Dental Services - uhcprovider.com · 41821 Operculectomy, excision pericoronal tissues 41822 Excision of fibrous tuberosities, dentoalveolar structures 41823 Excision of osseous tuberosities,

Dental Services Page 1 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019

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DENTAL SERVICES Guideline Number: MPG376.02 Approval Date: April 10, 2019 Table of Contents Page POLICY SUMMARY .................................................... 1 APPLICABLE CODES ................................................. 2 DEFINITIONS ......................................................... 11 QUESTIONS AND ANSWERS ..................................... 12 PURPOSE ............................................................... 12 REFERENCES .......................................................... 12 GUIDELINE HISTORY/REVISION INFORMATION .......... 13 TERMS AND CONDITIONS ........................................ 13 POLICY SUMMARY Overview Dental services are excluded from coverage in connection with the care, treatment, removal, filling, or replacement of

teeth, or structures directly supporting the teeth, except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures. Structures directly supporting the teeth means, the periodontium, which includes the gingivae, periodontal membrane, dentogingival junction, cementum, and alveolar process. In an outpatient setting when an excluded service is the primary procedure involved, it is not covered regardless of its difficulty or complexity. A frenectomy and an alveoloplasty are excluded from coverage when either of these

procedures is performed in connection with an excluded service: e.g. the non-covered extraction or the preparation of the mouth for dentures. *Dental coverage is separately available in some plans. Guidelines

Non-Covered Services Extraction of an impacted tooth Alveoloplasty, (the surgical improvement of the shape and condition of the alveolar process), when performed for

the preparation of the mouth for dentures Frenectomy when performed for the preparation of the mouth for dentures Extractions that are due to decay or periodontal disease Extractions done for the purpose of obtaining dentures

Services related to chronic dental disease (i.e. gingivectomy) Removal of a benign growth or radicular cyst, in the mouth, or from structures directly supporting the teeth

means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process)

Insertion of metallic implants used for enhancement of the structure of the jaws in order to support dentures or prosthesis

Excision of torus mandibularis or excision of a maxillary torus palatinus is usually performed to accommodate a

denture. The removal of the torus palatinus (a bony protuberance of the hard palate) and torus mandibularis could be a covered service. However, with rare exception, this surgery is performed in connection with an excluded service; i.e., the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made for this purpose.

(The only exception is for inpatient services: "except for inpatient hospital services in connection with such dental

procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures.")

Related Medicare Advantage Policy Guideline

Dental Examination Prior to Kidney Transplantation (NCD 260.6)

Related Medicare Advantage Coverage Summary

Dental Services, Oral Surgery and Treatment of Temporomandibular Joint (TMJ)

UnitedHealthcare® Medicare Advantage Policy Guideline

Terms and Conditions

See Purpose

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/d/dental-exam-kidney-transplant.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/d/dental-exam-kidney-transplant.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/dental-services-oral-surgery-treatment-temporomandibular-joint-tmj.pdf

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/dental-services-oral-surgery-treatment-temporomandibular-joint-tmj.pdf



Covered Services Wiring of the teeth when performed in connection with the reduction of a jaw fracture Extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease Reduction of any fracture of the jaw or any facial bone, including dental splints or other appliances, if used for this

purpose Reconstruction of a ridge if performed as a result of and at the same time as the surgical removal of a tumor (the

total surgical procedure is covered) Removal of a torus palatinus (a bony protuberance of the hard palate) may be covered, if the procedure is not

performed to prepare the mouth for dentures Surgery related to the jaw or any structure connected to the jaw including structures of the facial area below the

eyes, for example (mandible, teeth, gums, tongue, palate, salivary glands, sinuses, etc.)

Insertion of metallic implants if the implants are used to assist in or enhance the retention of a dental prosthetic as a result of a covered service

The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is also covered. This is an exception to the requirement that to be covered, a non-covered procedure or service performed by a dentist must be an incident to and integral part of a covered procedure or service performed by the dentist. Whether such services as

the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. Thus, an x-ray taken in connection with the

reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered. Associated Information Documentation Requirements

1. Documentation supporting the medical necessity, such as ICD-10 codes, including the need for the surgery in an inpatient setting, must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

2. Where the dental procedure is not the primary procedure performed, documentation of the primary procedure must be included in the patient’s medical records.

