, 40845, 40899, 41874

Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable.

Treatment notes if radiographic information not conclusive or radiographs are not applicable.

Criteria for codes D7310, D7311, D7320, D7321, D7340, D7350

Alveoloplasty

Alveoloplasty is indicated for the following:

For bone recontouring and smoothing as part of the tooth extraction process

For bone recontouring and smoothing as a standalone procedure prior to fixed or removable prosthetic construction




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COVERAGE GUIDELINE Oral Surgery: Alveoloplasty and Vestibuloplasty (continued)

To provide stability for implant placement

For debulking procedures for pathologic conditions of the bone

Alveoloplasty is not indicated for the following:

When performed solely for cosmetic/aesthetic reasons

When removing bone would harm vital structures

When there is diminished volume or atypical architecture of bone

For patients who have undergone radiation therapy to the head and neck

For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response

Vestibuloplasty

Vestibuloplasty is indicated for the following:

Ridge extension, or lowering or altering submucous displacing attachments prior to prosthetic construction

To complement and complete osseous procedure when reconstructing edentulous bone

To correct inadequate or inappropriate soft tissue drape where a resection has been previously performed and prosthetic restoration requires improvement

For overall stability of a dental implant and the maintenance of bone health around an implant

Vestibuloplasty is not indicated for the following:

When performed solely for cosmetic/aesthetic reasons


When there is minimal alveolar ridge height

For patients who have undergone radiation therapy to the head and neck


Alveoloplasty and vestibuloplasty procedures are subject to frequency limitations. Please refer to the member specific benefit plan document.

Oral surgery procedures may be covered under the member’s medical benefit when determined to be medical in nature. Refer to the member’s Certificate of Coverage and/or member specific benefit plan document for coverage guidelines.

Refer to coverage guideline: Oral Surgery: Alveoloplasty and Vestibuloplasty (DCG028.01)

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COVERAGE GUIDELINE Oral Surgery: Miscellaneous Surgical Procedures D7260, D7261, D7270, D7272, D7290, D7921, D7951, D7952, D7953, D7999

CPT codes: 21210, 21215, 30580, 41899

Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable.

Criteria for codes D7260, D7261, D7270, D7272, D7290, D7921, D7951, D7952, D7953, D7999

Oroantral Fistula Closure

Oroantral fistula closure is indicated for the closure of an oroantral fistula not related to cleft palate repair surgery

Primary Closure of a Sinus Perforation

Primary closure of a sinus perforation is generally indicated for large (> 2mm) defects resulting from routine tooth extraction, retrieval of root tips, or implant placement.

Primary closure of a sinus perforation is generally not indicated for defects less than 2mm in diameter.

Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth are indicated for the following:

Subluxation injuries to permanent teeth

Lateral luxation injuries of primary and permanent teeth

Extrusion injuries of <3mm in an immature developing primary tooth

Avulsion of permanent teeth

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth are not indicated for the following, and extraction is recommended:

For primary teeth if injury is severe or tooth is near exfoliation

For intrusion injuries to primary teeth when the apex is displaced toward the permanent tooth germ

For extrusion injuries to primary teeth > 3mm, or primary tooth is fully formed, mobile, near exfoliation, or the child is unable to cope with an emergency situation

For avulsion of primary teeth

When a tooth has been out of the oral cavity for 60 minutes or more


Lack of alveolar integrity

Surgical Repositioning of Teeth

Surgical repositioning of teeth is indicated for the following:

For the treatment of intrusion injuries to permanent teeth

Extrusion of teeth with crown/root fractures to prepare for restoration of permanent teeth

Surgical repositioning of teeth is not indicated for the treatment of injuries to

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COVERAGE GUIDELINE Oral Surgery: Miscellaneous Surgical Procedures (continued)

primary teeth.

