NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA
Revised: 4/1/2017
The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines.
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE DIAGNOSTIC Clinical Oral Evaluations Documentation in member record that includes all services performed D0120–D0191 for the code submitted
Pre-Diagnostic Services Documentation in member record that includes all services performed D0190 screening of a patient for the code submitted. D0191 assessment of a patient
Diagnostic Imaging Documentation in the member record. Diagnostic, clear, readable Criteria for codes D0364–D0368, D0380–D0386, D0391–D0395: images, dated with member name. Image capture with interpretation Cone beam computed tomography (CBCT) is unproven and not medically
D0210–D0371 necessary for routine dental applications. There is insufficient evidence that CBCT is beneficial for use in routine dental Image Capture only applications. CBCT should not replace traditional dental x-rays as a preliminary D0380–D0386 diagnostic tool, or for routine dental procedures such as restorations, but be Interpretation and Report only used as an adjunct when the level of detail CBCT is needed to safely render D0391–D0395 treatment for complex clinical conditions (e.g. oral surgery, implant placement and endodontics). These procedures may have a higher risk of complications CPT codes: 70486, 70487, 70488, without the level of detail CBCT imaging provides. CBCT imaging used for these 76376 and 76377 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
1 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Diagnostic Imaging determine whether CBCT improves treatment decision making and health (continued) outcomes.
Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP002.02)
Bacterial And Viral Testing Provider narrative including clinical reason/diagnosis for test and type of Criteria for codes D0414, D0415, D0416 D0414, D0415, D0416 test performed. Collection of Microorganisms for Culture and Sensitivity Collection of microorganisms for culture and sensitivity is indicated for the following: For odontogenic infections that do not respond to rational antibiotic empiric therapy and/or incision and drainage in a timely manner For odontogenic infections in patients with comorbidities including but not limited to impaired healing response, and compromised immune system
Collection of microorganisms for culture and sensitivity is not indicated for the following: As a routine procedure for all infections (unless patient has multiple comorbidities or infection is resistant to conventional therapy) If infection is small and limited to localized area If infection is draining on its own with no evidence of spread of infection For fungal infections For viral culturing (this procedure has its own reporting code)
Viral Culture Viral culturing is indicated for the presence of oral and perioral vesicles and ruptured vesicles resulting in lesions that may or may not be crusted over.
Viral culturing is not indicated for suspected cytomegalovirus (CMV) oral lesions (an incisional biopsy and testing is indicated).
Refer to coverage guideline: Bacterial And Viral Testing (DCG039.01)
Salivary Testing Provider narrative including clinical reason/diagnosis for test and type of Criteria for codes D0417, D0418 D0417, D0418 test performed. Collection, Preparation and Analysis of Saliva Sample for Laboratory Diagnostic Testing Collection, preparation and analysis of saliva sample for laboratory diagnostic testing may be indicated as part of oral disease risk assessment and management, including but not limited to caries, periodontal disease and xerostomia.
Refer to clinical policy: Salivary Testing (DCG037.01)
2 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Genetic Testing for Oral Disease Provider narrative including clinical reason/diagnosis for test and type of Criteria for codes D0422, D0423 D0422, D0423 test performed. Collection and Preparation of Genetic Sample Material for Laboratory Analysis and Report Genetic Test for Susceptibility to Diseases – Specimen Analysis The collection, preparation and testing of genetic samples are indicated for patients who have known human papilloma virus (HPV) infection, or have other related risk factors, to identify if the strain of HPV known to be related to oral and oropharyngeal cancers is present.
The clinical utility of genetic testing for susceptibility to periodontal diseases has not been established. Additionally, there is a lack of objective, high quality clinical evidence to support these tests.
Refer to clinical policy: Genetic Testing for Oral Disease (DCP036.01)
Miscellaneous Diagnostic Criteria for codes D0425, D0460, D0470 Procedures Caries Susceptibility Tests D0425, D0460, D0470 There is a lack of objective, high quality clinical evidence to support or refute the efficacy or superiority of this specific testing method as a tool for caries risk assessment and management.
Pulp Vitality Tests Pulp vitality tests are indicated for the following: For traumatic injuries to teeth Teeth with deep caries or defective restorations
Pulp vitality tests are not indicated for the following: Sensitivity of exposed dentin without evidence of pulp pathosis Teeth with no evidence of caries, resorption, defective restorations, or otherwise asymptomatic As part of routine dental examinations
Diagnostic Casts Combined with clinical and radiographic findings, diagnostic casts may be useful for select cases, as they can provide a further understanding of the overall dentition. They may be helpful in developing the treatment plan without the patient present, and can serve as an additional tool for educating the patient. They provide an opportunity for a more thorough evaluation of the following: Tooth interdigitation Functional occlusion, and any occlusal abnormalities Wear facets and defective restorations, coronal contours, proximal contacts and embrasure spaces between teeth
Refer to coverage guideline: Miscellaneous Diagnostic Procedures (DCG040.01)
3 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Non-Ionizing Diagnostic Provider narrative including clinical reason/diagnosis for test and type of Criteria for code D0600 Procedures test performed. There is inadequate evidence demonstrating the efficacy of these devices, D0600 limiting their use as a principal diagnostic tool. A non-ionizing diagnostic procedure refers to a device specifically designed to identify, quantify, monitor, and record changes in structure of enamel, dentin and cementum. These devices may be used as an adjunctive tool by the dental provider to identify high caries risk areas, and create non-invasive treatment plans for remineralization before caries begins. Visual and radiographic examinations remain the standard diagnostic methods for diagnosing active caries.
Refer to clinical policy: Non-Ionizing Diagnostic Procedures (DCP041.01)
Tests and Examinations Provider narrative including clinical reason/diagnosis for test and type of D0431 test performed. caries risk assessment D0601–D0603
Oral Pathology Laboratory D0472–D0502
Unspecified diagnostic procedure by report D0999
PREVENTIVE Dental Prophylaxis Services performed must be documented in the member record. D1110–D1120
Topical Fluoride Treatment Documentation Criteria for codes D1206, D1208 D1206, D1208 Age and medical necessity. An adult is generally defined as twelve years Topical Application of Fluoride – Excluding Varnish or older. CPT code: 99188 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
4 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Topical Fluoride Treatment For patients in active orthodontic treatment (continued) For the remineralization of incipient or white spot enamel carious lesions
Refer to clinical policy: Topical Fluoride Treatment (DCP018.01)
Other Preventive Services Documentation/narrative in member record that service was performed D1310–D1330 and materials supplied to member.
Sealants Documentation Criteria for codes: D1351, D1352, D1353 D1351, D1352, D1353 Sealant: Tooth numbers. Sealants
Dental caries is the most common pediatric disease. Dental sealants are recognized as an effective preventive approach to preventing pit and fissure caries in children and adolescents.
Sealants are indicated for the following: Caries prevention in pit and fissures on permanent molars of children and adolescents Non-cavitated carious lesions on permanent teeth in children and adolescents
Caries prevention for primary teeth in children with documented high
caries risk with a reasonable prognosis for retention anticipated. Risk
factors must be thoroughly documented by the provider in the dental
record, and include:
o Mother or primary caregiver have active caries
o White spot lesions or enamel defects
o Visible caries or previous restorations
o Poor oral hygiene
o Sub-optimal systemic fluoride intake
o Frequent exposure to cavity-producing foods and drinks
o Patients with special health care needs
o Low socioeconomic status
o Xerostomia
o More than one interproximal lesion
o Other factors identified by professional literature
o Deep pits and fissures
o Patients with special needs
Sealants are not generally indicated for the following: Widespread cavitated carious lesions Presence for interproximal or smooth surface lesions Occlusal surfaces that are already carious with involvement of the dentin that requires restoration Extrinsic staining of pits and fissures For placement on premolars, buccal and lingual pits of molars and cingula of anterior teeth
5 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Sealants Preventive Resin Restoration (PRR) (continued) Preventive resin restoration is done on an active cavitated lesion in a pit or fissure that does not extend into the dentin. This includes placement of a sealant in any radiating non-carious fissures or pits.
Preventive resin restorations are indicated for the restoration of pit and fissures carious lesions contained to enamel in moderate to high caries risk patients.
Preventive resin restorations are not indicated for the following: When no caries is evident in pits and fissures When a sealant is clinically indicated For carious lesions that extend into dentin
Coverage Limitations Sealants and PRRs are limited to one per tooth per 36 months.
Refer to coverage guideline: Sealants (DCG026.01)
Space Maintenance Radiographs of the involved arch. Criteria for codes D1510, D1515, D1520, D1525, D1550, D1555, D1575, D1999 D1510, D1515, D1520, D1525, Space maintainers are indicated for the following: D1550, D1555, D1575, D1999 Maintaining space due to premature loss of a primary tooth (teeth) To regain space
Space maintainers are contraindicated for the following: When tooth/teeth is/are close to eruption Patient is not compliant or has poor oral hygiene Severe crowing already exists Space has already been lost If sufficient amount of space already exists
Coverage Limitations and Exclusions Limited to one per tooth per consecutive 60 months Any space maintainer adjustments are inclusive for 6 months Limited to persons under the age of 16
Refer to coverage guideline: Space Maintenance (DCG035.01)
6 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE RESTORATIVE Direct Restorations Documentation Criteria for codes D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2140, D2150, D2160, D2161, Tooth number and surface. D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2941, D2330, D2331, D2332, D2335, Caries removal documented in member record. D2990, D2999 D2390, D2391, D2392, D2393, Direct Restorations D2394, D2410, D2420, D2430, D2940, D2941, D2990, D2999 Direct restorations are indicated for the following: To replace a tooth structure lost to caries or trauma Amalgam Restorations To replace restorative material lost in the course of accessing pulp chamber D2140–D2161 for endodontic therapy
Resin-Based Composite To replace existing restorations that exhibit recurrent decay, fracture or Restorations – Direct marginal defects
D2330–D2394 In addition to the above, glass ionomer restorations are indicated for the
Gold Foil Restorations following: D2410–D2430 When teeth cannot be isolated properly to allow placement of resin restorations As an alternative to resin sealants when the teeth cannot be properly isolated (patient cooperation, partially erupted teeth) Class I,II, III and V restorations on primary teeth Class III and V restorations on permanent teeth that cannot be isolated in high risk patients As a caries control plan for high risk patients using atraumatic techniques
Direct restorations are not indicated for the following:
Teeth with a hopeless prognosis in which extraction is indicated
Incipient enamel only lesions extending less than halfway to the dentinoenamel junction (DEJ) When there is sufficient loss of tooth structure that a crown or onlay is indicated When used as part of comprehensive or interceptive orthodontics to maintain an open bite For primary teeth that are near exfoliation or less than 50% of the tooth root remains Composite resin restorations are not indicated for patients with heavy bruxism Composite resin restorations are not indicated for patients with extensive active caries, or high caries risk Amalgam restorations are not indicated for placement on teeth in which they will have contact with gold restorations
In addition to the above, glass ionomer restorations are not indicated for the
following:
As a definitive, long term restoration in permanent teeth
7 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Direct Restorations When a sealant is indicated (continued) Required Documentation When a metal allergy is suspected, documentation from an allergist is required to support replacement of amalgam with composite.