Utilization Guidelines

If a non-covered service is performed as the primary procedure in conjunction with a covered procedure or service, regardless of the complexity, the total service is excluded from coverage. Anesthesia services, provided by the surgeon performing the surgery, are considered bundled into the payment for

the surgical procedure. Since the payment is bundled, the physician is precluded from billing the beneficiary for this service.

Where a patient is hospitalized solely for less than major noncovered dental treatment, both the professional services of the dentist and the inpatient hospital services are not covered. "Except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures." Items and services in connection with an excluded dental service (the care, treatment, filling, removal or replacement

of teeth, or structures directly supporting the teeth) are not covered. (i.e. anesthesia services, lab, x-ray services). A dentist qualifies as a physician if, he/she is a doctor of dental surgery or dental medicine, and is legally authorized to practice dentistry in the state in which he/she performs such function, and who is acting within the scope of his/her license when he/she performs such functions. Such services include any otherwise covered service that may legally and alternatively be performed by doctors of medicine, osteopathy and dentistry; e.g., dental examinations to detect infections prior to certain surgical procedures, treatment of oral infections and interpretations of diagnostic x-ray

examinations in connection with covered services. Payment for the services of dentists in an outpatient setting is

limited to those procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting the teeth. The coverage of any given dental service is not affected by the professional designation of the physician rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine or osteopathy. APPLICABLE CODES

The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.



CPT Code Description

The following codes are not covered if performed primarily for dental related conditions. These codes are not covered if done with endodontic surgery or third molar removal.

21030 Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage

21032 Excision of maxillary torus palatinus

21040 Excision of benign tumor or cyst of mandible, by enucleation and/or curettage

21046 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])

21047 Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s])

21048 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])

21060 Meniscectomy, partial or complete, temporomandibular joint (separate procedure)

21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

21242 Arthroplasty, temporomandibular joint, with allograft

21243 Arthroplasty, temporomandibular joint, with allograft

21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial

21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete

21299 Unlisted craniofacial and maxillofacial procedure

21480 Closed treatment of temporomandibular dislocation; initial or subsequent

29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)

29804 Arthroscopy, temporomandibular joint, surgical

40814 Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair

40816 Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle

40840 Vestibuloplasty; anterior

40842 Vestibuloplasty; posterior, unilateral

40843 Vestibuloplasty; posterior, bilateral

40844 Vestibuloplasty; entire arch

40845 Vestibuloplasty; complex (including ridge extension, muscle repositioning)

40899 Unlisted procedure, vestibule of mouth

41820 Gingivectomy, excision gingiva, each quadrant

41821 Operculectomy, excision pericoronal tissues

41822 Excision of fibrous tuberosities, dentoalveolar structures

41823 Excision of osseous tuberosities, dentoalveolar structures

41825 Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair

41828 Excision of hyperplastic alveolar mucosa, each quadrant (specify)

41830 Alveolectomy, including curettage of osteitis or sequestrectomy

41850 Destruction of lesion (except excision), dentoalveolar structures

41870 Periodontal mucosal grafting

41872 Gingivoplasty, each quadrant (specify)

41874 Alveoloplasty, each quadrant (specify)

41899 Unlisted procedure, dentoalveolar structures




The following radiological codes are not covered if performed primarily for dental related conditions.

70250 Radiologic examination, skull; less than 4 views

70300 Radiologic examination, teeth; single view

70310 Radiologic examination, teeth; partial examination, less than full mouth

70320 Radiologic examination, teeth; complete, full mouth

70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral

70330 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral

70332 Temporomandibular joint arthrography, radiological supervision and interpretation

70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

70350 Cephalogram, orthodontic

70355 Orthopantogram (eg, panoramic x-ray)

70390 Sialography, radiological supervision and interpretation

70486 Computed tomography, maxillofacial area; without contrast material

70487 Computed tomography, maxillofacial area; with contrast material(s)

70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections

70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)

70542 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)

70543 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

70544 Magnetic resonance angiography, head; without contrast material(s)

70546 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

76140 Consultation on X-ray examination made elsewhere, written report

76376

3D rendering with interpretation and reporting of computed tomography, magnetic

resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation

76377

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation

76536 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation

80500 Clinical pathology consultation; limited, without review of patient's history and medical records

80502 Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records

81599 Unlisted multianalyte assay with algorithmic analysis

82397 Chemiluminescent assay

83036 Hemoglobin; glycosylated (A1C)

83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates

87071 Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool

87181 Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip)




The following laboratory codes are not covered if performed primarily for dental related conditions.

