NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION …...hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.). Interproximal caries extending

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NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA

Revised: 6/1/2016

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

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 determine whether CBCT improves treatment decision making and health outcomes.

Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP.002.01)

Tests and Examinations D0415–D0470

caries risk assessment D0601–D0603

Oral Pathology Laboratory D0472–D0502

Unspecified diagnostic procedure by report D0999

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

PREVENTIVE

Dental Prophylaxis D1110–D1120

Services performed must be documented in the member record.

Topical Fluoride Treatment D1206, D1208

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

Criteria for codes D1206, D1208

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

For patients in active orthodontic treatment

For the remineralization of incipient or white spot enamel carious lesions

Refer to clinical policy: Topical Fluoride Treatment (DCP018.01)

Other Preventive Services D1310–D1330

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

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COVERAGE GUIDELINE Sealants D1351–D1352

Sealant: Tooth numbers. Provider responsible for three years for repair or Preventive Resin Restoration: replacement. No decay or restorations – the occlusal surface must be intact.

Sealant cannot be done on the same tooth as a preventive resin.

Space Maintenance D1510–D1555

Radiographs of the involved arch. For primary dentition only. Should be submitted for primary tooth that has been extracted.

All adjustments for 6 months are included.

No benefit if permanent tooth is ready to erupt.

If bilateral teeth are missing, benefit given for bilateral space maintainer, even if two unilateral space maintainers are requested.

RESTORATIVE

Direct Restorations:

Amalgam Restorations D2140–D2161 Resin-Based Composite Restorations – Direct D2330–D2394 Gold Foil Restorations D2410–D2340

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

Inclusive components: Local anesthesia; tooth prep; liners/bases; restorative material; polishing/sealing; adjustments; tooth etching.

Criteria: Primary teeth should not be ready to exfoliate and requests are subject to review based on the age of the patient and the tooth number.

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–D2664, D2710–D2799

Indications for Coverage 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. Coverage includes local anesthetic, impressions, tooth preparation, temporary restoration, fitting, cementation, adjustment and any liners or bases.

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

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COVERAGE GUIDELINE 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

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

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COVERAGE GUIDELINE undergone periodontal therapy/surgery



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

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

Coverage Limitations and Exclusions

Replacement of crowns if damage or breakage was directly related to provider error or patient noncompliance is not covered.

Complete oral rehabilitation or reconstruction is not covered.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion is not covered.

Refer to coverage guideline: Single Tooth Indirect Restorations (DCG008.01)

Other Restorative Services D2910–D2999 Porcelain/Ceramic Crown D2929

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

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COVERAGE GUIDELINE Stainless Steel Crown D2930, D2931, D2932, D2933, D2934

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 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 (DCP012.01)

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COVERAGE GUIDELINE 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 D2950 Note out of numerical order to keep code by crown procedures

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

Criteria Evidence of extensive caries or at least three surfaces of the tooth have severe breakdown.

Must be necessary for retention of the crown.

Not covered when procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation.

Vertical height of clinical crown must be adequate to support a prosthetic crown.

Evidence of radiographic decay around an existing restoration and removal of the filling is clinically indicated.

Not benefited with post/core.

Pin retention per tooth D2951

Documentation in member record One per lifetime per tooth

Post and Core D2952, D2953, D2954, D2957

Post-op endodontic radiographic image required showing adequate root canal treatment.

Criteria Only for retention or reinforcement when inadequate tooth structure remains for retention or to resist masticatory forces.

An anterior tooth with minimal access opening may not require a post/core.

There must be sufficient tooth structure to support a crown.

No periodontal disease and at least 50% bony support. No benefit for post preparation.

Labial Veneer D2960–D2962

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

Criteria May be benefited if the destruction is such that a crown is not recommended but a direct restoration will not suffice.

Not covered when strictly cosmetic.

Coping D2975

Documentation Bitewing or periapical if tooth has had root canal therapy

Criteria Only if insufficient natural tooth structure remains to retain the crown or alignment is a problem.

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COVERAGE GUIDELINE Repairs necessitated by restorative material failure D2980–D2999

Documentation Narrative required, radiographic images if indicated

ENDODONTICS

Endodontic therapy D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348

Documentation Pre and post-operative radiographic image and provider narrative if pathology is not evident on the film.