Protective Restoration Protective restoration is indicated for the following: To relieve pain To promote healing To prevent further deterioration To retain tissue form
Protective restoration is not indicated for the following: As a liner or base for a definitive restoration Not for endodontic access closure Not for pulp capping As a definitive restoration
Interim Therapeutic Restoration-Primary Dentition Interim therapeutic restorations are indicated for the following: For very young, uncooperative or special needs patients When traditional tooth preparation for an amalgam or composite restoration is not feasible or must be postponed As a caries control plan for high risk patients using atraumatic techniques
Resin Infiltration of Incipient Smooth Surface Lesions Resin infiltration of incipient smooth surface lesions is typically used for aesthetic purposes. It is used to describe a proprietary product, and there is a lack of established objective evidence to support its use.
Coverage Limitations and Exclusions Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Any dental procedure not directly associated with dental disease Posterior composites may be alternately benefitted to amalgam coverage unless specified in member plan Gold foil restorations are benefitted to amalgam unless specified in member plan, or used to replace material lost on a gold crown due to endodontic therapy Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure
Refer to coverage guideline: Single Tooth Direct Restorations (DCG023.01)
8 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Indirect Restorations: Documentation Criteria for codes D2510, D2520 D2530, D2542, D2543, D2544, D2610, D2620, Pre-operative x-rays. If endodontic therapy has been performed, a D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, Inlay/Onlay Restorations periapical radiographic image clearly showing the apex of the completed D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2510–D2664 (Inlay/onlays) treatment is required; otherwise, bitewing x-rays may be sufficient at D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2799 Crowns – Single Restorations Only the discretion of the reviewer. Indications for Coverage D2710–D2799 A narrative or photograph may provide additional information, For indirect restorations, the following clinical parameters apply: especially for replacement of existing crowns. Five-year longevity should be evident, periodontium must be healthy or have documentation the member has periodontal disease under control for “Cracked tooth syndrome” requires adequate documentation of extent a period of at least 6 months, and no evidence of endodontic pathology or of fracture, location and how it was diagnosed. Tooth must be potential endodontic issues on the radiographic image.
symptomatic. Crowns
Crowns are indicated for the following: Restorations for members under age 15 require statement of medical Extensive caries on three or more surfaces or 50% loss of clinical crown necessity. Large, >50% of the tooth, defective restoration that can be seen on the
radiographic image Inclusive Fracture of cusps Local anesthesia; tooth preparation; temporary crown; fitting; Endodontically treated teeth, unless minimal access opening on anterior cementation; post-op adjustments, impressions; bases. tooth
Documentation that a direct restoration is not possible Crown/root ratio must be favorable Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image 50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and one or more cusps involved 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
9 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Indirect Restorations of decay (continued) 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 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 Benefitted for primary teeth without permanent successor Bicuspids and molars: 3 or more surfaces and one or more cusps involved
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
10 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Indirect Restorations sufficient for replacement (continued) 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 complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). Any Dental Procedure performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance).
Refer to coverage guideline: Single Tooth Indirect Restorations (DCG008.02)
Other Restorative Services Criteria for codes: D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2910, D2915, D2920, D2921, D2982, D2999 D2971, D2975, D2980, D2981, Recement and Rebond of Single Tooth Indirect Restorations D2982, D2999 Recement and rebond of single tooth indirect restorations are subject to Repairs necessitated by frequency limitations. Please refer to member specific benefit plan document restorative material failure for guidance. D2980–D2999 Repair of Single Tooth Indirect Restorations Repair of single tooth indirect restorations is indicated to repair a fractured inlay, onlay, crown or veneer in which the functional area is involved due to restorative material failure.
Repair of single tooth indirect restorations is not indicated solely for
cosmetic/aesthetic purposes.
Reattachment of Tooth Fragment Reattachment of tooth fragment is indicated for a tooth fracture confined to enamel and dentin with loss of structure, but not exposing the pulp.
Reattachment of tooth fragment is not indicated for the following: Tooth fractures involving pulpal exposure Fractures involving roots
11 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Other Restorative Services Coping (continued) Coping is considered inclusive to the preparation of crowns and bridge abutments unless and indicated a separate procedure for the following: If insufficient natural tooth structure remains to retain the crown To allow a common path of insertion when retainer teeth are tipped or misaligned
Coverage Limitations and Exclusions Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Repairs are limited to those performed more than 12 months after the initial insertion. 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: Other Restorative Services (DCG024.01)
Prefabricated Crowns Documentation Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934 Tooth number Prefabricated Crowns are indicated for the following: Porcelain/Ceramic Crown D2929 For the restoration of teeth with more than two surfaces affected with carious lesions, or where extensive one or two surface lesions are present. Stainless Steel Crown For one and two surface carious lesions in documented high caries risk D2930, D2931, D2932, D2933, children. Risk factors must be thoroughly documented by the provider in D2934 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.
12 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Prefabricated Crowns For the intermediate restoration of fractured teeth. (continued) 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 (DCP012.02)
Protective restoration Documentation Criteria D2940 Recorded in member chart. Direct placement of a restorative material to protect tooth and/or tissue form. Used to relieve pain, promote healing, or prevent further deterioration.
Covered as a separate procedure only if no other service other than radiographic images and exam were performed on the same tooth on the same day.
Not to be used for endodontic access closure, or as a base or liner under a restoration
Core Buildup, Post and Core and Documentation Criteria for codes D2949, D2950, D2951, D2952, D2953, D2954, D2957, D2955, Pin Retention Bitewing unless tooth has had root canal therapy, then a periapical D2999 D2949 should be submitted. Restorative Foundation for an Indirect Restoration Core buildup: D2950 Restorative foundation for an indirect restoration is indicated as a filler to
Pin retention per tooth: D2951 eliminate undercuts, voids and other irregularities that have occurred during tooth preparation to create a more favorable tooth form for the retention of an Post and Core: D2952, D2953, indirect restoration. D2954, D2955, D2957 Core Buildup (Including Any Pins When Required) D2999 Core buildup is indicated for teeth with significant loss of coronal tooth structure (> 50%) due to caries or trauma to aid in retention of an indirect
13 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Core Buildup, Post and Core and restoration. Pin Retention Core buildup is not indicated for the following: (continued) When adequate tooth structure remains to retain a crown As a filler to correct irregularities in preparation As a definitive composite or amalgam restoration For retention of intracoronal restorations
Post and Core
Post and core are indicated for the following:
For teeth with significant loss of coronal tooth structure due to caries or
trauma in endodontically treated teeth
(> 50%) to aid in retention of an indirect restoration
Post and Core is not indicated for the following: For vital teeth For a post, when anatomic features are available to retain the core (e.g., for molars, as canals and pulp chamber can usually retain a core) For teeth with short roots
Pin Retention Pin retention is indicated for teeth with significant loss of coronal tooth structure due to caries or trauma, to allow retention of a direct restoration when preparation design alone is insufficient.
Pin retention is not indicated for the following:
For restoration of teeth with significant malocclusion
If the tooth cannot be properly restored with a direct restoration due to
anatomic or functional considerations
Post Removal
Post removal is indicated for the following:
When there has been loss of adequate retention
In the case of fracture of tooth and/or post and core
When there is recurrent caries associated with post and core
When access is needed to root canal system for non-surgical endodontics When the tooth has a reasonable long term prognosis for a new restoration
Coverage Limitations and Exclusions
Any dental procedure performed solely for cosmetic/aesthetic reasons.
(Cosmetic procedures are those procedures that improve physical
appearance.)
Fixed or removable prosthodontic restoration procedures for complete oral
rehabilitation or reconstruction.
Pin retention is limited to 2 pins per tooth; not covered in addition to cast restoration.
14 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Core Buildup, Post and Core and Post and core is covered only for teeth that have had root canal therapy. Pin Retention Post removal is considered inclusive to retreatment procedure, and not (continued) covered Restorative foundation for an Indirect Restoration is not covered 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: Core Buildup, Post and Core and Pin Retention (DCG021.01)
Labial Veneer Documentation Criteria for codes D2960, D2961, D2962 D2960, D2961, D2962 Radiographic image and narrative of medical necessity. A labial veneer is a thin layer of material placed over a tooth to protect it from Intraoral photo helpful. further damage or for aesthetic reasons. For most plans, veneers are not covered, but for those plans that do have coverage, the following identify guidelines for placement.
Labial Veneers Labial veneers are indicated for the following: For coverage of enamel only fractures Teeth with enamel defects including but not limited to enamel hypoplasia, severe decalcification, enamel hypocalcification and fluorosis
Labial veneers are not indicated for the coverage of fractures that extend into dentin.
Coverage Limitations and 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.)