87184 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents)

87207 Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses)

87209 Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites

87250 Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection

87252 Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect

87253 Virus isolation; tissue culture, additional studies or definitive identification (eg, hemabsorption, neutralization, immunofluorescence stain), each isolate

87254 Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus

87255 Virus isolation; including identification by non-immunologic method, other than by

cytopathic effect (eg, virus specific enzymatic activity)

87999 Unlisted microbiology procedure

88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation

88112 Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal

88160 Cytopathology, smears, any other source; screening and interpretation

88161 Cytopathology, smears, any other source; preparation, screening and interpretation

88162 Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains

88239 Tissue culture for neoplastic disorders; solid tumor

88264 Chromosome analysis; analyze 20-25 cells

88271 Molecular cytogenetics; DNA probe, each (eg, FISH)

88272 Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells (eg, for derivatives and markers)

88273 Molecular cytogenetics; chromosomal in situ hybridization, analyze 10-30 cells (eg, for microdeletions)

88274 Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells

88275 Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells

88291 Cytogenetics and molecular cytogenetics, interpretation and report

88300 Level I - Surgical pathology, gross examination only

88302

Level II - Surgical pathology, gross and microscopic examination Appendix, incidental

Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglion Testis, castration Vaginal mucosa, incidental Vas deferens, sterilization

88304

Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm - arterial/ventricular Anus, tag Appendix, other than incidental

Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologic fracture Bursa/synovial cyst Carpal tunnel tissue Cartilage, shavings Cholesteatoma Colon, colostomy stoma Conjunctiva - biopsy/pterygium Cornea Diverticulum - esophagus/small intestine Dupuytren's contracture tissue Femoral head, other than fracture Fissure/fistula Foreskin, other than newborn Gallbladder Ganglion cyst Hematoma Hemorrhoids Hydatid of Morgagni Intervertebral disc Joint, loose body Meniscus Mucocele, salivary Neuroma - Morton's/traumatic Pilonidal

cyst/sinus Polyps, inflammatory - nasal/sinusoidal Skin - cyst/tag/debridement Soft tissue, debridement Soft tissue, lipoma Spermatocele Tendon/tendon sheath Testicular appendage Thrombus or embolus Tonsil and/or adenoids Varicocele Vas deferens, other than sterilization Vein, varicosity





88305

Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis

Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx,

biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp,

cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than

cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy

88307

Level V - Surgical pathology, gross and microscopic examination Adrenal, resection

Bone - biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple Cervix, conization

Colon, segmental resection, other than for tumor Extremity, amputation, non-traumatic Eye, enucleation Kidney, partial/total nephrectomy Larynx, partial/total resection Liver, biopsy - needle/wedge Liver, partial resection Lung, wedge biopsy Lymph nodes, regional resection Mediastinum, mass Myocardium, biopsy Odontogenic tumor Ovary with or without tube, neoplastic Pancreas, biopsy Placenta,

third trimester Prostate, except radical resection Salivary gland Sentinel lymph node Small intestine, resection, other than for tumor Soft tissue mass (except lipoma) -

biopsy/simple excision Stomach - subtotal/total resection, other than for tumor Testis, biopsy Thymus, tumor Thyroid, total/lobe Ureter, resection Urinary bladder, TUR Uterus, with or without tubes and ovaries, other than neoplastic/prolapse

88309

Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity,

disarticulation Fetus, with dissection Larynx, partial/total resection - with regional lymph nodes Lung - total/lobe/segment resection Pancreas, total/subtotal resection Prostate, radical resection Small intestine, resection for tumor Soft tissue tumor, extensive resection Stomach - subtotal/total resection for tumor Testis, tumor Tongue/tonsil -resection for tumor Urinary bladder, partial/total resection Uterus, with or without tubes and ovaries, neoplastic Vulva, total/subtotal resection

88311 Decalcification procedure (List separately in addition to code for surgical pathology

examination)

88312 Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver)