Criteria for codes D3110–D3240, D3310–D3333, D3346–D3348, D3351–D3357

Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01)

Endodontic codes: D3110–D3240 D3310–D3333 D3346–D3348 D3351–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–D3240, D3310–D3333, D3346–D3348, D3351–D3357

Indications for Coverage – 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

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 the following:

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

Coverage Limitations and Exclusions for Direct and Indirect Pulp Cap

Limited to once every 36 months

Not to be billed on same day as any definitive restoration

Not to be billed when a liner or a base is placed

Not to be billed as a liner or base when the likelihood of pulpal exposure is absent

Therapeutic Pulpotomy Therapeutic pulpotomy is indicated for the following:

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COVERAGE GUIDELINE 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

Coverage Limitations and Exclusions for Therapeutic Pulpotomy

Not to be billed on same day as root canal therapy

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

Coverage Limitations and Exclusions for Partial Pulpectomy for Apexogenesis


Not to be billed on same day as a surgical endodontic procedure

Apexification/Recalcification Apexification/recalcification is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs. When closure or repair is complete, nonsurgical root canal treatment should be completed:

Incomplete apical closure in a permanent tooth root

External root resorption or when the possibility of external root resorption 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

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COVERAGE GUIDELINE

Pulpal Regeneration Pulpal regeneration is indicated for the following and involves two or more separate appointments:

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

Indications for Coverage – Non Vital Pulp Therapy Pulpal Debridement (Pulpectomy) Pulpal Debridement (Pulpectomy) is indicated for the following:

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

For the relief of acute pain prior to complete root canal therapy

For 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


Coverage Limitations and Exclusions for Pulpal Debridement (Pulpectomy)


Not to be billed on same day as a surgical or non-surgical endodontic procedure

Pulpal Therapy (resorbable filling) – Primary Teeth Pulpal Therapy for primary teeth is indicated for the following and includes all appointments need to complete treatment, as well as intra-operative radiographs:

For 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:


For permanent teeth

Coverage Limitations and Exclusions for Pulpal Therapy – Primary Teeth

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COVERAGE GUIDELINE Indicated to age 15

Endodontic Therapy Endodontic Therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs:

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

For teeth with radiographic periapical pathology

For 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

Coverage Limitations and Exclusions for Endodontic Therapy

Not for third molars, unless necessary as bridge abutment with a good prognosis, or if tooth will be in functional occlusion

Not covered solely for cosmetic/aesthetic reasons

Treatment of root canal obstruction; non-surgical access Treatment of a root canal obstruction is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs:

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 for the following:

When there is no obstruction evident

Coverage Limitations and Exclusions for Treatment of root canal obstruction

Limited to once per tooth per lifetime

Not billable if tooth has a history of incomplete endodontic therapy or internal root repair of perforation defects

Incomplete endodontic therapy: inoperable, unrestorable or fractured tooth Incomplete endodontic therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs:

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,

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COVERAGE GUIDELINE necessitating discontinuation of treatment

Coverage Limitations and Exclusions for Incomplete endodontic therapy


Internal root repair of perforation defects Internal root repair of perforation defects is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs:

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 that are considered non-restorable Teeth with inadequate bone support or advanced untreated periodontal disease

Coverage Limitations and Exclusions for Internal root repair of perforation defects


Not billable for iatrogenic root perforation

Retreatment of previous root canal therapy Retreatment of previous root canal therapy is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs:

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

Coverage Limitations and Exclusions for Retreatment of previous root canal therapy

Original treatment must be at least 8 weeks prior to the retreatment date

Not benefited within 12 months of original treatment if by same dentist

Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01)

Surgical Endodontics D3410–D3950, D3999

Documentation Pre and post-operative radiograph image. Provider narrative may be requested if pathology is not visible.

Criteria for codes D3410–D3950, D3999

Apicoectomy Apicoectomy is indicated for the following:

Failed retreatment of endodontic therapy

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COVERAGE GUIDELINE Date of last root canal treatment if needed. 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

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

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COVERAGE GUIDELINE 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

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

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COVERAGE GUIDELINE 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.

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.

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.

Refer to coverage guideline: Surgical Endodontics (DCG010.01)

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.


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.

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COVERAGE GUIDELINE 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

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 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;

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COVERAGE GUIDELINE 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.

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

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COVERAGE GUIDELINE 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 (DCP013.01)

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.


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).

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COVERAGE GUIDELINE 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;

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 (DCP014.01)

Surgical Periodontics – Mucogingival Procedures D4270 D4273 D4275 D4276 D4277 D4278 D4283 D4285

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.

Criteria for codes D4265–D4267, D4270–D4273, D4275–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.

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COVERAGE GUIDELINE 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

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:





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:




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

gingiva to improve plaque control;

Ridge augmentation;




Gingival clefting.