Bone Replacement Graft for Ridge Preservation

Bone replacement graft for ridge preservation is indicated for the following:

When bone has been lost in extraction site, or site of implant removal to prepare for new implant

When there has been loss of alveolar ridge needed to support a removable prosthesis or fill space under the pontic of a fixed partial denture

Bone replacement graft for ridge preservation is not indicated for the following:

As a routine procedure to fill extraction sites


Collection and Application of Autologous Blood Concentrate Product

Evidence in the published scientific literature is inconsistent and does not lend strong support to the clinical utility of using platelet rich plasma (PRP) to augment bone or soft tissue healing for oral surgery applications.

Sinus Augmentation Procedures

Sinus augmentation or sinus lift is a procedure associated with implant placement. For most plans, implants are not covered, but for those plans that do have coverage, the following identify guidelines for this procedure.

Sinus augmentation is indicated for the following:

To prevent the displacement of dental implants in the posterior maxilla due to pneumatization of the maxillary sinus

When there is poor bone quality that prevents adequate initial stability during implant placement

Sinus augmentation is not indicated for the following:

Conditions blocking the ventilation and clearance of the maxillary sinus. (Many of these causes are reversible and should be treated before the sinus lift procedure, and include, but are not limited to: history of smoking; allergic rhinitis; previous nasal surgery or trauma; a history of chronic and/or recurrent sinusitis; chronic nasal obstruction and/or rhinorrhea; chronic hyposmia and/or hypogeusia; previous treatment for head and neck neoplasms; and comorbidities, particularly systemic diseases and pathologies that interfere with mucosal composition or ciliary movements)



Any dental procedure performed solely for cosmetic/aesthetic reasons.

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COVERAGE GUIDELINE Oral Surgery: Miscellaneous Surgical Procedures (continued)

(Cosmetic procedures are those procedures that improve physical appearance.)

Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure.

Refer to clinical policy: Oral Surgery: Miscellaneous Surgical Procedures (DCP027.01)

Oral Surgery: Non-Pathologic Excisional Procedures D7291, D7471, D7472, D7473, D7960, D7963, D7970, D7971, D7972, D7999 CPT codes: 21031, 21032, 40806, 40819, 41010, 41115, 41520, 41821, 41822, 41828



Frenectomy or frenotomy (D7960) and Frenuloplasty (D7963) Narrative if applicable

Excision of periocoronal gingival (D7971) and Surgical reduction of fibrous tuberosity (D7972) Narrative and radiographic images to document the clinical need

Criteria for codes D7291, D7471, D7472, D7473, D7960, D7963, D7970, D7971, D7972, D7999

Frenulectomy

Frenulectomy is indicated for the following:

When attachment of the frenum is coronal to the mucogingival junction, within the free gingiva, or in the papilla causing a diastema, gingival recession or stripping

When the position attachment of the frenum is interfering with proper oral hygiene

Prior to the construction of a removable denture replacing teeth in the area of frenum attachment

When there is a functional disturbance, including, but not limited to mastication, swallowing and speech

For ankyloglossia or severe papillary penetrating attachment of maxillary labial frenum in newborns when there is interference with feeding

Frenuloplasty

Frenuloplasty is indicated for the following:

When attachment of the frenum is coronal to the mucogingival junction, within the free gingiva, or in the papilla causing a diastema, gingival recession or stripping and its depth or width requires surgical restoration of physiologic function

When the position attachment of the frenum is interfering with proper oral hygiene

Prior to the construction of a removable denture replacing teeth in the area of aberrant frenal attachment


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COVERAGE GUIDELINE Oral Surgery: Non-Pathologic Excisional Procedures (continued)

For ankyloglossia or severe papillary penetrating attachment of maxillary labial frenum in newborns when there is interference with feeding

Excision of Hyperplastic Tissue – Per Arch

Excision of hyperplastic tissue is indicated when the presence of hyperplastic tissue (fibrous tuberosities, loose ridges, folds of redundant tissues in vestibule or floor of mouth, and palatal papillomatosis) interferes with the fit of a partial or complete denture (existing or new).

Excision of Pericoronal Gingiva

Excision of pericoronal gingiva is indicated for the following:

For recurrent infections of the operculum around impacted or partially erupted lower third molars

When an erupted maxillary third molar is traumatizing soft tissue around opposing tooth

When the presence interferes with the fit of a partial or complete denture

Surgical Reduction of Fibrous Tuberosity

Surgical reduction of fibrous tuberosity is indicated when the presence interferes with the fit of a partial or complete denture.