88313 Special stain including interpretation and report; Group II, all other (eg, iron,

trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry

88314 Special stain including interpretation and report; histochemical stain on frozen tissue block (List separately in addition to code for primary procedure)

88321 Consultation and report on referred slides prepared elsewhere

88323 Consultation and report on referred material requiring preparation of slides

88346 Immunofluorescence, per specimen; initial single antibody stain procedure





88348 Electron microscopy, diagnostic

88364 In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure)

88365 In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure

88366 In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure

88367 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; initial single probe stain procedure

88368 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure

88369 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative),

manual, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure)

88373 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure)

88374 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure

88377 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure

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CDT Codes

Dental Services: CDT Code List

CDT® is a registered trademark of the American Dental Association

Coding Clarification: The following ICD-10-CM codes are considered to be routine dental diagnoses and are not covered.

ICD-10 Diagnosis Code Description

K00.0 Anodontia

K00.1 Supernumerary teeth

K00.2 Abnormalities of size and form of teeth

K00.3 Mottled teeth

K00.4 Disturbances in tooth formation

K00.5 Hereditary disturbances in tooth structure, not elsewhere classified

K00.6 Disturbances in tooth eruption

K00.7 Teething syndrome

K00.8 Other disorders of tooth development

K00.9 Disorder of tooth development, unspecified

K02.3 Arrested dental caries

K02.52 Dental caries on pit and fissure surface penetrating into dentin

K02.53 Dental caries on pit and fissure surface penetrating into pulp

K02.61 Dental caries on smooth surface limited to enamel

K02.62 Dental caries on smooth surface penetrating into dentin

K02.63 Dental caries on smooth surface penetrating into pulp

K02.7 Dental root caries

K02.9 Dental caries, unspecified

K03.0 Excessive attrition of teeth

K03.1 Abrasion of teeth

K03.2 Erosion of teeth

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K03.3 Pathological resorption of teeth