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

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.

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COVERAGE GUIDELINE 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 (DCP015.01)

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.

Criteria for codes D4320–D4321

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.

Coverage Limitations and Exclusions for Provisional Splinting

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 (DCG011.01)

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

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, D4381, D4910

Scaling and Root Planing Scaling and Root planing is indicated for any of the following:

Localized or generalized mild chronic periodontal disease-characterized by 1-2 millimeters of clinical attachment loss (CAL).

Localized or generalized moderate chronic periodontal disease-characterized by 3-4 millimeters clinical attachment loss (CAL). In molars, furcation involvement not to exceed Class 1.

Localized or generalized severe periodontal disease-characterized by more than 5 millimeters of CAL.

Chronic refractory mild or moderate periodontal disease-characterized by patients who demonstrate additional attachment loss despite being longitudally monitored with periodontal maintenance.

Periodontal abscess 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

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COVERAGE GUIDELINE attachment (bone and tissue).

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).

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 (DCP.004.01)

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

Criteria for codes D4355

Indications for Coverage 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.

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COVERAGE GUIDELINE hygiene status.

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 (DCG.001.01)

Unscheduled Dressing Change D4920

Gingival Irrigation – per quadrant D4921

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–D5140, D5211–D5281, D5410–D422, D5510, D5520, D5610–D5671, D5710–D5721, D5730–D5761, D5810–D5821, D5850–D5875

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

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

Patient convenience

Coverage Limitations

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

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COVERAGE GUIDELINE

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

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

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COVERAGE GUIDELINE 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:

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

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COVERAGE GUIDELINE 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.

Exclusions 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 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.

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COVERAGE GUIDELINE 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 (DCG020.01)

MAXILLOFACIAL PROSTHETICS

Maxillofacial Prosthetics D5900–D5999

Documentation Narrative Radiographic images if indicated

IMPLANTS

D6010–D6013, D6040–D6050, D6104, 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–D6013, D6040–D6050, D6104, 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:

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 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;

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COVERAGE GUIDELINE 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: Implant Placement (DCG.007.01)

D6101–D6103 Documentation Pre-op periapical; request full mouth images or panoramic image if needed.

Review for medical necessity

Interim abutment D6051

Documentation/Criteria

Post of radiograph to confirm interim abutment.

Includes placement and removal.

Healing cap is not an interim abutment.

Loading of interim abutment on the same day as implant placement is acceptable for anterior teeth to allow for an esthetic temporary crown/bridge.

FIXED PROSTHETICS

Fixed Prosthodontics D6205–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–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 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

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COVERAGE GUIDELINE 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 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.

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COVERAGE GUIDELINE

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

Exclusions 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 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.


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.

Refer to coverage guideline: Fixed Prosthodontics (DCG017.01)

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COVERAGE GUIDELINE

ORAL SURGERY

D7111–D7999 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 are 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

D7260, oroantral closure

D7270, reimplantation (copy of accident report helpful)

D7340, 7350, vestibuloplasty

D7953, bone graft for ridge preservation

D7970, excision of hyperplastic tissue 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.

Alternate benefit permitted if submitted code is not supported by documentation.

Extractions D7210–D7250

Criteria

Inappropriate removal of teeth to construct full dentures is excluded. Patient preference in the absence of clinical indications, is not sufficient

Must be pathology involved (non-restorable caries, untreatable periodontal disease, untreatable endodontic disease)

Exception to above may be made based on underlying medical condition

Extraction of bicuspids may be ortho-related and fall under that benefit Bone graft with extraction is not a benefit unless a significant residual defect is present

Inclusive components

Sutures, local anesthesia, normal post-op care

Third molar removal

Classification is based on anatomic position of the tooth, not the technique required for its removal. Classification is based on ADA CDT descriptor for the

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COVERAGE GUIDELINE code submitted. See codes for specific guidelines.

Extraction includes removal of soft tissue including but not limited to granulomatous, follicular or minor cystic tissue associated with the tooth.

No bone graft is allowed unless a significant residual defect remains and is radiographically documented post op.

ERUPTED THIRD MOLAR – one that is so positioned that the entire clinical crown in visible

PARTIALLY ERUPTED THIRD MOLAR – one that is so positioned that only a portion of the clinical crown is visible

UNERUPTED/IMPACTED THIRD MOLAR – one that has not penetrated through bone and/or soft tissue and entered the oral cavity.

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 (DCG022.01)

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.


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;

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COVERAGE GUIDELINE Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Treatment notes if radiographic information not conclusive.