Refer to coverage guideline: Labial Veneers (DCG025.01)
ENDODONTICS Non-Surgical Endodontics General documentation requirements Criteria for codes D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, Pre and post endodontic periapical radiographic images showing apex of D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, Endodontic codes: tooth. D3353, D3355, D3356, D3357 D3110, D3120, D3220, D3221, For retreatment, surgical endodontics, cracked tooth syndrome and D3222, D3230, D3240, D3310, Vital Pulp Therapy other procedures: pre and post-op images, taken within one year and D3320, D3330, D3331, D3332, narrative if the reason for treatment is not evident on films. Direct Pulp Cap D3333, D3346, D3347, D3348, Direct pulp capping is indicated for the following: D3351, D3352, D3353, D3355, Diagnosis Tooth has a vital pulp or been diagnosed with reversible pulpitis D3356, D3357 Diagnostic tests used to determine a diagnosis of irreversible pulpitis or All caries has been removed periapical pathology must be documented in the record. Mechanical exposure of a clinically vital and asymptomatic pulp occurs
Bleeding is controlled at the exposure site
15 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Non-Surgical Endodontics Exposure permits the capping material to make direct contact with the vital (continued) 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 a carious exposure in primary teeth
Indirect Pulp Cap
Indirect pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation No history of subjective pretreatment symptoms Pretreatment radiographs should not show periradicular pathosis
Therapeutic Pulpotomy
Therapeutic pulpotomy is indicated for the following: Exposed vital pulps or irreversible pulpitis of primary teeth Any bleeding was controlled within several minutes As an emergency procedure in permanent teeth until root canal treatment can be accomplished As an interim procedure for permanent teeth with immature root formation to allow continued root development In primary teeth, where there is a reasonable period of retention expected (approximately one year)
Therapeutic pulpotomy is not indicated for the following: Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor As the first stage of complete root canal therapy Removal of pulp apical to the dentinocemental junction For primary teeth that are near exfoliation or less than 50% of the tooth root remains
Partial Pulpectomy for Apexogenesis
A partial pulpotomy for apexogenesis is indicated for the following: In a young permanent tooth for a carious pulp exposure When the pulpal bleeding is controlled within several minutes A vital tooth, with a diagnosis of normal pulp or reversible pulpitis
Apexification/Recalcification
Apexification/recalcification is indicated for the following:
16 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Non-Surgical Endodontics Incomplete apical closure in a permanent tooth root (continued) 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
Pulpal Regeneration Pulpal regeneration is indicated for the following: Permanent tooth with immature apex Necrotic pulp Pulp space not needed for post/core or final restoration When tooth is not restorable
Pulpal regeneration is not indicated for the following: Primary teeth The pulp space would be needed for final restoration
Non-Vital Pulp Therapy
Pulpal Debridement (Pulpectomy) Pulpal debridement (pulpectomy) is indicated for the following: A restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified The relief of acute pain prior to complete root canal therapy A primary tooth, where there is a reasonable period of retention expected (approximately one year)
Pulpal debridement (pulpectomy) is not indicated for the following:
Complete root canal therapy of an infected or necrotic tooth Primary teeth that are near exfoliation or less than 50% of the tooth root remains
Pulpal Therapy (Resorbable Filling) – Primary Teeth
Pulpal therapy for primary teeth is indicated for the following:
A restorable primary tooth with irreversible pulpitis or a necrotic pulp in
which the root is apexified
The prognosis for keeping the tooth is up to one year and the tooth root lies in at least 25% bone
Pulpal therapy is not indicated for the following: Primary teeth that are near exfoliation or less than 50% of the tooth root
17 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Non-Surgical Endodontics remains (continued) Permanent teeth
Endodontic Therapy Endodontic therapy is indicated for the following: A restorable mature, completely developed permanent or primary tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure Teeth with radiographic periapical pathology Primary teeth without a permanent successor Trauma When needed for prosthetic rehabilitation
Endodontic therapy is not indicated for the following: Teeth with a poor long term prognosis Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease Teeth with incompletely formed root apices
Treatment of Root Canal Obstruction; Non-Surgical Access Treatment of a root canal obstruction is indicated for the following: When there is an obstruction of the root canal system, (biological, iatrogenic ledges or post removal) and endodontic retreatment is needed Removal of obstruction is complex and/or requires significant time
Treatment of a root canal obstruction is not indicated when there is no
obstruction evident.
Incomplete Endodontic Therapy: Inoperable, Unrestorable or Fractured Tooth Incomplete endodontic therapy is indicated for the following:
During endodontic treatment of a tooth, it becomes apparent that the
procedure cannot be successfully completed
The tooth will not be able to be restored, or the tooth fractures,
necessitating discontinuation of treatment
Internal Root Repair of Perforation Defects Internal root repair of perforation defects is indicated for the following: There is a root perforation caused by pathology such as resorption or decay
A communication between the pulp space and external root surface as a
result of internal root resorption.
Internal root repair of perforation defects is not indicated for the following: Teeth that are considered non-restorable Teeth with inadequate bone support or advanced untreated periodontal disease
18 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Non-Surgical Endodontics (continued) Retreatment of Previous Root Canal Therapy Retreatment of previous root canal therapy is indicated for the following: Canal fill appears to extend to a point shorter than 2millimeters from the apex, or extends significantly beyond the apex Fill appears to be incomplete Tooth is sensitive to pressure and percussion or other subjective symptoms The existing endodontics is poor Placement of a post has the potential to compromise the existing obturation or apical seal of the canal system The canal is accessible and allows for retreatment with a non-surgical procedure
Refer to coverage guideline: Non-Surgical Endodontics (DCG009.02)
Surgical Endodontics Documentation Criteria for codes D3410, D3421, D3425, D3426, D3427, D3430, D3450, D3470, D3410, D3421, D3425, D3426, Pre and post-operative radiograph image. Provider narrative may be D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, D3999 D3427, D3430, D3450, D3470, requested if pathology is not visible. Apicoectomy D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, Date of last root canal treatment if needed. Apicoectomy is indicated for the following: D3999 Failed retreatment of endodontic therapy When the apex of tooth cannot be accessed due to calcification or other anomaly Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked over extension of obturating materials interfering with healing
Apicoectomy is not indicated for the following:
Unusual bony or root configurations resulting in lack of surgical access
The possible involvement of neurovascular structures
Teeth that are considered non-restorable
Teeth with inadequate bone support or advanced or untreated periodontal disease 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
19 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Endodontics When a biopsy of periradicular tissue is necessary (continued) Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked overextension of obturating materials interfering with healing
Periradicular surgery without apicoectomy is not indicated for the following: Unusual bony or root configurations resulting in lack of surgical access The possible involvement of neurovascular structures Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease When non-surgical endodontic treatment has not been attempted or was not indicated
Retrograde Filling
Retrograde filling is indicated for the following: Periradicular pathosis and a blockage of the root canal system that could not be obturated by nonsurgical root canal treatment Persistent periradicular pathosis resulting from an inadequate apical seal that cannot be corrected nonsurgically. Root perforations Resorptive defects
Retrograde filling is not indicated for the following:
When canals are successfully obturated and no evidence of radiographic
pathology or clinical symptoms persist
When a tooth has an overall poor prognosis with or without retrograde
filling placement
Root Amputation Root amputation is indicated for the following: Class III furcation involvement Untreatable bony defect (of one root)
Root fracture
Root caries
Root resorption
Persistent sinus tract or recurrent apical pathology
When there is greater than 75% bone supporting remaining root(s) The tooth has had successful endodontic treatment on remaining root(s)
Root amputation is not indicated for the following:
20 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Endodontics Teeth with an overall poor prognosis with or without root amputation (continued) Vital teeth
Intentional Reimplantation Intentional replantation is indicated when all of the following clinical conditions exist: Persistent periradicular pathosis following endodontic treatment Nonsurgical retreatment is not possible or has an unfavorable prognosis Periradicular surgery is not possible or involves a high degree of risk to adjacent anatomical structures The tooth presents a reasonable opportunity for removal without fracture The tooth has an acceptable periodontal status prior to the replantation procedure
Intentional replantation is not indicated when any of the above criteria are not met.
Hemisection Hemisection of multirooted teeth is indicated for the following: Class III or Class IV periodontal furcation defect
Infrabony defect of one root of a multi-rooted tooth that cannot be
successfully treated periodontally
Coronal fracture extending into the furcation
Vertical root fracture confined to the root to be separated and removed
Carious, resorptive root or perforation defects that are inoperable or
cannot be corrected without root removal
Persistent periradicular pathosis where nonsurgical treatment or periradicular surgery is not possible and the problem is confined to one root The tooth has had successful endodontic treatment on remaining portion of tooth
Hemisection of multirooted teeth is not indicated for the following: Teeth with overall poor prognosis with or without hemisection Vital teeth
Bone Graft in Conjunction with Periradicular Surgery Bone graft in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate possible benefits of bone grafting in endodontic surgery.
Biologic Materials to Aid in Soft and Osseous Tissue Regeneration in
Conjunction with Periradicular Surgery
Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery are unproven for the treatment of lesions that are
21 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Endodontics endodontic in origin. Additional clinical studies are needed to further evaluate (continued) possible benefits of biologic material to aid in tissue and osseous regeneration in endodontic surgery.
Guided Tissue Regeneration Resorbable Barrier in Conjunction with Periradicular Surgery Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate possible benefits of guided tissue regeneration techniques in endodontic surgery.
Refer to coverage guideline: Surgical Endodontics (DCG010.02)
PERIODONTICS Surgical Periodontics: Documentation/Other for codes D4210, D4211, D4212, D4230, D4231, Criteria for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, Resective Procedures D4240, D4241, D4245, D4249, D4261 D4249, D4261, D4274 D4210, D4211, D4212, D4230, Full radiographic images (panoramic with bitewings or full periapical Gingivectomy/Gingivoplasty D4231, D4240, D4241, D4245, series with bitewings) taken within 24 months. The reviewer will D4249, D4261, D4274 Gingivectomy/Gingivoplasty is indicated for the following: determine what type of radiographic images are appropriate, given that Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is the practical reality is that many offices take only panoramic and fibrous and firm and there is an adequate zone of keratinized tissue; bitewing films. Elimination of gingival enlargements/overgrowth due to medications,
Tooth numbers or site designations. medical conditions or tooth position; Elimination of suprabony periodontal abscesses; Periodontal charting performed within 12 months, including six point For exposure of soft tissue impacted teeth to aid in eruption; probing, furcation, mucogingival relationship, bleeding, case type, oral To reestablish gingival contour following an episode of acute necrotizing hygiene status. ulcerative gingivitis;
Documentation for code D4274 To allow restorative access, including root surface caries.
Pre-surgical radiograph images. Gingivectomy/Gingivoplasty is not indicated for the following:
Grafts: When bone surgery is required for infrabony defects, or for the purpose of One soft tissue graft per two contiguous teeth. examining bone shape and morphology; Bone graft and guided tissue regeneration: only one or the other Situations in which the bottom of the pocket is apical to the mucogingival allowed. junction; Evidence of mobility, bruxism and/or hyperocclusion may Areas where aesthetics are a concern (particularly in the anterior maxilla); contraindicate grafting 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:
22 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Periodontics: In an otherwise periodontally healthy area to facilitate the restoration of Resective Procedures subgingival caries; (continued) 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: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies.
Apically Positioned Flap Procedure
Apically Positioned Flap Procedure is indicated for the following: The presence of moderate to deep probing depths; Loss of attachment; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful; The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods; To preserve keratinized tissue in conjunction with osseous surgery.