K03.4 Hypercementosis

K03.5 Ankylosis of teeth

K03.6 Deposits [accretions] on teeth

K03.7 Posteruptive color changes of dental hard tissues

K03.81 Cracked tooth

K03.89 Other specified diseases of hard tissues of teeth

K03.9 Disease of hard tissues of teeth, unspecified

K04.01 Reversible pulpitis

K04.02 Irreversible pulpitis

K04.1 Necrosis of pulp

K04.2 Pulp degeneration

K04.3 Abnormal hard tissue formation in pulp

K04.4 Acute apical periodontitis of pulpal origin

K04.5 Chronic apical periodontitis

K04.6 Periapical abscess with sinus

K04.7 Periapical abscess without sinus

K04.90 Unspecified diseases of pulp and periapical tissues

K04.99 Other diseases of pulp and periapical tissues

K05.00 Acute gingivitis, plaque induced

K05.01 Acute gingivitis, non-plaque induced

K05.10 Chronic gingivitis, plaque induced

K05.11 Chronic gingivitis, non-plaque induced

K05.20 Aggressive periodontitis, unspecified

K05.211 Aggressive periodontitis, localized, slight

K05.212 Aggressive periodontitis, localized, moderate

K05.213 Aggressive periodontitis, localized, severe

K05.219 Aggressive periodontitis, localized, unspecified severity

K05.221 Aggressive periodontitis, generalized, slight

K05.222 Aggressive periodontitis, generalized, moderate

K05.223 Aggressive periodontitis, generalized, severe

K05.229 Aggressive periodontitis, generalized, unspecified severity

K05.30 Chronic periodontitis, unspecified

K05.311 Chronic periodontitis, localized, slight

K05.312 Chronic periodontitis, localized, moderate

K05.313 Chronic periodontitis, localized, severe

K05.319 Chronic periodontitis, localized, unspecified severity

K05.321 Chronic periodontitis, generalized, slight

K05.322 Chronic periodontitis, generalized, moderate

K05.323 Chronic periodontitis, generalized, severe

K05.329 Chronic periodontitis, generalized, unspecified severity

K05.4 Periodontosis

K05.5 Other periodontal diseases

K05.6 Periodontal disease, unspecified

K06.010 Localized gingival recession, unspecified

K06.011 Localized gingival recession, minimal

K06.012 Localized gingival recession, moderate




K06.013 Localized gingival recession, severe

K06.020 Generalized gingival recession, unspecified

K06.021 Generalized gingival recession, minimal

K06.022 Generalized gingival recession, moderate

K06.023 Generalized gingival recession, severe

K06.1 Gingival enlargement

K06.2 Gingival and edentulous alveolar ridge lesions associated with trauma

K06.3 Horizontal alveolar bone loss

K06.8 Other specified disorders of gingiva and edentulous alveolar ridge

K06.9 Disorder of gingiva and edentulous alveolar ridge, unspecified

K08.0 Exfoliation of teeth due to systemic causes

K08.101 Complete loss of teeth, unspecified cause, class I

K08.102 Complete loss of teeth, unspecified cause, class II

K08.103 Complete loss of teeth, unspecified cause, class III

K08.104 Complete loss of teeth, unspecified cause, class IV

K08.109 Complete loss of teeth, unspecified cause, unspecified class

K08.111 Complete loss of teeth due to trauma, class I

K08.112 Complete loss of teeth due to trauma, class II

K08.113 Complete loss of teeth due to trauma, class III

K08.114 Complete loss of teeth due to trauma, class IV

K08.119 Complete loss of teeth due to trauma, unspecified class

K08.121 Complete loss of teeth due to periodontal diseases, class I

K08.122 Complete loss of teeth due to periodontal diseases, class II

K08.123 Complete loss of teeth due to periodontal diseases, class III

K08.124 Complete loss of teeth due to periodontal diseases, class IV

K08.129 Complete loss of teeth due to periodontal diseases, unspecified class

K08.131 Complete loss of teeth due to caries, class I

K08.132 Complete loss of teeth due to caries, class II

K08.133 Complete loss of teeth due to caries, class III

K08.134 Complete loss of teeth due to caries, class IV

K08.139 Complete loss of teeth due to caries, unspecified class

K08.191 Complete loss of teeth due to other specified cause, class I

K08.192 Complete loss of teeth due to other specified cause, class II

K08.193 Complete loss of teeth due to other specified cause, class III

K08.194 Complete loss of teeth due to other specified cause, class IV

K08.199 Complete loss of teeth due to other specified cause, unspecified class

K08.20 Unspecified atrophy of edentulous alveolar ridge

K08.21 Minimal atrophy of the mandible

K08.22 Moderate atrophy of the mandible

K08.23 Severe atrophy of the mandible

K08.24 Minimal atrophy of maxilla

K08.25 Moderate atrophy of the maxilla

K08.26 Severe atrophy of the maxilla

K08.3 Retained dental root

K08.401 Partial loss of teeth, unspecified cause, class I

K08.402 Partial loss of teeth, unspecified cause, class II

K08.403 Partial loss of teeth, unspecified cause, class III




K08.404 Partial loss of teeth, unspecified cause, class IV

K08.409 Partial loss of teeth, unspecified cause, unspecified class

K08.411 Partial loss of teeth due to trauma, class I

K08.412 Partial loss of teeth due to trauma, class II

K08.413 Partial loss of teeth due to trauma, class III

K08.414 Partial loss of teeth due to trauma, class IV

K08.419 Partial loss of teeth due to trauma, unspecified class

K08.421 Partial loss of teeth due to periodontal diseases, class I

K08.422 Partial loss of teeth due to periodontal diseases, class II

K08.423 Partial loss of teeth due to periodontal diseases, class III

K08.424 Partial loss of teeth due to periodontal diseases, class IV

K08.429 Partial loss of teeth due to periodontal diseases, unspecified class

K08.431 Partial loss of teeth due to caries, class I

K08.432 Partial loss of teeth due to caries, class II

K08.433 Partial loss of teeth due to caries, class III

K08.434 Partial loss of teeth due to caries, class IV

K08.439 Partial loss of teeth due to caries, unspecified class

K08.491 Partial loss of teeth due to other specified cause, class I

K08.492 Partial loss of teeth due to other specified cause, class II

K08.493 Partial loss of teeth due to other specified cause, class III

K08.494 Partial loss of teeth due to other specified cause, class IV

K08.499 Partial loss of teeth due to other specified cause, unspecified class

K08.50 Unsatisfactory restoration of tooth, unspecified

K08.51 Open restoration margins of tooth

K08.52 Unrepairable overhanging of dental restorative materials

K08.530 Fractured dental restorative material without loss of material

K08.531 Fractured dental restorative material with loss of material

K08.539 Fractured dental restorative material, unspecified

K08.54 Contour of existing restoration of tooth biologically incompatible with oral health