There is insufficient remaining clinical crown to allow a non-surgical 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 (DCG.005.01)

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 are 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;



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

Pulpal exposure;

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;

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

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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COVERAGE GUIDELINE When a more conservative procedure can be performed;


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

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COVERAGE GUIDELINE 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 (DCP006.01)

Oroantral fistula closure D7260

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

Benefitted if the condition cannot be treated by approximating the soft tissue and suturing and requires excision of fistulous tract with closure by advancement flap.


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COVERAGE GUIDELINE Primary closure of sinus perforation D7261



Criteria Subsequent to surgical removal of tooth, exposure of sinus requiring repair in absence of fistulous tract.

Tooth reimplantation D7270



Criteria Recent history of facial trauma.

Avulsion of tooth.

Performed within 3 hours of accident.

Includes splinting/stabilization.

Surgical exposure of unerupted tooth D7280



Criteria Tooth developing normally and in good position.

Adequate space to erupt.

Dense, fibrotic tissue appears to prevent eruption.

Part of orthodontic treatment plan.

Supernumeraries and third molars not benefited.

Mobilization of erupted or malpositioned tooth to aid eruption D7282



Tooth developing normally and in good position. Adequate space to erupt.. Hx. Of 7280

Placement of device to aid eruption of impacted tooth D7283

Documentation

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



Surgical placement of temporary anchorage device D7279, D7293, D7294

Documentation

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



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COVERAGE GUIDELINE Alveoloplasty with extractions D7310, D7311



Criteria Bone requires osteoplasty as preparation for prosthesis beyond that expected during healing.

For full quad: at least four contiguous extractions. Can be done up to 6 months post extraction of >4 teeth if indicated.

Alveoloplasty without extractions D7320, D7321



Criteria Teeth removed sometime in the past.

Narrative that current prosthesis is causing irritation, sore spots or inflammatory lesions due to thin or irregular alveolar crest.

Needed to remove spicules or exostoses that result in chronic irritation or pathology.

Vestibuloplasty D7340, D7350



Criteria Sometimes performed for periodontal purposes when an abnormally shallow vestibule threatens the attached gingiva.

May be performed to prepare an area for a denture.

Should be reviewed if on the same date as a soft tissue graft or periodontal surgery.

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.

Removal of exostoses or tori D7471, D7472, D7473



Criteria Impinges on speech or freeway space of tongue.

Prevents adequate extension of denture.

Frequent sore spots from denture.

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COVERAGE GUIDELINE Prevents fabrication of denture.

Factor in periodontal disease.

Not with osseous surgery or alveoloplasty.

Incision and drainage D7510, D7520



Criteria Not usually benefited when at same time as extraction.

Collection and application of autologous blood concentrate product D7921



Criteria Must be history of extraction on same day

Sinus augmentation via lateral open approach D7951



Criteria Usually for purposes of placement of an implant. Narrative and radiographic images to document the clinical need.

Sinus augmentation via a vertical approach D7952



Criteria Medically necessary

Bone graft for ridge preservation D7953



Criteria The healing process normally repairs the defect following an extraction. In cases such as a large defect after lesion removal, the graft may be allowed.

Implant note: if an implant is a covered procedure, this does not automatically imply approval of a bone graft. Radiographic images and narrative should be reviewed. SEE IMPLANT CRITERIA

If implant is placed at time of bone graft then use code D6104

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COVERAGE GUIDELINE Frenectomy or frenotomy D7960 Frenuloplasty D7963

Documentation Narrative if applicable

Criteria/Documentation Narrative may be requested from reviewer

Apparent cause of diastema.

Causing recession.

Tissue hinders home care.

Pre-prosthetic.

Tongue movement limited.

Denture lacerates or irritates frenum and cannot be resolved by denture adjustment.

Excision of hyperplastic tissue D7970

Documentation Narrative if applicable

Criteria (see also D4210)

Severe or gross overgrowth of tissue associated with ill-fitting denture.

Tissue not responsive to non-invasive therapy (conditioning, liners).

Pre-prosthetic purposes.

Hinders fit of existing prosthesis.

Tissue hinders home care.

Must be in an area of missing teeth where a full or partial denture or pontic will rest.

Excision of periocoronal gingival D7971

Narrative and radiographic images to document the clinical need Medically necessary

Surgical reduction of fibrous tuberosity D7972

Narrative and radiographic images to document the clinical need Medically Necessary

ORTHODONTICS

Medically Necessary Orthodontic Treatment D8050–D8090, D8220, D8660–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–D8090, D8220, D8660–D8680, D8690–D8691, D8999

Indications for Coverage 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;

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COVERAGE GUIDELINE 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.