Apically Positioned Flap Procedure is not indicated for the following:
Solely for cosmetic/aesthetic purposes;
Patients with an uncontrolled underlying medical condition;
Patients who have been non-compliant with previous periodontal
therapies.
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
23 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Periodontics: on a tooth with little to no crown exposure. Resective Procedures Clinical Crown Lengthening-Hard Tissue is not indicated for the following: (continued) As treatment for periodontal disease; Solely for cosmetic/aesthetic purposes; 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); Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies.
Distal or Proximal Wedge (When Not Performed in Conjunction with Surgical Procedures in the Same Anatomical Area) Distal or Proximal Wedge procedure is indicated for the following: The presence of moderate to deep probing depths (greater than 5mm) on a surface adjacent to an edentulous/terminal tooth area; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful on a surface adjacent to an edentulous/terminal tooth area; The diagnosis of a cracked tooth, fractured root or external root resorption on a surface adjacent to an edentulous/terminal tooth area, when this cannot be accomplished by non-invasive methods.
Distal or Proximal Wedge procedure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies; In areas in which there are teeth with proximal contact.
Refer to clinical policy: Surgical Periodontics: Resective Procedures (DCP013.03)
24 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Periodontics: Documentation Criteria for codes D4263, D4264, D4265, D4266, D4267, D4268, D4999 Regenerative Procedures Full radiographic images (panoramic image) with bitewings or full Bone Replacement Grafts D4263, D4264, D4265, D4266, periapical series with bitewings) taken within 24 months. The reviewer D4267, D4268, D4999 will determine what type of radiographic images are appropriate, given Bone Replacement Grafts are indicated for the following: that the practical reality is that many offices take only panoramic and Infrabony/Intrabony vertical defects; Codes D4265, D4266, D4267 and bitewing films. Class II furcation involvements. D4999 are each addressed in the
Regenerative, Mucogingival and Bone Replacement Grafts are not indicated for the following: Tooth numbers or site designations. Resective Surgical Periodontics Class I furcation involvement; clinical policies. Class III or higher furcation involvement; Periodontal charting performed within 12 months, including six point Non-vertical defects; probing, furcation, mucogingival relationship, bleeding, case type, oral Patients with an uncontrolled underlying medical condition; hygiene status. Patients who have been non-compliant with previous periodontal therapies; 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; Class II furcation involvements.
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;
Non-vertical defects; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies; Patients with poor oral hygiene; Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility).
Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier (includes Membrane Removal)
Guided Tissue Regeneration is indicated for the following:
Intrabony/infrabony vertical defects;
Class II furcation involvements.
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;
25 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Periodontics: Class III or higher furcation involvement; Regenerative Procedures Horizontal bone loss; (continued) Non-vertical defects; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies; Patients with poor oral hygiene; Crater defects.
Surgical Revision Procedure (per Tooth) Surgical Revision Procedure is indicated to correct an abnormal healing response that interferes with the therapeutic goals of the original regenerative surgical procedure.
Surgical Revision Procedure is not indicated solely for cosmetic/aesthetic purposes.
Refer to clinical policy: Surgical Periodontics: Regenerative Procedures (DCP014.03)
Surgical Periodontics: Documentation/Other Criteria for codes D4265, D4266, D4267, D4270, D4273, D4275, D4276, D4277, Mucogingival Procedures D4278, D4283, D4285, D4999 Pedicle soft tissue graft (D4270) is not benefited at the same time with D4265, D4266, D4267, D4270, other periodontal surgery. Pedicle Soft Tissue Graft Procedure D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4999 Soft tissue grafts are benefitted once per two contiguous teeth Pedicle Soft Tissue Graft Procedure is indicated for the following: Areas with less than 2 mm of attached gingiva; Codes D4265, D4266, D4267 and Documentation (see Note) Unresolved sensitivity in areas of recession; D4999 are each addressed in the Full radiographic images (panoramic with bitewings or full periapical Progressive recession or chronic inflammation; Regenerative, Mucogingival and series with bitewings) taken within 24 months. The reviewer will For teeth with subgingival restorations where there is little or no attached Resective Surgical Periodontics determine what type of radiographic images are appropriate, given that gingiva to improve plaque control; clinical policies. the practical reality is that many offices take only panoramic and Ridge augmentation;
bitewing films. To increase vestibular depth for the correct fit of prosthesis;
To widen zone of attached gingiva for prosthetic abutment teeth; Tooth numbers or site designations. To increase vestibular depth to allow proper oral hygiene techniques;
Periodontal charting performed within 12 months, including six point Gingival clefting. probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Pedicle Soft Tissue Graft Procedure is not indicated for the following: Roots covered with thin bony plates; Note Patients with an untreated medical condition. No radiographs required for the following codes: D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285 Autogenous Connective Tissue Graft Autogenous connective tissue graft 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
26 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Periodontics: gingiva to improve plaque control; Mucogingival Procedures Ridge augmentation; (continued) 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.
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; Patients with an untreated medical condition.
Non-Autogenous Connective Tissue Graft
Non-autogenous connective tissue graft 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.
Non-autogenous connective tissue graft is not indicated for the following: When indications for connective tissue grafting are not met; Patients with an untreated medical condition.
Combined Connective and Double Pedicle Graft
Combined Connective and Double Pedicle Graft 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.
Combined Connective and Double Pedicle Graft is not indicated for the following:
27 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Periodontics: Roots covered with thin bony plates; Mucogingival Procedures Patients with an untreated medical condition. (continued) Free Soft Tissue Graft Procedure (including Donor Site Surgery) Free Soft Tissue Graft Procedure is indicated for the following: 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; 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.
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; Patients with an untreated medical condition.
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; Progressive recession or chronic inflammation; Areas of bone dehiscence and fenestration’ Single tooth, wide and deep localized recession; For areas associated with failed cervical restorations.
Guided Tissue Regeneration is not indicated for the following: Multiple adjacent tooth sites of root coverage required; Solely for cosmetic/aesthetic purposes.
Refer to clinical policy: Surgical Periodontics: Mucogingival Procedures (DCP015.02)
28 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Provisional Splinting Full radiographic images (panoramic image with bitewings or full Criteria for codes D4320, D4321 D4320, D4321 periapical series with bitewings) taken within 24 months. The reviewer Provisional Splinting using these codes is indicated for the following: will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and Multiple teeth that have become mobile due to loss of alveolar bone loss bitewing films. and periodontium; During surgical and healing phases of regenerative periodontal therapy.
Tooth numbers or site designations. Provisional Splinting using these codes is not indicated for the following: Tooth transplantation; Periodontal charting performed within 12 months, including six point Trauma resulting in the reimplantation of completely avulsed tooth/teeth; probing, furcation, mucogingival relationship, bleeding, case type, oral Trauma resulting in displacement or fracture of tooth/teeth. hygiene status. Coverage Limitations and Exclusions Limited to once per 36 months per same tooth/teeth. Not to be billed on same day as any restoration, prostheses or implant for same tooth/teeth.
Refer to coverage guideline: Provisional Splinting (DCG011.02)
Non-Surgical Periodontal Therapy Documentation Criteria for codes D4341, D4342, D4346, D4381, D4910, D4921 D4341, D4342, D4346, D4381, Full radiographic images (panoramic image with bitewings or full Scaling and Root Planing D4910, D4921 periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given Scaling and Root planing is indicated for any of the following: that the practical reality is that many offices take only panoramic and Localized or generalized mild chronic periodontal disease-characterized by bitewing films. 1-2 millimeters of clinical attachment loss (CAL). Localized or generalized moderate chronic periodontal disease- Tooth numbers or site designations. characterized by 3-4 millimeters clinical attachment loss (CAL). In molars, furcation involvement not to exceed Class 1. Periodontal charting performed within 12 months, including six point Localized or generalized severe periodontal disease-characterized by more probing, furcation, mucogingival relationship, bleeding, case type, oral than 5 millimeters of CAL. hygiene status. 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 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
29 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Non-Surgical Periodontal Therapy periodontal diseases. (continued) Localized Delivery of Antimicrobial Agents Localized Delivery of Antimicrobial Agents is indicated as an adjunct to scaling and root planing in cases of refractory disease and/or residual probing depths greater than or equal to 5 millimeters with inflammation that are still present following conventional therapies.
Localized Delivery of Antimicrobial Agents is unproven and not indicated in the absence of periodontal scaling and root planing (SRP) procedure.
Periodontal Maintenance Periodontal Maintenance is indicated for the following: To maintain the results of non-surgical periodontal scaling and root planing therapy and prevent recurrent disease. As an extension of active periodontal therapy at selected intervals.
Periodontal Maintenance is not indicated for the following: No history of scaling and root planing (SRP) or surgical procedures. Gingivitis – defined as inflammation of the gingival tissue without loss of attachment (bone and tissue).
Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation – Full Mouth Scaling in presence of generalized moderate or severe gingival inflammation is indicated for the removal of plaque, calculus and stains from supra- and sub- gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing.
Gingival Irrigation Per Quadrant Gingival Irrigation per quadrant is unproven. There is limited evidence to support the efficacy of a single episode or multiple in office irrigation appointments. The available studies show the greatest problem with irrigation as an adjunctive therapy is that the antimicrobials are quickly eliminated.
Refer to clinical policy: Non-Surgical Periodontal Therapy (DCP004.02)
Full Mouth Debridement Full radiographic images (panoramic image with bitewings or full Criteria for codes D4355 D4355 periapical series with bitewings) taken within 24 months. The reviewer Indications for Coverage will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and Full Mouth Debridement is a covered dental service and indicated when the bitewing films. following criteria have been met: Heavy calculus is present on teeth and usually visible on radiographs. Tooth numbers or site designations. Due to the amount of calculus, plaque and debris, a comprehensive
30 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Full Mouth Debridement examination and diagnosis is not possible. (continued) Periodontal charting performed within 12 months, including six point Coverage Limitations and Exclusions probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Limited to once every 36 months. Not to be billed on same day as any exam code or non-surgical periodontal therapy code. Not to be billed within 12 months of prophylaxis or periodontal maintenance. Not to be used as a therapeutic or preventive procedure such as scaling and root planing or prophylaxis.