K08.55 Allergy to existing dental restorative material

K08.56 Poor aesthetic of existing restoration of tooth

K08.59 Other unsatisfactory restoration of tooth

K08.81 Primary occlusal trauma

K08.82 Secondary occlusal trauma

K08.89 Other specified disorders of teeth and supporting structures

K08.9 Disorder of teeth and supporting structures, unspecified

K09.1 Developmental (nonodontogenic) cysts of oral region

M26.20 Unspecified anomaly of dental arch relationship

M26.211 Malocclusion, Angle's class I

M26.212 Malocclusion, Angle's class II

M26.213 Malocclusion, Angle's class III

M26.219 Malocclusion, Angle's class, unspecified

M26.220 Open anterior occlusal relationship

M26.221 Open posterior occlusal relationship

M26.23 Excessive horizontal overlap

M26.24 Reverse articulation

M26.25 Anomalies of interarch distance




M26.29 Other anomalies of dental arch relationship

M26.30 Unspecified anomaly of tooth position of fully erupted tooth or teeth

M26.31 Crowding of fully erupted teeth

M26.32 Excessive spacing of fully erupted teeth

M26.33 Horizontal displacement of fully erupted tooth or teeth

M26.34 Vertical displacement of fully erupted tooth or teeth

M26.35 Rotation of fully erupted tooth or teeth

M26.36 Insufficient interocclusal distance of fully erupted teeth (ridge)

M26.37 Excessive interocclusal distance of fully erupted teeth

M26.39 Other anomalies of tooth position of fully erupted tooth or teeth

M26.4 Malocclusion, unspecified

M26.70 Unspecified alveolar anomaly

M26.71 Alveolar maxillary hyperplasia

M26.72 Alveolar mandibular hyperplasia

M26.73 Alveolar maxillary hypoplasia

M26.74 Alveolar mandibular hypoplasia

M26.79 Other specified alveolar anomalies

M26.81 Anterior soft tissue impingement

M26.82 Posterior soft tissue impingement

M26.89 Other dentofacial anomalies

M26.9 Dentofacial anomaly, unspecified

M27.3 Alveolitis of jaws

M27.61 Osseointegration failure of dental implant

M27.62 Post-osseointegration biological failure of dental implant

M27.63 Post-osseointegration mechanical failure of dental implant

M27.69 Other endosseous dental implant failure

DEFINITIONS D.D.S.: Doctor of Dental Surgery. D.M.D.: Doctor of Medicine in Dentistry or Doctor of Dental Medicine (same degree as a D.D.S.).

Endodontist: Endodontists are dentists who specialize in maintaining teeth through endodontic therapy - procedures, involving the soft inner tissue of the teeth, called the pulp. The word "endodontic" comes from "endo" meaning inside and "odont" meaning tooth. Orthodontist: Orthodontia is an area of dentistry that prevents, diagnoses and treats dental and facial irregularities.

Pedodontist: A pedodontist is a dentist who specializes in caring for children’s teeth.

Peridontist: A dentist who specializes in the prevention, diagnosis, and treatment of periodontal disease, and in the placement of dental implants. Periodontists are also experts in the treatment of oral inflammation. Prosthodontist: A dentist specialized in the field of Prosthodontics. Prosthodontics is “that branch and specialty of

dentistry concerned with the diagnosis, restoration and maintenance of oral function, comfort, appearance and health of the patient by the restoration of the natural teeth and/or the replacement of missing teeth and contiguous oral and maxillofacial tissues with artificial substitutes”. T.M.D.: Temporomandibular disorders (TMD). TMD refers to problems associated with the jaw joint, also known as the temporomandibular joint (TMJ), and the surrounding tissues—with symptoms ranging from slight discomfort to severe pain.



QUESTIONS AND ANSWERS

1

Q: Does my medical plan have dental coverage?

A:

No, not for routine dental services ie: dental caries.

Under the general exclusion of coverage, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered by Medicare. Structures directly supporting the teeth can be defined as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.