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 (DCG.003.01)

ANESTHESIA SERVICES

General Anesthesia and Conscious Sedation D9210–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

Criteria for codes D9210–D9212, D9215, D9219, D9223, D9230, D9243, D9248

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

Coverage Limitations/Exclusions o Limited to once per day o Excluded when reported on same date of service as IV sedation, non-

IV sedation or General Anesthesia o Patient convenience

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

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COVERAGE GUIDELINE 3-6 Teeth D7111, D7140 45 min. 1-3 Teeth D7111, D7140 30 min. Nitrous Oxide: Extraction Coverage Recommendations:

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

o Ineffective local anesthesia o Anxiety o Special needs patients o Lengthy procedures for special needs patients and children o Behaviorally challenged or uncooperative patients

Nitrous Oxide is contraindicated for patients with but not limited to the following: o 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)

o Severe emotional disturbances o Drug related dependencies o Pregnancy – first trimester o Treatment with bleomycin sulfate (injection used in cancer patients) o Methlenetetrahydropfolate reductase deficiency o Vitamin B12 deficiency

Intravenous (IV) Sedation

Coverage Limitations/Exclusions o Limited to once per day

IV sedation is proven and effective for the following: o Anxiety/Fear o Pain Control o Oral Surgery o Medically compromised patients or those with special needs

IV sedation is contraindicated for patients with but not limited to the following: o Allergy to IV medications o Certain prescribe pharmaceuticals o In any patient where IV sedation has been considered unsafe

Non-IV Sedation

Coverage Limitations/Exclusions o Not allowed on same day as general anesthesia

Non-IV sedation is proven and effective for the following: o Anxiety o Uncooperative or unmanageable patient

Non-IV sedation is contraindicated for patients with but not limited to the following: o Patient or dentist convenience

Nerve Blocks are not covered for dental services; please refer to appropriate medical policy for specifics regarding coverage for nerve blocks.

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COVERAGE GUIDELINE 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: o Clinical procedures of extensiveness or complexity or situations that

require more than a local anesthetic o At least 2 attempts using office technique and the failure documented o Uncooperative or Unmanageable Patient o Physical, Cognitive or Developmental Disabilities o Significant underlying medical condition o Allergy or sensitivity to local anesthesia o Lengthy restoration procedures for pediatric patients o A child who has resisted all other conventional management

procedures

General anesthesia is contraindicated for patients with but not limited to the following: o Patients with predisposing medical and/or physical conditions that

potentially make general anesthesia unsafe o Cooperative patients with minimal dental needs o Choice of an alternative option for treatment o Language or cultural barriers o Parental objection

Refer to coverage guideline: General Anesthesia Conscious Sedation Services (DCG.016.01)

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.

Professional Visits D9410–D9450

Documentation Narrative from member record.

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COVERAGE GUIDELINE Therapeutic parenteral drugs D9610, D9612 Other drugs D9630

Criteria Inclusive when administered through the IV during IV sedation.

Covered when administered as a separate IV or intramuscular injection.

D9610 Single administration of antibiotics, steroids, anti-inflammatory drugs, or other therapeutic medications. NOT to be used to report administration of sedative, anesthetic or reversal agents. D9612 Multiple administrations of drugs listed for D9610. Only used when two or more drugs are used and no to be reported in addition to code D9610. D9630 Dispensing of oral antibiotics/home fluoride, oral analgesics, not limited to these drugs. Does not include writing of a prescription.

Application of Desensitizing Medicament D9910

Documentation Narrative with explanation of symptoms.

Criteria Typically used for root sensitivity per tooth. Not covered for bases/liners.

Desensitizing Resin D9911

Documentation Narrative with explanation of symptoms.

Criteria Adhesive application for root sensitivity per tooth. Not covered for bases/liners/adhesives under restorations.

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 D9940

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

Not for temporomandibular joint treatment.

Indications: bruxism, grinding, clenching, excessive wear &/or myofascial pain due to bruxing, grinding, clenching,

Athletic guard D9941

Documentation Narrative

Repair/Reline of Occlusal Guard D9942

Documentation Narrative

Occlusal analysis D9950

Criteria Not for TMJ treatment.

Occlusal adjustment D9951, D9952

Criteria Not for TMJ treatment, completed prosthetic appliance or with endodontic therapy.

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COVERAGE GUIDELINE 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.

Documents

NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION …...hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.). Interproximal caries extending