Refer to coverage guideline: Full Mouth Debridement (DCG001.02)
Unscheduled Dressing Change D4920
REMOVABLE PROSTHETICS Removable Prosthodontics Documentation Criteria for codes D5110, D5120, D5130, D5140, D5211, D5212, D5213, D5214, D5110–D5899 Full mouth radiographic images. D5221, D5222, D5223, D5224, D5225, D5226, D5281, D5410, D5411, D5421, D5422, D5510, D5520, D5610, D5620, D5630, D5640, D5650, D5660, D5670, Tooth numbers for missing teeth to be replaced, and other missing Complete dentures D5671, D5710, D5711, D5720, D5721, D5730, D5731, D5740, D5741, D5750, teeth. D5110–D5140 D5751, D5760, D5761, D5810, D5811, D5820, D5821, D5850, D5851, D5862,
Partial dentures Date of extractions if indicated. D5863, D5864, D5865, D5866, D5867, D5875, D5899
D5211–D5281 Age of existing prosthesis. Removable prosthodontic appliances are indicated for replacement of missing
teeth loss to disease or injury. The following outlines indications and coverage Adjustments to Dentures Immediate denture: X-rays showing at least one tooth present and severe periodontal disease or caries. guidelines for complete and partial removable prosthodontics. D5410–D5422 Complete Dentures Repair to Complete Dentures D5510, D5520 Complete dentures are indicated for the following: To replace teeth that are non-restorable due to gross caries and/or Repair to Partial Dentures advanced periodontal disease D5610–D5671 To replace teeth lost due to orofacial trauma To replace teeth lost due to oral cancer surgery and subsequent Denture Rebase Procedures reconstruction D5710–D5721 Complete Dentures are not indicated for the following: Denture Reline Procedures When there is no evidence of dental disease D5730–D5761 When teeth appear to be restorable Interim partial dentures When there has been extensive bone atrophy resulting in an inadequate D5810–D5821 edentulous ridge for retention of appliance Patient convenience Other Removable Prosthetic Services Coverage Limitations and Exclusions D5850–D5875 Limited to once per 60 months from initial or supplemental placement Not allowed if within 60 months of an existing partial denture, interim
31 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Removable Prosthodontics partial denture, removable partial denture, pontic, retainer, inlay (continued) abutment, crown abutment, onlay abutment, or an interim retainer crown for same tooth Not allowed if there is a history of an implant, implant abutment, denture, or interim partial for the same tooth
Partial Dentures Partial Dentures are indicated for the following: To replace teeth that are non-restorable due to gross caries and/or advanced periodontal disease To replace teeth lost due to trauma or injury When a fixed partial denture is contraindicated (e.g., immediately following extractions, for a long edentulous span, distal extension needs, a periodontally involved dentition, resorption and loss of edentulous ridge)
Partial Dentures are not indicated for the following:
Chronic poor oral hygiene
Severe periodontal disease with questionable ability to support a partial
denture
Coverage Limitations and Exclusions 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
32 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Removable Prosthodontics When reline is sufficient (continued) Complete and Partial Denture Reline Procedures Relining of removable appliances is considered inclusive for the first 6 months, and then subject to frequency limitations. For immediate dentures, one reline covered in the first six months; then additional relining subject to frequency limitations.
Denture Relining is indicated for the following: When appliance has become mobile or unstable
To reestablish a soft tissue base for a distal extension appliance when
denture rotation is evident
When there has been loss of occlusal contact with opposing arch
Denture Relining is not indicated for the following: When the appliance is broken or worn to the extent that replacing the appliance is warranted When the occlusion or structural integrity of the denture teeth are no longer functional
Interim Prosthesis Interim Prostheses are indicated for the following: While tissue is healing following extractions For the maintenance of a space for future permanent treatment such as an implant, bridge or definitive fixed appliance To condition teeth and ridge tissue for optimum support of a definitive removable partial denture To maintain established jaw relation until all restorative treatment has been completed and a definitive partial denture can be constructed
Interim Prostheses are not indicated for the following:
As a permanent, definitive prosthesis
Overdentures Overdentures are indicated for the following: To preserve the integrity of the edentulous ridge
When there are teeth available as abutments that have a good long term
prognosis
Overdentures are not indicated for the following: 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
33 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Removable Prosthodontics Tissue Conditioning is considered inclusive for the first 12 months, and is then (continued) subject to frequency limitations.
Tissue Conditioning is indicated for the following:
In the presence of inflammation and irritation of the mucosa covering den- ture-bearing areas When there is distortion of normal anatomic structures, such as incisive papillae, rugae, and retromolar pads A burning sensation in residual ridge areas, the tongue, and the cheeks and lips not related to a systemic medical condition Subsequent to placement of immediate dentures to facilitate short term denture retention
Tissue Conditioning is not indicated for the following: For long term appliance stability and/or comfort
Repairs and Adjustments Repairs and adjustments of removable appliances are considered inclusive for the first 12 months, and are then subject to frequency limitations. Adding teeth to appliances is also subject to frequency limitations.
Maxillofacial Prosthetics These are removable appliances for the loss of orofacial structures due to trauma, congenital deformity or destruction of structures due to cancer and resection. This code section also includes radiation shields, carriers for fluoride, radiation carriers, as well as specific medicaments. These removable prosthetics are considered to be medical in nature and are typically covered under the member’s medical plan. Please see appropriate medical policy.
Coverage Limitations and 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
34 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Removable Prosthodontics elective endodontic procedure related to a tooth or root involved in the (continued) construction of a prosthesis of this nature. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.
Clinical situations that can be effectively treated by a less costly dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure.
Refer to coverage guideline: Removable Prosthodontics (DCG020.01)
MAXILLOFACIAL PROSTHETICS Maxillofacial Prosthetics Documentation D5900–D5999 Narrative Radiographic images if indicated
IMPLANTS Implants Documentation Criteria for codes D6010, D6011, D6012, D6013, D6040, D6050, D6051, D6052, D6010, D6011, D6012, D6013, Single implant: periapical acceptable; request full mouth images or D6055, D6056, D6057, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6040, D6050, D6051, D6052, panoramic image if needed. D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6055, D6056, D6057, D6058, More than one implant: full mouth images or panoramic image D6075, D6076, D6077, D6080, D6081, D6085, D6090, D6091, D6092, D6093, D6059, D6060, D6061, D6062, required. D6094, D6095, D6100, D6101, D6102, D6103, D6104, D6110, D6111, D6112, D6063, D6064, D6065, D6066, Bone graft at time of implant placement: periapical pre-op D6113, D6114, D6115, D6116, D6117, D6190, D6194, D6199 D6067, D6068, D6069, D6070, radiograph, request full mouth images or panoramic image if A dental implant is an artificial tooth root that is placed into the jaw to hold a D6071, D6072, D6073, D6074, needed. replacement tooth or bridge. Adequate bone in the jaw is needed to support the D6075, D6076, D6077, D6080, implant, and recipients should have healthy gum tissues that are free of D6081, D6085, D6090, D6091, periodontal disease. For most plans, implants are not covered, but for those D6092, D6093, D6094, D6095, plans that do have coverage, the following identify guidelines for implant D6100, D6101, D6102, D6103, placement, subsequent implant supported restorations, and any necessary D6104, D6110, D6111, D6112, treatment of peri-implant defects: D6113, D6114, D6115, D6116, D6117, D6190, D6194, D6199 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:
35 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Implants Location of tooth/teeth; (continued) Bone quality/quantity; Periodontal status; Restorability; Patient cost; Patient age (implants not appropriate for patients under age 15); Patients undergoing strong chemotherapy; Myocardial infarction: within 6 months of an attack; Anticoagulant therapy; Severe neuropsychiatric disease, mental disability, and narcotic drug addicts ; Severe blood diseases; Systemic Risk Factors: o Smoking o Diabetes o Hypertension o Decreased estrogen levels in postmenopausal women o Use of IV bisphosphonates
Refer to coverage guideline: Implants (DCG007.03)
FIXED PROSTHETICS Fixed Prosthodontics Documentation Criteria for codes D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6205, D6210, D6211, D6212, Radiographic images: full periapical set with bitewings. Panoramic with D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6549, D6600, D6601, D6214, D6240, D6241, D6242, bitewings and PA of area (not preferable/panoramic needs to be high D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6245, D6250, D6251, D6252, quality) of involved teeth, as well as contralateral and opposing sites. D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6253, D6545, D6548, D6549, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6600, D6601, D6602, D6603, Pontic must be at least 2/3 the size of the tooth being replaced. D6792, D6793, D6794, D6920, D6930, D6940, D6950, D6980, D6985, D6999 D6604, D6605, D6606, D6607, Fixed Partial Dentures (FPD) D6608, D6609, D6610, D6611, Repair: Reviewer may request narrative if needed. D6612, D6613, D6614, D6615, Fixed partial dentures are indicated for the following: D6624, D6634, D6710, D6720, Replacement: Reviewer may request narrative if needed. For the replacement of missing teeth in which the retainer teeth have a D6721, D6722, D6740, D6750, favorable long term prognosis D6751, D6752, D6780, D6781, For the replacement of one to two missing posterior teeth in a tooth D6782, D6783, D6790, D6791, bounded space
D6792, D6793, D6794, D6920, In addition to the above, the following applies: D6930, D6940, D6950, D6980, Resin bonded appliances are indicated for the replacement of one missing D6985, D6999 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
36 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Fixed Prosthodontics disease or an unfavorable crown: root ratio (continued) When teeth intended as retainers have inadequate remaining tooth structure For the primary dentition When an arch or dentition is deemed terminal When tooth to be used as a retainer has tipped or drifted into edentulous space, rendering seating of retainer difficult or impractical
In addition to the above, the following applies: Cantilever FPD is not indicated in an area with significant malocclusion, heavy occlusion or parafunctional habits (e.g., nail biting, bruxism, clenching) Resin bonded FPD is not indicated when there is a pontic width discrepancy, in patients with parafunctional habits (e.g., nail biting, bruxism, clenching), in an area with significant malocclusion or heavy occlusion Resin bonded FPD is not indicated as a temporary prosthesis
Provisional Fixed Partial Dentures
Provisional Fixed Partial Dentures are indicated for the following: When the prognosis of a permanent fixed partial denture is questionable due to periodontal involvement, endodontic pathology or patient compliance To replace a lost tooth in young patients to allow maturity of the dentition and jaws before constructing a definitive fixed prosthetic appliance When a systemic medical condition prohibits the placement of a definitive fixed prosthetic appliance
Provisional Fixed Partial Dentures are not indicated for the following: As a definitive fixed partial denture unless indicated by above criteria
Fixed Partial Denture Repair (Necessitated by Restorative Material Failure) Fixed partial denture repair is indicated for the following: When the appliance to be repaired is functional and has a favorable long term prognosis
Fixed partial denture repair is not indicated for the following:
For porcelain fracture if margins are intact and functional area not involved
Precision Attachments 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
37 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Fixed Prosthodontics placement (continued) When the prognosis of an abutment is uncertain
Connector Bar Connector bars are indicated to brace individual abutment teeth with considerable coronal length for enhances stabilization of removable partial dentures, complete dentures and overdentures.