Transseptal Fiberotomy/Supra Crestal Fiberotomy, By Report

Transseptal fiberotomy/supra crestal fiberotomy is indicated to reduce rotational relapse of individual teeth following orthodontic treatment.

Removal of Lateral Exostosis (Maxilla or Mandible)

Removal of lateral exostosis is indicated for the following:

If a partial or complete denture cannot be adapted successfully to the alveolar ridge

When causing soft tissue trauma with existing removable appliances

For unusually large exostoses that are prone to recurrent traumatic injury

Removal of lateral exostosis is not indicated for patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response.

Removal of Torus Palatinus

Removal of torus palatinus is indicated for the following:

When a dental prosthesis will cover the palate and a large palatal torus will interfere with fit

For unusually large tori that are prone to recurrent traumatic injury


Removal of torus palatinus is not indicated for patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance

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COVERAGE GUIDELINE Oral Surgery: Non-Pathologic Excisional Procedures (continued)

to infection, or poor healing response.

Removal of Torus Mandibularis

Removal of torus mandibularis is indicated for the following:

If a mandibular partial or complete denture cannot be adapted successfully to the alveolar ridge

For unusually large tori that are prone to recurrent traumatic injury

When the tori is so large that it interferes with normal tongue movement


Removal of torus mandibularis is not indicated for patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response.


Frenulectomy and frenuloplasty are considered incidental if performed on the same day, same area as gingivectomy/gingivoplasty, alveoloplasty and vestibuloplasty surgical procedures.

The following are excluded from coverage:

Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.


Refer to coverage guideline: Oral Surgery: Non-Pathologic Excisional Procedures (DCG029.01)

Oral Surgery: Orthodontic Related Procedures D7280, D7282, D7283, D7292, D7293, D7294, D7997 CPT code: 41899



Criteria for codes D7280, D7282, D7283, D7292, D7293, D7294, D7997

For plans that have comprehensive orthodontic coverage, the following identify guidelines for the use of related oral surgery procedures.

Surgical Placement of Temporary Anchorage Device (Not Related to Distraction Osteogenesis or Orthognathic Surgery)

The surgical placement of temporary anchorage devices are used in conjunction with orthodontic treatment and are indicated for patients aged 12 and over for the following:

Intrusion of maxillary teeth

Molar distalization

Canine retraction and intrusion retraction mechanics

Correction of anterior open bite and deep overbite

Correction of canted occlusal planes

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COVERAGE GUIDELINE Oral Surgery: Orthodontic Related Procedures (continued)

The surgical placement of a temporary anchorage device is not indicated for the following:

Patients with a known allergy to titanium alloy

Patients with a history of heavy tobacco use

Patients with advanced osteoporosis

Patients with uncontrolled immune or metabolic bone disorders

Patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response

Patients with poor oral hygiene

In areas with poor quality cortical bone density and volume

For ankylosed teeth

Surgical Access of Unerupted Tooth

Surgical access of unerupted tooth is indicated for the following:

When a tooth is in such a position that it is unable to erupt into a functional position within the dental arch

Tooth developing normally and appears to be in a good position to be moved into position orthodontically, or spontaneously

Only for labially impacted teeth when there will be 2-3 mm of gingival cuff present after eruption

Surgical access of unerupted tooth is not indicated for the following:

Teeth with abnormal development or positioning

For supernumerary teeth and third molars

For primary teeth

When surgical access of impacted tooth would threaten vital structures

Patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response

Placement of Device to Facilitate Eruption of Impacted Tooth

This is the placement of an orthodontic bracket, band or other device and attached with a chain, on an unerupted tooth, after surgical exposure, to aid in its eruption. This procedure is done following the surgical access of an unerupted tooth.

Mobilization of Erupted or Malpositioned Tooth to Aid Eruption

Mobilization of erupted or malpositioned tooth to aid eruption is indicated for the treatment of ankylosed permanent teeth. Mobilization of erupted or malpositioned tooth to aid eruption is not indicated for primary teeth.

