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Number: 020
(Updated)
Subject: Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans
Reviewed: September 23, 2013
Important note
This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:
Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.
Policy:
CPT Codes / HCPCS Codes/ ICD-9 Codes*
CPT codes covered if selection criteria are met: | |
00100 - 00102 | Anesthesia for procedure on salivary glands, including biopsy or anesthesia for procedures on plastic repair of cleft lip |
00170 - 00192 | Anesthesia for intraoral procedures, including biopsy; not otherwise specified, or repair of cleft palate, or excision of retropharyngeal tumor, or radical surgery, or anesthesia for procedures on facial bones or skull; not otherwise specified, or radical surgery (including prognathism) |
21010 | Arthrotomy, temporomandibular joint |
21025 | Excision of bone (for example, osteomyelitis or bone abscess); mandible |
21026 | facial bone(s) |
21030 | Excision of benign tumor or cyst maxilla or zygoma by enucleation and curettage |
21031 | Excision of torus mandibularis |
21032 | Excision of maxillary torus palatinus |
21034 | Excision of malignant tumor of maxilla or zygoma |
21040 | Excision of benign tumor or cyst of mandible, by enucleation and curettage |
21044 | Excision of malignant tumor of mandible; |
21045 | radical resection |
21046 | Excision of benign tumor or cyst of mandible; requiring intraoral osteotomy (for example, locally aggressive or destructive lesion(s)) |
21047 | requiring extraoral osteotomy and partial mandibulectomy (for example, locally aggressive or destructive lesion(s)) |
21048 | Excision of benign tumor or cyst of maxilla; requiring intraoral osteotomy (for example, locally aggressive or destructive lesion(s)) |
21049 | requiring extraoral osteotomy and partial maxillectomy (for example, locally aggressive or destructive lesion(s)) |
21050 | Condylectomy, temporomandibular joint (separate procedure) |
21060 | Meniscectomy, partial or complete, temporomandibular joint (separate Procedure) |
21070 | Coronoidectomy (separate procedure) |
21076 | Impression and custom preparation; surgical obturator prosthesis |
21077 | orbital prosthesis |
21079 | interim obturator prosthesis |
21080 | definitive obturator prosthesis |
21081 | mandibular resection prosthesis |
21082 | palatal augmentation prosthesis |
21083 | palatal lift prosthesis |
21084 | speech aid prosthesis |
21085 | oral surgical prosthesis |
21086 | auricular prosthesis |
21087 | nasal prosthesis |
21088 | facial prosthesis |
21100 | Application of halo-type appliance for maxillofacial fixation, includes removal (separate procedure) |
21110 | Application of interdental fixation device for conditions other than fracture or dislocation, includes removal |
21116 | Injection procedure for temporomandibular joint arthrography |
21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction (for example, for Long Face Syndrome), without bone graft |
21142 | two pieces, segment movement in any direction, without bone graft |
21143 | three or more pieces, segment movement in any direction, without bone graft |
21145 | single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) |
21146 | two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (for example, ungrafted unilateral alveolar cleft) |
21147 | three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (for example, ungrafted bilateral alveolar cleft or multiple osteotomies) |
21150 | Reconstruction midface, LeFort II; anterior intrusion (for example, Treacher-Collins Syndrome) |
21151 | Any direction, requiring bone grafts (includes obtaining autografts) |
21154 | Reconstruction midface, LeFort III; (extracranial and intracranial) any type, requiring bone grafts (includes obtaining autografts); without LeFort I |
21155 | with LeFort I |
21160 | with LeFort I |
21193 | Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; without bone graft |
21194 | with bone graft (includes obtaining graft) |
21195 | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation |
21196 | with internal rigid fixation |
21198 | Osteotomy, mandible, segmental; |
21199 | with genioglossus advancement |
21206 | Osteotomy, maxilla, segmental (for example, Wassmund or Schuchard) |
21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) |
21209 | reduction |
21210 | Graft, bone, nasal, maxillary or malar areas (includes obtaining graft) |
21215 | mandible (includes obtaining graft) |
21240 | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining grafts) |
21242 | Arthroplasty, temporomandibular joint, with allograft |
21243 | Arthroplasty, temporomandibular joint, with prosthetic joint replacement |
21244 | Reconstruction of mandible, extraoral, with transosteal bone plate (for example, mandibular staple bone plate) |
21245 | Reconstruction of mandible or maxilla, subperiosteal implant; partial |
21246 | complete |
21247 | Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (for example, for hemifacial microsomia) |
21248 | Reconstruction of mandible or maxilla, endosteal implant (for example, blade, cylinder): partial |
21249 | complete |
21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) |
21295 | Reduction of masseter muscle and bone (for example, for treatment of benign masseteric hypertrophy); extraoral approach |
21296 | intraoral approach |
21421 | Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint |
21422 | Open treatment of palatal or maxillary fracture (LeFort I type); |
21423 | complicated (comminuted or involving cranial nerve foramina), multiple approaches |
21431 | Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint |
21432 | Open treatment of craniofacial separation (LeFort III type) with wiring and/or internal fixation |
21433 | complicated (comminuted or involving cranial nerve foramina), multiple surgical approaches |
21435 | complicated, utilizing internal and/or external fixation techniques (for example, head cap, halo device, and/or intermaxillary fixation) |