PURPOSE

The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable: Medicare coding or billing requirements, and/or Medical necessity coverage guidelines; including documentation requirements.

UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of

determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.

REFERENCES

CMS National Coverage Determinations (NCDs)

Dental Examination Prior to Kidney Transplantation (NCD 260.6) Manipulation (NCD 150.1)

CMS Local Coverage Determinations (LCDs)

LCD Medicare Part A Medicare Part B

L34574 (Dental Services) Palmetto AL, GA, NC, SC, TN, VA, WV

L33428 (Cosmetic and Reconstructive Surgery) Palmetto

AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV

CMS Articles

Article Medicare Part A Medicare Part B

A52977 (Routine Dental Services) Noridian

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY

A52978 (Routine Dental Services) Noridian

AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV

A53497 (Oral Maxillofacial Prosthesis) Palmetto

AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV

CMS Benefit Policy Manual

Chapter 1; § 70 Inpatient Services in Connection With Dental Services Chapter 15; § 150 Dental Services

Chapter 15; § 150.1 Treatment of Temporomandibular Joint (TMJ) Syndrome

Chapter 16; § 140 Dental Services Exclusion

CMS Claims Processing Manual

Chapter 23; § 20.7 Use of the American Medical Association’s (AMA’s) Physicians’ Current Procedural Terminology (CPT) Fourth Edition Codes, and Use of the American Dental Association’s (ADA’s) Current Dental Terminology-Fourth Edition (CDT) Codes, on A/B MACs (A)’s, (B)’s, (HHH)’s, and DME MACs’ Web Sites and Other Electronic Media

CMS Transmittals

Transmittal 323, Change Request 3499, Dated 10/22/2004 (Update Regarding the Use of American Dental Association’s (ADA) Current Dental Terminology (CDT) Codes on Medicare Contractors’ Web Sites and Other Electronic Media)

MLN Matters

Article ICN 906765, Items and Services Not Covered Under Medicare

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=194&ncdver=1&DocID=260.6&clickon=search&bc=gAAAABAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=3&ncdver=1&DocID=150.1&clickon=search&bc=gAAAABAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34574&ver=16&Date=&DocID=L34574&bc=iAAAABAAAAAA&



https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52977&ver=12&DocID=A52977&bc=gAAAABAAAAAA&




https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53497&ver=10&Date=&DocID=A53497&bc=hAAAABAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53497&ver=10&Date=&DocID=A53497&bc=hAAAABAAAAAA&

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c01.pdf




https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf



https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R323CP.pdf



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Items-and-Services-Not-Covered-Under-Medicare-Booklet-ICN906765.pdf



Article ICN 900943, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets

Others

Medicare Dental Coverage, CMS Website

GUIDELINE HISTORY/REVISION INFORMATION

Revisions to this summary document do not in any way modify the requirement that services be provided and documented in accordance with the Medicare guidelines in effect on the date of service in question.

Date Action/Description

04/10/2019

Administrative updates

Reorganized policy template; relocated Terms and Conditions and Purpose section

Reformatted lists of applicable CDT and ICD-10 diagnosis codes

TERMS AND CONDITIONS

The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.

These Policy Guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and healthcare providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.

Benefit coverage for health services is determined by the member specific benefit plan document* and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes the Medicare Advantage Policy Guidelines.

Medicare Advantage Policy Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this website. Medicare source materials used to develop these guidelines include, but are not limited to, CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Benefit Policy Manual, Medicare

Claims Processing Manual, Medicare Program Integrity Manual, Medicare Managed Care Manual, etc. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of

publication, and is provided on an "AS IS" basis. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply. You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT® or other sources

are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment. Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. *For more information on a specific member's benefit coverage, please call the customer service number on the back

of the member ID card or refer to the Administrative Guide.

D0210 D0220 D0230 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0351 D1320 D1352 D4210 D4211















































D9951 D9952

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD9-10CM-ICD10PCS-CPT-HCPCS-Code-Sets-Educational-Tool-ICN900943.pdf

https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html

https://www.uhcprovider.com/en/admin-guides.html

Documents

Dental Services - uhcprovider.com · 41821 Operculectomy, excision pericoronal tissues 41822 Excision of fibrous tuberosities, dentoalveolar structures 41823 Excision of osseous tuberosities,