Stress Breaker (a Non-Rigid Connector)
Stress Breakers are indicated for the following:
When it is not possible to prepare two abutments with a common path of
placement
When the prognosis of an abutment is uncertain Control of loading and rotational forces For the redistribution of occlusal forces
Coverage Limitations and Exclusions
Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement Limited to repairs or adjustments performed more than 12 months after the initial insertion; limited to 1 per consecutive 6 months Limited to 1 time per tooth per consecutive 60 months Stress breakers, and connector bars are not covered Clinical situations that can be effectively treated by a less costly alternative procedure will be assigned a benefit based on the least costly procedure Any Dental Procedure performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance) Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error (this type of replacement is the responsibility of the Dentist; if replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement) Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction Attachments to conventional removable prostheses or fixed bridgework (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
38 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Fixed Prosthodontics dimension of occlusion (VDO) (continued) Placement of fixed partial dentures solely for the purpose of achieving periodontal stability
Refer to coverage guideline: Fixed Prosthodontics (DCG017.01)
ORAL SURGERY Non-Surgical Extractions Documentation Criteria for codes D7111, D7140 D7111, D7140 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 Documentation Criteria for codes D7210, D7250 Teeth and Retained Roots Dated and labeled radiographic images including panoramic image or D7210, D7250 periapicals usually taken within one year and appropriate to document Surgical Extraction of an Erupted Tooth the case. Surgical extraction of an erupted tooth is indicated for any of the following: No clinical crown is visible in the mouth; Panoramic, periapicals, or tomography for third molar extractions is There is insufficient remaining clinical crown to allow a non-surgical indicated by the clinical presentation. extraction; The fracture of a tooth or roots during a non-surgical extraction procedure; Treatment notes if radiographic information not conclusive. 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;
39 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Extraction of Erupted In the presence of periapical lesions; Teeth and Retained Roots For maxillary posterior teeth whose roots extend into the maxillary sinus; (continued) When severe crowding or ectopic position of the tooth is present; When tooth has been crowned or been treated endodontically; Other conditions as deemed necessary by a licensed dentist.
Surgical extraction is not proven or indicated for the following: When a conservative non-surgical procedure is possible; When the Indications for Coverage criteria above are not met.
Surgical Removal of Residual Tooth Roots Surgical removal of residual tooth roots is indicated for the following: When tooth roots, or fragments of tooth roots remain in the bone following a previous incomplete tooth extraction; Extreme tooth decay resulting in the destruction of the dentition to the extent that only root tips remain.
Refer to coverage guideline: Surgical Extraction of Erupted Teeth and Retained Roots (DCG005.02)
Surgical Extraction of Impacted Documentation Criteria for codes D7220, D7230, D7240, D7241, D7251 Teeth Dated and labeled radiographic images including panoramic image or The prophylactic extraction of impacted third molars that are asymptomatic and D7220, D7230, D7240, D7241, periapicals usually taken within one year and appropriate to document disease free remains highly controversial. In the absence of strong clinical D7251 the case. evidence to support or refute prophylactic extractions of asymptomatic and
Panoramic, periapicals, or tomography for third molar extractions is disease free third molars, the following coverage rationale has been adopted.
indicated by the clinical presentation. Surgical Extraction of Soft Tissue Impacted Teeth Narrative: Surgical extraction of soft tissue impacted teeth is indicated for the following: If reason for extraction is not apparent Extraction of premolars, third molars and other teeth as deemed necessary For bicuspid with no apparent pathology, to determine if for the facilitation of orthodontic treatment when this service is benefitted; orthodontic extractions For a tooth/teeth in the line of a jaw fracture or complicating fracture D7241, full bony impaction with complications management;
As part of comprehensive treatment in orthognathic surgery; Cyst removal (D7450, 7451, 7460, 7461): Documentation of special Moderate to severe or acute pain, or recurrent episodes that do not services; size greater than 1.25mm and/or unrelated to tooth removal; respond to conservative treatment (i.e. pain medication or antibiotics); operative notes and pathology report. Non-restorable caries;
Treatment notes if radiographic information not conclusive. 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; 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;
40 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Extraction of Impacted Ectopic position; Teeth For purposes of prosthetic rehabilitation (partial dentures and complete (continued) 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;
As part of comprehensive treatment in orthognathic surgery;
Moderate to severe or acute pain, or recurrent episodes that do not
respond to conservative treatment (i.e. pain medication or antibiotics);
Non-restorable caries; Management of, or limiting the progression of periodontal disease; In the case of acute/chronic infection (abscess, cellulitis, pericoronitis); Pulpal exposure; 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 partially bony 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 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
41 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Extraction of Impacted benefitted; Teeth Tooth/teeth in the line of a jaw fracture or complicating fracture (continued) 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 progression of periodontal disease; In the case of acute/chronic infection (abscess, cellulitis, pericoronitis); 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: 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 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 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 progression of periodontal disease; In the case of acute/chronic infection (abscess, cellulitis, pericoronitis); Pulpal exposure; Periapical lesion;
Internal resorption;
42 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Surgical Extraction of Impacted As a prophylactic procedure for an underlying medical condition (e.g. organ Teeth transplants, alloplastic implants, chemotherapy, radiation therapy prior to (continued) 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: 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.
Coronectomy Coronectomy is indicated for the following: When clinical criteria for extraction of impacted teeth is met. When the removal of complete tooth would likely result in damage to the neurovascular bundle.
Coronectomy is not indicated for the following: For routine extractions; When clinical criteria for extraction of impacted teeth is not met; For prophylactic reasons.
Refer to clinical policy: Surgical Extraction of Impacted Teeth (DCP006.02)
Oral Surgery: Alveoloplasty and Documentation Criteria for codes D7310, D7311, D7320, D7321, D7340, D7350 Vestibuloplasty Dated and labeled radiographic images including panoramic or D7310, D7311, D7320, D7321, periapicals usually taken within one year and appropriate to document Alveoloplasty D7340, D7350 the case as applicable. Alveoloplasty is indicated for the following: For bone recontouring and smoothing as part of the tooth extraction Treatment notes if radiographic information not conclusive or CPT codes: 40840, 40842, 40843, process radiographs are not applicable. 40844, 40845, 40899, 41874 For bone recontouring and smoothing as a standalone procedure prior to fixed or removable prosthetic construction To provide stability for implant placement For debulking procedures for pathologic conditions of the bone
Alveoloplasty is not indicated for the following: When performed solely for cosmetic/aesthetic reasons When removing bone would harm vital structures When there is diminished volume or atypical architecture of bone For patients who have undergone radiation therapy to the head and neck
43 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Oral Surgery: Alveoloplasty and For patients with unmanaged medical conditions that result in excessive or Vestibuloplasty uncontrolled bleeding, reduced resistance to infection, or poor healing (continued) response
Vestibuloplasty Vestibuloplasty is indicated for the following: Ridge extension, or lowering or altering submucous displacing attachments prior to prosthetic construction To complement and complete osseous procedure when reconstructing edentulous bone To correct inadequate or inappropriate soft tissue drape where a resection has been previously performed and prosthetic restoration requires improvement For overall stability of a dental implant and the maintenance of bone health around an implant
Vestibuloplasty is not indicated for the following: When performed solely for cosmetic/aesthetic reasons For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response When there is minimal alveolar ridge height For patients who have undergone radiation therapy to the head and neck
Coverage Limitations and Exclusions Alveoloplasty and vestibuloplasty procedures are subject to frequency limitations. Please refer to the member specific benefit plan document. Oral surgery procedures may be covered under the member’s medical benefit when determined to be medical in nature. Refer to the member’s Certificate of Coverage and/or member specific benefit plan document for coverage guidelines.
Refer to coverage guideline: Oral Surgery: Alveoloplasty and Vestibuloplasty (DCG028.01)
Oral Surgery: Miscellaneous Documentation Criteria for codes D7260, D7261, D7270, D7272, D7290, D7921, D7951, D7952, Surgical Procedures Dated and labeled radiographic images including panoramic or D7953, D7999 D7260, D7261, D7270, D7272, periapicals usually taken within one year and appropriate to document Oroantral Fistula Closure D7290, D7921, D7951, D7952, the case as applicable. D7953, D7999 Oroantral fistula closure is indicated for the closure of an oroantral fistula not Treatment notes if radiographic information not conclusive or related to cleft palate repair surgery CPT codes: 21210, 21215, 30580, radiographs are not applicable. 41899 Primary Closure of a Sinus Perforation Primary closure of a sinus perforation is generally indicated for large (> 2mm) defects resulting from routine tooth extraction, retrieval of root tips, or implant placement.
44 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Oral Surgery: Miscellaneous Primary closure of a sinus perforation is generally not indicated for defects less Surgical Procedures than 2mm in diameter. (continued) Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced
Tooth
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth are indicated for the following: Subluxation injuries to permanent teeth Lateral luxation injuries of primary and permanent teeth Extrusion injuries of <3mm in an immature developing primary tooth Avulsion of permanent teeth
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced
tooth are not indicated for the following, and extraction is recommended:
For primary teeth if injury is severe or tooth is near exfoliation
For intrusion injuries to primary teeth when the apex is displaced toward
the permanent tooth germ
For extrusion injuries to primary teeth > 3mm, or primary tooth is fully formed, mobile, near exfoliation, or the child is unable to cope with an emergency situation For avulsion of primary teeth When a tooth has been out of the oral cavity for 60 minutes or more For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response Lack of alveolar integrity
Surgical Repositioning of Teeth
Surgical repositioning of teeth is indicated for the following:
For the treatment of intrusion injuries to permanent teeth
Extrusion of teeth with crown/root fractures to prepare for restoration of permanent teeth
Surgical repositioning of teeth is not indicated for the treatment of injuries to primary teeth.