Refer to clinical policy: Oral Surgery: Orthodontic Related Procedures (DCP032.02)

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COVERAGE GUIDELINE Excision of benign lesions D7411, D7412

Narrative of procedure

Removal of benign odontogenic cyst or tumor D7450, D7451



Criteria Cyst is not attached to or removed with tooth.

Size, color or consistency indicates need for pathology examination.

Removal of benign non-odontogenic cyst or tumor D7460, D7461



Criteria

Presence of hard, attached or freely movable raised or erythematous lesion.

Incision and drainage D7510, D7520



Criteria Not usually benefited when at same time as extraction.

ORTHODONTICS

Medically Necessary Orthodontic Treatment D8050, D8060, D8070, D8080, D8090, D8220, D8660, D8670, D8680, D8690, D8691, D8999

All of the following documentation must be received:

Panoramic imaging;

Cephalometric imaging;

5-7 intraoral photographs;

Other forms as required by the state.

Criteria for codes D8050, D8060, D8070, D8080, D8090, D8220, D8660, D8670, D8680, D8690, D8691, D8999


Orthodontic treatment is a covered dental service and medically necessary when the following criteria have been met:

All services must be approved by the plan; and

The member is under the age 19 (through age 18, unless the benefit plan document indicates a different age); and

Services are related to one of the following conditions: o Cleft lip and/or cleft palate; o Crouzon’s Syndrome; o Treacher-Collins Syndrome; o Pierre-Robin Syndrome o Hemi-facial atrophy; o Hemi-facial hypertrophy o Severe craniofacial deformities that result in a physically handicapping

malocclusion; OR o Other clinical criteria based on state specific language.

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COVERAGE GUIDELINE Medically Necessary Orthodontic Treatment (continued)

Required Documentation

All of the following documentation must be received:

Panoramic imaging;

Cephalometric imaging;

5-7 intraoral photographs;

Other forms as required by the state.


Orthodontic services that do not meet the criteria listed above.

Orthodontic services that are specifically excluded.

Orthodontic services for crowded dentitions (crooked teeth), excessive spacing between teeth, temporomandibular joint (TMJ) conditions and/or horizontal/vertical discrepancies (overjet/overbite).

Refer to coverage guideline: Medically Necessary Orthodontic Treatment (DCG003.02)

ANESTHESIA SERVICES

General Anesthesia and Conscious Sedation D9210, D9211, D9212, D9215, D9219, D9223, D9230, D9243, D9248

Documentation: Time Recommendations & Nitrous/Extraction Recommendations Provider notes including: duration, type of anesthetic, dosage. If restorative/surgical procedures and age do not meet criteria: Narrative documenting medical necessity, including description of underlying medical problem; description of behavior problem and age of patient. Anesthesia time is defined as the period between the beginning of the administration of the agent and the time that the anesthetist is no longer in personal attendance. General Time Guidelines for IV sedation & General Anesthesia: 3-4 Teeth D7230, D7240 1.5 hours 1-2 Teeth D7230, D7240 45 min 3-4 Teeth D7210, D7220 1 hour 1-2 Teeth D7210, D7220 45 min Full Mouth Extractions or + Teeth D7111, D7140 1.5 hours 3-6 Teeth D7111, D7140 45 min. 1-3 Teeth D7111, D7140 30 min. Nitrous Oxide: Extraction Coverage Recommendations:


Sedation for dentistry is proven to help decrease anxiety, diminish fear and increase tolerance for dental procedures. It is necessary for the safe and comprehensive dental treatment of patients that meet selection criteria. Local anesthesia is not covered in conjunction with operative or surgical procedures. Nerve blocks are not addressed in this coverage guideline; please refer to appropriate medical policy.

Local Anesthesia is considered an inclusive component of any dental procedure unless used for pain relief or if pain relief is required to make an accurate diagnosis.

Regional and trigeminal block anesthesia is not a covered service.