21436 | complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) |
21440 | Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
21445 | Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
21450 | Closed treatment of mandibular fracture; without manipulation |
21451 | with manipulation |
21452 | Percutaneous treatment of mandibular fracture, with external fixation |
21453 | Closed treatment of mandibular fracture with interdental fixation |
21454 | Open treatment of mandibular fracture with external fixation |
21461 | Open treatment of mandibular fracture; without interdental fixation |
21462 | with interdental fixation |
21465 | Open treatment of mandibular condylar fracture |
21470 | Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints |
21480 | Closed treatment of temporomandibular dislocation; initial or subsequent |
21485 | complicated (for example, recurrent requiring intermaxillary fixation or splinting) initial or subsequent |
21490 | Open treatment of temporomandibular dislocation |
41825 | Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair |
41826 | with simple repair |
41827 | with complex repair |
41830 | Alveolectomy, including curettage of osteitis or sequestrectomy |
41850 | Destruction of lesion (except excision), dentoalveolar structures |
41874 | Alveoplasty, each quadrant (specify) |
42280 | Maxillary impression for palatal prosthesis |
42281 | Insertion of pin-retained palatal prosthesis |
70300 - 70320 | Radiologic examination, teeth; single view, partial examination, less than full mouth, or complete, full mouth |
Other CPT codes related to the CPB: | |
42200 - 42225 | Palatoplasty |
77401 - 77418 | Radiation treatment delivery |
HCPCS codes covered if selection criteria are met: | |
D4210 - D4261, D4268, D4274 | Dental procedures, surgical services (including usual postoperative care) |
D7210 - D7250 | Dental procedures, surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care) |
D7410 - D7415 | Surgical excision of reactive inflammatory lesions (scar tissue or localized congenital lesions |
D7440 - D7465 | Removal of tumors, cysts, and neoplasms |
D7471 - D7490 | Excision of bone tissue |
D7510 - D7560 | Surgical incision |
D7610 - D7780 | Treatment of fractures |
D7810 - D7899 | Reduction of dislocation and management of other temporomandibular joint dysfunctions |
D7910 | Suture of recent small wounds up to 5 cm |
D7911 - D7912 | Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure |
D7920 - D7951, D7960 - D7998 | Other repair procedures |
D9220 | Deep sedation/general anesthesia - first 30 minutes |
D9221 | Deep sedation/general anesthesia - additional 15 minutes |
D9241 | Intravenous conscious sedation/analgesia - first 30 minutes |
D9242 | Intravenous conscious sedation/analgesia - each additional 15 minutes |
D9248 | Non-intravenous conscious sedation |
HCPCS codes not covered for indications listed in the CPB: | |
D4263 | Bone replacement graft; first site in quadrant |
D4264 | Bone replacement graft - each additional site in quadrant (use if performed on same date of service as D4263) |
D4265 | Biologic materials to aid in soft and osseous tissue regeneration |
D4266 | Guided tissue regeneration; resorbable barrier, per site |
D4267 | Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal) |
D4270 | Pedicle soft tissue graft procedure |
D4271 | Free soft tissue graft procedure (including donor site surgery) |
D4273 | Subepithelial connective tissue graft procedures, per tooth |
D4275 | Soft tissue allograft |
D4276 | Combined connective tissue and double pedicle graft, per tooth |
D5986 | Fluoride gel carrier |
D6010 - D6199 | Implant services |
D7292 - D7294 | Surgical placement: temporary anchorage device |
D7953 | Bone replacement graft for ridge preservation - per site |
D7955 | Repair of maxillofacial soft and/or hard tissue defect |
ICD-9 codes covered if selection criteria are met: | |
143.0 - 143.9 | Malignant neoplasm of gum |
170.0 - 170.1 | Malignant neoplasm of bones of skull and face, except mandible, or malignant neoplasm of mandible |
195.0 | Malignant neoplasm of head, face, and neck |
210.4 | Benign neoplasm of other and unspecified parts of mouth |
213.0 - 213.1 | Benign neoplasm of bones of skull and face, or lower jaw bone |
520.6 | Disturbances in tooth eruption |
522.4 - 522.8 | Diseases of pulp and periapical tissues |
524.3 | Anomalies of tooth position |
524.4 | Malocclusion, unspecified |
525.0 - 525.8 | Other diseases and conditions of the teeth and supporting structures |
526.0 - 526.89 | Diseases of jaws |
749.00 - 749.25 | Cleft palate and cleft lip |
802.20 - 802.5 | Fracture of mandible or malar and maxillary bones, closed or open |
830.0 - 830.1 | Dislocation or jaw, closed, or open |
873.40 - 873.9 | Open wound of face, internal structures of mouth, or other and unspecified, without mention of complication, or complicated |
905.0 | Late effect of fracture of skull and face bones |
906.0 | Late effect of open wound of head, neck, and trunk |
959.01 - 959.09 | Injury to head, face, and neck |
996.5 | Mechanical complications of other specified prosthetic device, implant, and graft |
996.69 | Infection and inflammatory reaction due to other implant and internal device, not elsewhere classified |
996.78 | Other complications due to other internal orthopedic device, implant, and device |
V72.2 | Dental examination |
The above policy is based on the following references:
1UK National Health Service (NHS), Centre for Reviews and Dissemination (CRD). Prophylactic removal of impacted third molars: Is it justified? Effectiveness Matters. 1998; 3(2):1-4.Please reference other policy bulletins
Revision Dates
Original policy: November 4, 2004
Updated: September 25, 2006; November 16, 2009; January 20, 2011; June 5, 2012; September 23, 2013
Revised: August 26, 2008
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
*Current Procedural Terminology (CPT®) 2010 copyright
2010 American Medical Association. All Rights Reserved.
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