Bone Replacement Graft for Ridge Preservation Bone replacement graft for ridge preservation is indicated for the following: When bone has been lost in extraction site, or site of implant removal to prepare for new implant When there has been loss of alveolar ridge needed to support a removable prosthesis or fill space under the pontic of a fixed partial denture
Bone replacement graft for ridge preservation is not indicated for the following:
As a routine procedure to fill extraction sites
For patients with unmanaged medical conditions that result in excessive or
45 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Oral Surgery: Miscellaneous uncontrolled bleeding, reduced resistance to infection, or poor healing Surgical Procedures response (continued) Collection and Application of Autologous Blood Concentrate Product
Evidence in the published scientific literature is inconsistent and does not lend strong support to the clinical utility of using platelet rich plasma (PRP) to augment bone or soft tissue healing for oral surgery applications.
Sinus Augmentation Procedures
Sinus augmentation or sinus lift is a procedure associated with implant
placement. For most plans, implants are not covered, but for those plans that do
have coverage, the following identify guidelines for this procedure.
Sinus augmentation is indicated for the following: To prevent the displacement of dental implants in the posterior maxilla due to pneumatization of the maxillary sinus When there is poor bone quality that prevents adequate initial stability during implant placement
Sinus augmentation is not indicated for the following: Conditions blocking the ventilation and clearance of the maxillary sinus. (Many of these causes are reversible and should be treated before the sinus lift procedure, and include, but are not limited to: history of smoking; allergic rhinitis; previous nasal surgery or trauma; a history of chronic and/or recurrent sinusitis; chronic nasal obstruction and/or rhinorrhea; chronic hyposmia and/or hypogeusia; previous treatment for head and neck neoplasms; and comorbidities, particularly systemic diseases and pathologies that interfere with mucosal composition or ciliary movements) For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response
Coverage Limitations and Exclusions
Any dental procedure performed solely for cosmetic/aesthetic reasons.
(Cosmetic procedures are those procedures that improve physical
appearance.)
Reconstructive surgery, regardless of whether or not the surgery is
incidental to a dental disease, injury, or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved
part of the body.
Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure.
46 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Oral Surgery: Miscellaneous Surgical Procedures Refer to clinical policy: Oral Surgery: Miscellaneous Surgical Procedures (continued) (DCP027.01)
Oral Surgery: Non-Pathologic Documentation Criteria for codes D7291, D7471, D7472, D7473, D7960, D7963, D7970, D7971, Excisional Procedures Dated and labeled radiographic images including panoramic or D7972, D7999 D7291, D7471, D7472, D7473, periapicals usually taken within one year and appropriate to document Frenulectomy D7960, D7963, D7970, D7971, the case as applicable. D7972, D7999 Frenulectomy is indicated for the following: Treatment notes if radiographic information not conclusive or When attachment of the frenum is coronal to the mucogingival junction, radiographs are not applicable. within the free gingiva, or in the papilla causing a diastema, gingival CPT codes: 21031, 21032, 40806, 40819, 41010, 41115, 41520, Frenectomy or frenotomy (D7960) and Frenuloplasty (D7963) recession or stripping 41821, 41822, 41828 Narrative if applicable When the position attachment of the frenum is interfering with proper oral hygiene Excision of periocoronal gingival (D7971) and Surgical reduction of Prior to the construction of a removable denture replacing teeth in the area fibrous tuberosity (D7972) of frenum attachment Narrative and radiographic images to document the clinical need When there is a functional disturbance, including, but not limited to mastication, swallowing and speech For ankyloglossia or severe papillary penetrating attachment of maxillary labial frenum in newborns when there is interference with feeding
Frenuloplasty
Frenuloplasty is indicated for the following: When attachment of the frenum is coronal to the mucogingival junction, within the free gingiva, or in the papilla causing a diastema, gingival recession or stripping and its depth or width requires surgical restoration of physiologic function When the position attachment of the frenum is interfering with proper oral hygiene Prior to the construction of a removable denture replacing teeth in the area of aberrant frenal attachment When there is a functional disturbance, including, but not limited to mastication, swallowing and speech For ankyloglossia or severe papillary penetrating attachment of maxillary labial frenum in newborns when there is interference with feeding
Excision of Hyperplastic Tissue – Per Arch
Excision of hyperplastic tissue is indicated when the presence of hyperplastic tissue (fibrous tuberosities, loose ridges, folds of redundant tissues in vestibule or floor of mouth, and palatal papillomatosis) interferes with the fit of a partial or complete denture (existing or new).
Excision of Pericoronal Gingiva Excision of pericoronal gingiva is indicated for the following:
For recurrent infections of the operculum around impacted or partially
47 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Oral Surgery: Non-Pathologic erupted lower third molars Excisional Procedures When an erupted maxillary third molar is traumatizing soft tissue around (continued) opposing tooth When the presence interferes with the fit of a partial or complete denture
Surgical Reduction of Fibrous Tuberosity Surgical reduction of fibrous tuberosity is indicated when the presence interferes with the fit of a partial or complete denture.
Transseptal Fiberotomy/Supra Crestal Fiberotomy, By Report
Transseptal fiberotomy/supra crestal fiberotomy is indicated to reduce
rotational relapse of individual teeth following orthodontic treatment.
Removal of Lateral Exostosis (Maxilla or Mandible) Removal of lateral exostosis is indicated for the following: If a partial or complete denture cannot be adapted successfully to the alveolar ridge When causing soft tissue trauma with existing removable appliances
For unusually large exostoses that are prone to recurrent traumatic injury
Removal of lateral exostosis is not indicated for patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response.
Removal of Torus Palatinus
Removal of torus palatinus is indicated for the following: When a dental prosthesis will cover the palate and a large palatal torus will interfere with fit For unusually large tori that are prone to recurrent traumatic injury When there is a functional disturbance, including, but not limited to mastication, swallowing and speech
Removal of torus palatinus is not indicated for patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response.
Removal of Torus Mandibularis Removal of torus mandibularis is indicated for the following: If a mandibular partial or complete denture cannot be adapted successfully to the alveolar ridge For unusually large tori that are prone to recurrent traumatic injury When the tori is so large that it interferes with normal tongue movement When there is a functional disturbance, including, but not limited to mastication, swallowing and speech
Removal of torus mandibularis is not indicated for patients with unmanaged
48 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Oral Surgery: Non-Pathologic medical conditions that result in excessive or uncontrolled bleeding, reduced Excisional Procedures resistance to infection, or poor healing response. (continued) Coverage Limitations and Exclusions Frenulectomy and frenuloplasty are considered incidental if performed on the same day, same area as gingivectomy/gingivoplasty, alveoloplasty and vestibuloplasty surgical procedures.
The following are excluded from coverage: Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body. Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Refer to coverage guideline: Oral Surgery: Non-Pathologic Excisional Procedures (DCG029.01)
Oral Surgery: Orthodontic Related Documentation Criteria for codes D7280, D7282, D7283, D7292, D7293, D7294, D7997 Procedures Dated and labeled radiographic images including panoramic or For plans that have comprehensive orthodontic coverage, the following identify D7280, D7282, D7283, D7292, periapicals usually taken within one year and appropriate to document guidelines for the use of related oral surgery procedures. D7293, D7294, D7997 the case as applicable. Surgical Placement of Temporary Anchorage Device (Not Related to Treatment notes if radiographic information not conclusive or CPT code: 41899 Distraction Osteogenesis or Orthognathic Surgery) radiographs are not applicable. The surgical placement of temporary anchorage devices are used in conjunction with orthodontic treatment and are indicated for patients aged 12 and over for the following: Intrusion of maxillary teeth Molar distalization
Canine retraction and intrusion retraction mechanics
Correction of anterior open bite and deep overbite
Correction of canted occlusal planes
The surgical placement of a temporary anchorage device is not indicated for the following: Patients with a known allergy to titanium alloy Patients with a history of heavy tobacco use Patients with advanced osteoporosis Patients with uncontrolled immune or metabolic bone disorders Patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response Patients with poor oral hygiene In areas with poor quality cortical bone density and volume
For ankylosed teeth
49 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Oral Surgery: Orthodontic Related Surgical Access of Unerupted Tooth Procedures (continued) Surgical access of unerupted tooth is indicated for the following: When a tooth is in such a position that it is unable to erupt into a functional position within the dental arch Tooth developing normally and appears to be in a good position to be moved into position orthodontically, or spontaneously Only for labially impacted teeth when there will be 2-3 mm of gingival cuff present after eruption
Surgical access of unerupted tooth is not indicated for the following: Teeth with abnormal development or positioning For supernumerary teeth and third molars For primary teeth When surgical access of impacted tooth would threaten vital structures Patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response
Placement of Device to Facilitate Eruption of Impacted Tooth This is the placement of an orthodontic bracket, band or other device and attached with a chain, on an unerupted tooth, after surgical exposure, to aid in its eruption. This procedure is done following the surgical access of an unerupted tooth.
Mobilization of Erupted or Malpositioned Tooth to Aid Eruption Mobilization of erupted or malpositioned tooth to aid eruption is indicated for the treatment of ankylosed permanent teeth. Mobilization of erupted or malpositioned tooth to aid eruption is not indicated for primary teeth.
Refer to clinical policy: Oral Surgery: Orthodontic Related Procedures (DCP032.02)
Excision of benign lesions Narrative of procedure D7411, D7412
Removal of benign odontogenic Documentation Criteria cyst or tumor Dated and labeled radiographic images including panoramic or Cyst is not attached to or removed with tooth. D7450, D7451 periapicals usually taken within one year and appropriate to document Size, color or consistency indicates need for pathology examination. the case as applicable.
Treatment notes if radiographic information not conclusive or radiographs are not applicable.
50 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Removal of benign non- Documentation Criteria odontogenic cyst or tumor Dated and labeled radiographic images including panoramic or Presence of hard, attached or freely movable raised or erythematous lesion. D7460, D7461 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.
Incision and drainage Documentation Criteria D7510, D7520 Dated and labeled radiographic images including panoramic or Not usually benefited when at same time as extraction. 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.
ORTHODONTICS Medically Necessary Orthodontic All of the following documentation must be received: Criteria for codes D8050, D8060, D8070, D8080, D8090, D8220, D8660, D8670, Treatment Panoramic imaging; D8680, D8690, D8691, D8999 D8050, D8060, D8070, D8080, Cephalometric imaging; Indications for Coverage D8090, D8220, D8660, D8670, 5-7 intraoral photographs; Orthodontic treatment is a covered dental service and medically necessary D8680, D8690, D8691, D8999 Other forms as required by the state. when the following criteria have been met: All services must be approved by the plan; and The member is under the age 19 (through age 18, unless the benefit plan document indicates a different age); and Services are related to one of the following conditions: o Cleft lip and/or cleft palate; o Crouzon’s Syndrome; o Treacher-Collins Syndrome; o Pierre-Robin Syndrome o Hemi-facial atrophy; o Hemi-facial hypertrophy o Severe craniofacial deformities that result in a physically handicapping malocclusion; OR o Other clinical criteria based on state specific language.