Nitrous Oxide

Nitrous oxide is proven effective for sedation in adults and children for the following:

Ineffective local anesthesia

Anxiety

Special needs patients

Lengthy procedures for special needs patients and children

Behaviorally challenged or uncooperative patients

Management of a severe gag reflex

Nitrous oxide is contraindicated for patients with but not limited to the

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COVERAGE GUIDELINE General Anesthesia and Conscious Sedation (continued)

More than one soft tissue impacted tooth D7220

One or more partial or full bony D7230, D7240

More than six simple extractions D7140

Multiple surgical extractions D7210

following:

Severe underlying medical conditions ( e.g., severe chronic obstructive pulmonary diseases, congestive heart failure, sickle cell anemia, acute otitis media, recent tympanic membrane graft, acute severe head injury)

Severe emotional disturbances

Severe behavioral disorders

Drug related dependencies

Pregnancy – first trimester

Treatment with bleomycin sulfate (injection used in cancer patients)

Methlenetetrahydropfolate reductase deficiency

Vitamin B12 deficiency


Limited to once per day

Excluded when reported on same date of service as IV sedation, non-IV sedation or general anesthesia

Patient convenience

Intravenous (IV) Sedation

IV sedation is proven and effective for the following:

Anxiety/fear

Pain control

Oral surgery

Medically compromised patients or those with special needs

IV sedation is contraindicated for patients with but not limited to the following:

Allergy to IV medications

Certain prescribed pharmaceuticals

In any patient where IV sedation has been considered unsafe


Limited to once per day

Non-IV Sedation

Non-IV sedation is proven and effective for the following:

Anxiety

Uncooperative or unmanageable patient

Non-IV sedation is contraindicated for patients with but not limited to the following:

Patient or dentist convenience


Not allowed on same day as general anesthesia

Nerve Blocks

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COVERAGE GUIDELINE General Anesthesia and Conscious Sedation (continued)

Nerve blocks are not covered for dental services. Please refer to appropriate Medical Policy for specifics regarding coverage for nerve blocks.

General Anesthesia

General anesthesia is proven and effective. The decision to administer should be made on an individual patient basis and should be limited to:

Clinical procedures of extensiveness or complexity or situations that require more than a local anesthetic

Minimum of 2 failed attempts at other office anesthetic techniques with the failures documented

Uncooperative or Unmanageable Patient

Physical, Cognitive or Developmental Disabilities

Significant underlying medical condition

Allergy or sensitivity to local anesthesia

Lengthy restoration procedures for pediatric patients

A child who has resisted all other conventional management procedures

Patients with extreme anxiety or fear

General anesthesia is contraindicated for patients with but not limited to the following:

Patients with predisposing medical and/or physical conditions that potentially make general anesthesia unsafe

Cooperative patients with minimal dental needs

Choice of an alternative option for treatment

Language or cultural barriers

Parental objection

Refer to coverage guideline: General Anesthesia Conscious Sedation Services (DCG016.02)

ADJUNCTIVE SERVICES

Palliative treatment D9110

Criteria Not payable with other services such as extraction, incision/drainage, sedative on same date-of-service, with the exception of x-rays and exam (usually D0140).

For immediate relief of pain and not a definitive procedure

Bridge sectioning D9120

Radiographic image required. Code for both preparing teeth for extraction and for retaining part of fixed prosthesis.

Consultation D9310

Criteria A diagnostic service not by the practitioner providing the specific or on-going treatment.

The condition may be out of the scope of practice, requiring second opinion.

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COVERAGE GUIDELINE Professional Visits D9410–D9450

Documentation Narrative from member record.

Therapeutic Parenteral Drug Administration and In-Office Dispensing of Medications D9610, D9612, D9630


Therapeutic Parenteral Drug Administration (Single or Two or More Administrations)

Therapeutic parenteral drug administration may be indicated to enhance healing of surgical procedures, or reduce pain and/or risk of infection. Medications may include antibiotics, steroids or anti-inflammatory medications when administered as a separate IV or intramuscular injection.

Other Drugs and/or Medicaments (By Report)

Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions.


