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Dental and Oral Surgical Procedures – Oxford Administrative Policy

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Dental and Oral Surgical Procedures – Oxford Administrative Policy UnitedHealthcare® Oxford Administrative Policy Dental and Oral Surgical Procedures Policy Number: DENTAL 002.33 T2 Effective Date: April 1, 2021 Instructions for Use Table of Contents Page Related Policies Purpose .......................................................................................... 1 • Orthognathic (Jaw) Surgery Prior Authorization Requirements ................................................ 1 • Temporomandibular Joint Disorders Policy .............................................................................................. 1 Procedures and Responsibilities .................................................. 2 Applicable Codes .......................................................................... 3 References ..................................................................................... 7 Policy History/Revision Information ............................................. 8 Instructions for Use ....................................................................... 8 Purpose The purpose of this document is to outline the circumstances in which Oxford will reimburse dental or oral surgical services and related anesthesia. Prior Authorization Requirements Prior authorization is required in all sites of service. Notes: Participating providers in the office setting: Prior authorization is required for services performed in the office of a participating provider. Non-participating/out-of-network providers in the office setting: Prior authorization is not required but is encouraged for out-of-network services. If prior authorization is not obtained, Oxford will review for out-of-network benefits and medical necessity after the service is rendered. Specialty review of all dental and oral surgical services is required when services are to be rendered by practitioners of the following specialties: o Endodontics o General Dentistry o Oral Surgery o Oral/Maxillofacial Surgery o Orthodontics o Pediatric Dentistry o Periodontics Policy Oxford will cover certain oral surgical and dental procedures when determined to be medical in nature. In addition, under certain circumstances, coverage for anesthesia services in conjunction with dental or oral surgical services may be approved. Dental and Oral Surgical Procedures Page 1 of 8 UnitedHealthcare Oxford Administrative Policy Effective 04/01/2021 ©1996-2021, Oxford Health Plans, LLC Procedures and Responsibilities Before using this policy, check the member specific benefit plan document and any federal or state mandates, if applicable. If there is a difference between this policy and the member specific benefit plan document, the member specific benefit plan document will govern. Note: Members enrolled on Essential Health Benefit plans may have coverage for Pediatric Dental. Pediatric Dental coverage may provide additional coverage beyond what is outlined below. Indications for Coverage Coverage for dental and oral surgical procedures may qualify for coverage under a member’s benefit plan when determined to be medical in nature. Dental Services – Accidental Only Coverage may include: • Oral surgical procedures for jaw bones or surrounding tissue and dental services for the repair (not replacement) of sound natural teeth when both of the following are true: o Treatment is needed because of accidental damage. o You receive dental services from a Doctor of Medicine (for NJ plans only), Doctor of Dental Surgery or Doctor of Medical Dentistry. • Dental services for the repair or replacement of sound and natural teeth, maxilla, mandible, and surrounding tissues following accidental injury (not including injuries caused by eating, biting, or chewing or intentional misuse of the teeth) when the following criteria have been met: o Documentation that may be requested: . Accidental injury must be documented. Pre- and post-accident x-rays are required. o Teeth were stable and functional immediately prior to the time of the accident without evidence of decay, periodontal disease, or endodontic pathology. Note: Dental services to repair damage caused by accidental injury must be completed within 12 months of the accident, or if not a Covered Person at the time of the accident, within the first 12 months of coverage under the Policy. Additional Dental Coverage Requirements Connecticut Members Coverage must be provided for general anesthesia, nursing, and related hospital services provided in conjunction with inpatient, outpatient or one-day dental services when the dentist or oral surgeon and the physician determine that the services are medically necessary for the treatment of either of the following types of patient: o A person who is determined by a dentist, in conjunction with a physician who specializes in primary care, to have a dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital or alternate facility. o A person who has a developmental disability, as determined by a physician who specializes in primary care that places the person at serious risk. Coverage will be provided for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders if such processes and appliances are prescribed by a craniofacial team recognized by the American Cleft Palate- Craniofacial Association and are not required for cosmetic surgery. New Jersey Members Coverage must be provided to individuals who are severely disabled or a child age five or under for expenses incurred for: o General anesthesia and hospitalization for dental services; or o A medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are provided. Dental and Oral Surgical Procedures Page 2 of 8 UnitedHealthcare Oxford Administrative Policy Effective 04/01/2021 ©1996-2021, Oxford Health Plans, LLC Oral Surgery Coverage may include: • Oral surgical procedures for the correction of a non-dental physiological condition which results in a severe functional impairment. • Oral surgical procedures for the excision of cysts and tumors requiring pathological examination jaws, cheeks, lips, tongue, roof and floor of the mouth. • Surgical and nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. • Surgical removal of bony impacted teeth.* • Removal of odontogenic cysts or tumors.* • Removal of soft tissue neoplasms of the lips, tongue, palate, floor of mouth, and vestibule (e.g., fibromas, mucocoeles, etc.). *Note: These benefits are limited to specific benefit plans; refer to the member specific benefit plan document and any federal or state mandates, if applicable. Additional Dental and Oral Surgery Coverage Requirements New York Members Oral surgical procedures for jaw bones or surrounding tissue and dental services for the repair (not replacement) of sound natural teeth when both of the following are true: Treatment is needed due to congenital anomaly. Note: A congenital anomaly is defined as a physical developmental defect that is present at the time of birth. Dental services are received from a Doctor of Dental Surgery or Doctor of Medical Dentistry. Note: Dental services for the replacement of sound natural teeth due to accidental injury is covered only when repair is not possible. Coverage Limitations and Exclusions Refer to the member specific benefit plan document and any federal or state mandates, if applicable. • Dental damage that happens as a result of normal activities of daily living (such as biting or chewing) or intentional misuse of the teeth is not considered an accidental injury. Benefits are not available for repairs to teeth that are damaged as a result of such activities. • Removal of cysts related to teeth is not covered. Applicable Codes The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply. CPT Code Description 21015 Radical resection of tumor (e.g., sarcoma), soft tissue of face or scalp; less than 2 cm 21016 Radical resection of tumor (e.g., sarcoma), soft tissue of face or scalp; 2 cm or greater 21025 Excision of bone (e.g., for osteomyelitis or bone abscess); mandible 21026 Excision of bone (e.g., for osteomyelitis or bone abscess); facial bone(s) 21029 Removal by contouring of benign tumor of facial bone (e.g., fibrous dysplasia) 21030 Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage 21031 Excision of torus mandibularis 21032 Excision of maxillary torus palatinus Dental and Oral Surgical Procedures Page 3 of 8 UnitedHealthcare Oxford Administrative Policy Effective 04/01/2021 ©1996-2021, Oxford Health Plans, LLC CPT Code Description 21034 Excision of malignant tumor of maxilla or zygoma 21040 Excision of benign tumor or cyst of mandible, by enucleation and/or curettage 21044 Excision of malignant tumor of mandible; 21045 Excision of malignant tumor of mandible; radical resection Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (e.g., locally aggressive or 21046 destructive lesion[s]) Excision
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