Required Documentation
All of the following documentation must be received: Panoramic imaging; Cephalometric imaging; 5-7 intraoral photographs; Other forms as required by the state.
Coverage Limitations and Exclusions
Orthodontic services that do not meet the criteria listed above.
51 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Medically Necessary Orthodontic Orthodontic services that are specifically excluded. Treatment Orthodontic services for crowded dentitions (crooked teeth), excessive (continued) spacing between teeth, temporomandibular joint (TMJ) conditions and/or horizontal/vertical discrepancies (overjet/overbite).
Refer to coverage guideline: Medically Necessary Orthodontic Treatment (DCG003.02)
ANESTHESIA SERVICES General Anesthesia and Conscious Documentation: Time Recommendations & Nitrous/Extraction Criteria for codes D9210, D9211, D9212, D9215, D9219, D9223, D9230, D9243, Sedation Recommendations D9248 Provider notes including: duration, type of anesthetic, dosage. Sedation for dentistry is proven to help decrease anxiety, diminish fear and D9210, D9211, D9212, D9215, increase tolerance for dental procedures. It is necessary for the safe and D9219, D9223, D9230, D9243, If restorative/surgical procedures and age do not meet criteria: Narrative comprehensive dental treatment of patients that meet selection criteria. Local D9248 documenting medical necessity, including description of underlying anesthesia is not covered in conjunction with operative or surgical procedures. medical problem; description of behavior problem and age of patient. Nerve blocks are not addressed in this coverage guideline; please refer to
appropriate medical policy. Anesthesia time is defined as the period between the beginning of the administration of the agent and the time that the anesthetist is no Local Anesthesia is considered an inclusive component of any dental procedure longer in personal attendance. 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. General Time Guidelines for IV sedation & General Anesthesia: Nitrous Oxide 3-4 Teeth D7230, D7240 1.5 hours Nitrous oxide is proven effective for sedation in adults and children for the 1-2 Teeth D7230, D7240 45 min following:
Ineffective local anesthesia 3-4 Teeth D7210, D7220 1 hour Anxiety 1-2 Teeth D7210, D7220 45 min Special needs patients
Lengthy procedures for special needs patients and children Full Mouth Extractions or + Teeth D7111, D7140 1.5 hours 3-6 Teeth D7111, D7140 45 min. Behaviorally challenged or uncooperative patients Management of a severe gag reflex 1-3 Teeth D7111, D7140 30 min. Nitrous oxide is contraindicated for patients with but not limited to the Nitrous Oxide: Extraction Coverage Recommendations: following: More than one soft tissue impacted tooth D7220 Severe underlying medical conditions ( e.g., severe chronic obstructive One or more partial or full bony D7230, D7240 pulmonary diseases, congestive heart failure, sickle cell anemia, acute otitis More than six simple extractions D7140 media, recent tympanic membrane graft, acute severe head injury) Multiple surgical extractions D7210 Severe emotional disturbances Severe behavioral disorders Drug related dependencies
Pregnancy – first trimester
Treatment with bleomycin sulfate (injection used in cancer patients)
Methlenetetrahydropfolate reductase deficiency
52 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE General Anesthesia and Conscious Vitamin B12 deficiency Sedation (continued) Coverage Limitations and Exclusions Limited to once per day Excluded when reported on same date of service as IV sedation, non-IV sedation or general anesthesia Patient convenience
Intravenous (IV) Sedation
IV sedation is proven and effective for the following: Anxiety/fear Pain control Oral surgery Medically compromised patients or those with special needs
IV sedation is contraindicated for patients with but not limited to the following:
Allergy to IV medications
Certain prescribed pharmaceuticals
In any patient where IV sedation has been considered unsafe
Coverage Limitations and Exclusions Limited to once per day
Non-IV Sedation Non-IV sedation is proven and effective for the following: Anxiety Uncooperative or unmanageable patient
Non-IV sedation is contraindicated for patients with but not limited to the following: Patient or dentist convenience
Coverage Limitations and Exclusions
Not allowed on same day as general anesthesia
Nerve Blocks Nerve blocks are not covered for dental services. Please refer to appropriate Medical Policy for specifics regarding coverage for nerve blocks.
General Anesthesia General anesthesia is proven and effective. The decision to administer should be made on an individual patient basis and should be limited to: Clinical procedures of extensiveness or complexity or situations that require more than a local anesthetic Minimum of 2 failed attempts at other office anesthetic techniques with the failures documented
53 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE General Anesthesia and Conscious Uncooperative or Unmanageable Patient Sedation Physical, Cognitive or Developmental Disabilities (continued) Significant underlying medical condition Allergy or sensitivity to local anesthesia Lengthy restoration procedures for pediatric patients A child who has resisted all other conventional management procedures Patients with extreme anxiety or fear
General anesthesia is contraindicated for patients with but not limited to the following: Patients with predisposing medical and/or physical conditions that potentially make general anesthesia unsafe Cooperative patients with minimal dental needs Choice of an alternative option for treatment Language or cultural barriers Parental objection
Refer to coverage guideline: General Anesthesia Conscious Sedation Services (DCG016.02)
ADJUNCTIVE SERVICES Palliative treatment Criteria D9110 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 Radiographic image required. Code for both preparing teeth for D9120 extraction and for retaining part of fixed prosthesis.
Consultation Criteria D9310 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 Documentation D9410–D9450 Narrative from member record.
Therapeutic Parenteral Drug Criteria for codes D9610, D9612, D9630 Administration and In-Office Therapeutic Parenteral Drug Administration (Single or Two or More Dispensing of Medications Administrations) D9610, D9612, D9630 Therapeutic parenteral drug administration may be indicated to enhance healing of surgical procedures, or reduce pain and/or risk of infection. Medications may include antibiotics, steroids or anti-inflammatory medications when administered as a separate IV or intramuscular injection.
54 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Therapeutic Parenteral Drug Other Drugs and/or Medicaments (By Report) Administration and In-Office Dispensing of Medications Includes, but is not limited to oral antibiotics, oral analgesics, and topical (continued) fluoride dispensed in the office for home use; does not include writing prescriptions.
Coverage Limitations and Exclusions Therapeutic parenteral drug administration is inclusive when administered intravenously (IV) during IV sedation and general anesthesia. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
Refer to clinical policy: Therapeutic Parenteral Drug Administration and In-Office Dispensing of Medications (DCP033.01)
Application of Medicaments and Documentation Criteria for codes D1354, D9910, D9911 Desensitizing Resins Narrative with explanation of symptoms. Application of Desensitizing Medicament or Resin D1354, D9910, D9911 Application of desensitizing medicament or resin is indicated for the following: For teeth with sensitivity that does not resolve with an over the counter desensitizing dentifrice
Application of desensitizing medicament or resin is not indicated for the following: Placement on teeth with erosion, recession, cervical abrasion or abfraction when asymptomatic
As a base or liner prior to restoration placement
Interim Caries Arresting Medicament Application Interim caries arresting medicament application is indicted for the following: As conservative treatment for active, non-symptomatic carious lesions Patients with extreme risk of caries (such as xerostomia or severe early childhood caries) Patients that cannot tolerate standard treatment for medical or psychological reasons. These may be included but are not limited to the following: o An extremely uncooperative child o Frail elderly patients o Patients with severe cognitive or physical disability o Patients that are immunocompromised Patients with multiple lesions that cannot be treated in one office visit Recurrent caries that are difficult to treat
Patients without access to dental care
Interim caries arresting medicament application is not indicted for the following: Patients with a silver allergy Pregnant women
55 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Application of Medicaments and During the first six months of breast feeding Desensitizing Resins (continued) Coverage Limitations and Exclusions Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure. These codes are for medicaments and resins, and not for the use of lasers for desensitization.
Refer to clinical policy: Application of Medicaments and Desensitizing Resins (DCP034.01)
Behavior management Criteria D9920 Appropriate in cases where substantial time and effort is expended in allaying the patient’s fear and apprehension. Narrative required.
Treatment of complication Criteria D9930 Narrative and/or radiographic images required. Examples: dry socket, extensive hemorrhage.
Occlusal guard Documentation/Criteria Criteria for codes D7880, D7881, D9940, D9941, D9942, D9943, D9950, D9951, D7880, D7881, D9940, D9941, Provider narrative which includes a history of bruxism, grinding, &/or D9952 D9942, D9943, D9950, D9951, clenching resulting in excessive wear. Should include occlusal analysis D9952 and symptoms. Occlusal Guards Occlusal guards are indicated for the following: Bruxism or clenching either as a nocturnal parasomnia or during waking hours, resulting in excessive wear or fractures of natural teeth or restorations To protect natural teeth when the opposing dentition has the potential to cause enamel wear such as the presence of porcelain or ceramic restorations When nocturnal clenching or bruxism results in tooth sensitivity
Occlusal guards are not indicated for the following: For treatment of temporomandibular disorders or myofacial pain disfunction As an athletic mouthguard As an appliance intended for orthodontic tooth movement
Coverage Limitations and Exclusions
Exclude when used for sports-related activities Prefabricated occlusal guards are excluded Limited to once per 36 months
56 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Occlusal guard Repair and relines are limited to once per 12 months (continued) Adjustments are inclusive within the first 12 months and thereafter allowed once every 6 months
Fabrication of Athletic Mouthguard Athletic mouthguards are intended to protect the dentition during athletic activities and not a covered service.
Occlusal Orthotic Devices Occlusal orthotic devices are appliances intended for the management of orofacial pain or to reposition or stabilize the jaw for the treatment of temporomandibular disorders (TMD) and not a covered service under the dental plan. TMD and these appliances are considered to be medical in nature and are typically covered under the medical plans. Please see the appropriate medical policy for information.
Refer to coverage guideline: Occlusal Guards (DCG019.01)
Enamel Microabrasion Documentation Criteria D9970 Narrative, intraoral photos helpful. Discolored surface enamel from altered mineralization/decalcification. Per visit basis.
Odontoplasty Documentation Criteria D9971 Narrative, intraoral photos helpful. 1-2 teeth –includes removal of enamel projections.
Bleaching and unspecified report Documentation D9972–D9999 Narrative, intraoral photos, images.
57