Therapeutic parenteral drug administration is inclusive when administered intravenously (IV) during IV sedation and general anesthesia.

Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

Refer to clinical policy: Therapeutic Parenteral Drug Administration and In-Office Dispensing of Medications (DCP033.01)

Application of Medicaments and Desensitizing Resins D1354, D9910, D9911

Documentation Narrative with explanation of symptoms.


Application of Desensitizing Medicament or Resin

Application of desensitizing medicament or resin is indicated for the following:

For teeth with sensitivity that does not resolve with an over the counter desensitizing dentifrice

Application of desensitizing medicament or resin is not indicated for the following:

Placement on teeth with erosion, recession, cervical abrasion or abfraction when asymptomatic

As a base or liner prior to restoration placement

Interim Caries Arresting Medicament Application

Interim caries arresting medicament application is indicted for the following:

As conservative treatment for active, non-symptomatic carious lesions

Patients with extreme risk of caries (such as xerostomia or severe early childhood caries)

Patients that cannot tolerate standard treatment for medical or psychological reasons. These may be included but are not limited to the following:

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COVERAGE GUIDELINE Application of Medicaments and Desensitizing Resins (continued)

o An extremely uncooperative child o Frail elderly patients o Patients with severe cognitive or physical disability o Patients that are immunocompromised

Patients with multiple lesions that cannot be treated in one office visit

Recurrent caries that are difficult to treat

Patients without access to dental care

Interim caries arresting medicament application is not indicted for the following:

Patients with a silver allergy

Pregnant women

During the first six months of breast feeding



Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure.

These codes are for medicaments and resins, and not for the use of lasers for desensitization.

Refer to clinical policy: Application of Medicaments and Desensitizing Resins (DCP034.01)

Behavior management D9920

Criteria Appropriate in cases where substantial time and effort is expended in allaying the patient’s fear and apprehension. Narrative required.

Treatment of complication D9930

Criteria Narrative and/or radiographic images required. Examples: dry socket, extensive hemorrhage.

Occlusal guard D7880, D7881, D9940, D9941, D9942, D9943, D9950, D9951, D9952

Documentation/Criteria Provider narrative which includes a history of bruxism, grinding, &/or clenching resulting in excessive wear. Should include occlusal analysis and symptoms.


Occlusal Guards

Occlusal guards are indicated for the following:

Bruxism or clenching either as a nocturnal parasomnia or during waking hours, resulting in excessive wear or fractures of natural teeth or restorations

To protect natural teeth when the opposing dentition has the potential to cause enamel wear such as the presence of porcelain or ceramic restorations

When nocturnal clenching or bruxism results in tooth sensitivity

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COVERAGE GUIDELINE Occlusal guard (continued)

Occlusal guards are not indicated for the following:

For treatment of temporomandibular disorders or myofacial pain disfunction

As an athletic mouthguard

As an appliance intended for orthodontic tooth movement


Exclude when used for sports-related activities

Prefabricated occlusal guards are excluded

Limited to once per 36 months

Repair and relines are limited to once per 12 months

Adjustments are inclusive within the first 12 months and thereafter allowed once every 6 months

Fabrication of Athletic Mouthguard

Athletic mouthguards are intended to protect the dentition during athletic activities and not a covered service.

Occlusal Orthotic Devices

Occlusal orthotic devices are appliances intended for the management of orofacial pain or to reposition or stabilize the jaw for the treatment of temporomandibular disorders (TMD) and not a covered service under the dental plan. TMD and these appliances are considered to be medical in nature and are typically covered under the medical plans. Please see the appropriate medical policy for information.

Refer to coverage guideline: Occlusal Guards (DCG019.01)

Enamel Microabrasion D9970

Documentation Narrative, intraoral photos helpful.

Criteria Discolored surface enamel from altered mineralization/decalcification. Per visit basis.

Odontoplasty D9971

Documentation Narrative, intraoral photos helpful.

Criteria 1-2 teeth –includes removal of enamel projections.

Bleaching and unspecified report D9972–D9999

Documentation Narrative, intraoral photos, images.

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NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION …...Caries prevention for primary teeth in children...

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