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NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA Revised: 6/1/2016 The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines. PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION DIAGNOSTIC Clinical Oral Evaluations D0120–D0191 Documentation in member record that includes all services performed for the code submitted Pre-Diagnostic Services D0190 screening of a patient D0191 assessment of a patient Documentation in member record that includes all services performed for the code submitted. Diagnostic Imaging Documentation in the member record. Diagnostic, clear, readable images, dated with member name. Image capture with interpretation D0210–D0371 Image Capture only D0380–D0386 Interpretation and Report only D0391–D0395 Criteria for codes D0364–D0368, D0380–D0386, D0391–D0395: Cone beam computed tomography (CBCT) is unproven and not medically necessary for routine dental applications. There is insufficient evidence that CBCT is beneficial for use in routine dental applications. CBCT should not replace traditional dental x-rays as a preliminary diagnostic tool, or for routine dental procedures such as restorations, but be used as an adjunct when the level of detail CBCT is needed to safely render treatment for complex clinical conditions (e.g. oral surgery, implant placement and endodontics). These procedures may have a higher risk of complications without the level of detail CBCT imaging provides. CBCT imaging used for these reasons should be read and interpreted by an appropriately trained professional. In addition, radiation exposure associated with CBCT needs to be weighed against possible benefits, which have not been supported in the published literature. Limited definitive conclusions regarding the clinical role of CBCT can be reached due to the lack of well-designed studies that systematically evaluate diagnostic accuracy and the impact of CBCT on clinical decision making and patient health outcomes. Additional studies are needed to verify that CBCT provides added diagnostic value beyond two-dimensional imaging such as panoramic radiography and conventional computed tomography and to 1 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION determine whether CBCT improves treatment decision making and health outcomes. Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP.002.01) Tests and Examinations D0415–D0470 Provider narrative including clinical reason/diagnosis for test and type of test performed. caries risk assessment D0601–D0603 Oral Pathology Laboratory D0472–D0502 Unspecified diagnostic procedure by report D0999 PREVENTIVE Dental Prophylaxis D1110–D1120 Services performed must be documented in the member record. Topical Fluoride Treatment D1206, D1208 Documentation Age and medical necessity. An adult is generally defined as twelve years or older. Criteria for codes D1206, D1208 Topical Application of Fluoride – Excluding Varnish Topical fluoride treatments in the form of gel, foam and rinses applied as a caries preventive agent in the dental office are benefitted twice per consecutive twelve months for children up to age 15. Patients at low risk of developing caries may not need additional topical fluorides other than over-the-counter fluoridated toothpaste and fluoridated water. Topical Application of Fluoride Varnish Fluoride varnish is indicated for the following: As the preferred caries prevention agent for children under age 6 For head and neck radiation therapy patients Sensitivity that does not resolve with an over-the-counter desensitizing dentifrice For moderate to high caries risk patients with a medical or cognitive impairment that limits cooperation with a tray or rinse delivery method Xerostomia due to systemic disease or medication For patients in active orthodontic treatment For the remineralization of incipient or white spot enamel carious lesions Refer to clinical policy: Topical Fluoride Treatment (DCP018.01) Other Preventive Services D1310–D1330 Documentation/narrative in member record that service was performed and materials supplied to member. 2 PROCEDURE Sealants D1351–D1352 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Sealant: Tooth numbers. Provider responsible for three years for repair or Preventive Resin Restoration: replacement. No decay or restorations – the occlusal surface must be intact. Sealant cannot be done on the same tooth as a preventive resin. Space Maintenance D1510–D1555 Radiographs of the involved arch. For primary dentition only. Should be submitted for primary tooth that has been extracted. All adjustments for 6 months are included. No benefit if permanent tooth is ready to erupt. If bilateral teeth are missing, benefit given for bilateral space maintainer, even if two unilateral space maintainers are requested. RESTORATIVE Direct Restorations: Amalgam Restorations D2140–D2161 Documentation Tooth number and surface. Caries removal documented in member record. Inclusive components: Local anesthesia; tooth prep; liners/bases; restorative material; polishing/sealing; adjustments; tooth etching. Criteria: Primary teeth should not be ready to exfoliate and requests are subject to review based on the age of the patient and the tooth number. Resin-Based Composite Restorations – Direct D2330–D2394 Gold Foil Restorations D2410–D2340 Indirect Restorations: Inlay/Onlay Restorations D2510–D2664 (Inlay/onlays) Crowns – Single Restorations Only D2710–D2799 Documentation Pre-operative x-rays. If endodontic therapy has been performed, a periapical radiographic image clearly showing the apex of the completed treatment is required; otherwise, bitewing x-rays may be sufficient at the discretion of the reviewer. A narrative or photograph may provide additional information, especially for replacement of existing crowns. “Cracked tooth syndrome” requires adequate documentation of extent of fracture, location and how it was diagnosed. Tooth must be symptomatic. Restorations for members under age 15 require statement of medical necessity. Inclusive Local anesthesia; tooth preparation; temporary crown; fitting; cementation; post-op adjustments, impressions; bases. 3 Criteria for codes D2510–D2664, D2710–D2799 Indications for Coverage Five-year longevity should be evident, periodontium must be healthy or have documentation the member has periodontal disease under control for a period of at least 6 months, and no evidence of endodontic pathology or potential endodontic issues on the radiographic image. Coverage includes local anesthetic, impressions, tooth preparation, temporary restoration, fitting, cementation, adjustment and any liners or bases. Crowns Crowns are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Large, >50% of the tooth, defective restoration that can be seen on the radiographic image Fracture of cusps Endodontically treated teeth, unless minimal access opening on anterior tooth Documentation that a direct restoration is not possible Crown/root ratio must be favorable PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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 of decay For molars exhibiting bone loss with a class III furcation involvement Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable Fracture of porcelain not involving the margin or a functional ridge is not sufficient for replacement Onlays Onlays are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Large, >50% of the tooth, defective restoration that can be seen on the radiographic image Fracture of cusps Endodontically treated teeth, unless minimal access opening on anterior tooth Documentation that a direct restoration is not possible Crown/root ratio must be favorable Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image 50% bone support with no ligament or root pathology unless patient has 4 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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 sufficient for replacement Inlays Inlays are unproven Inlays have not been proven superior over direct restorations and are alternative benefitted to amalgam restorations. Coverage Limitations and Exclusions Replacement of crowns if damage or breakage was directly related to provider error or patient noncompliance is not covered. Complete oral rehabilitation or reconstruction is not covered. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion is not covered. Refer to coverage guideline: Single Tooth Indirect Restorations (DCG008.01) Other Restorative Services D2910–D2999 Documentation Tooth number Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934 Prefabricated Crowns are indicated for the following: For the restoration of teeth with more than two surfaces affected with carious lesions, or where extensive one or two surface lesions are present. For one and two surface carious lesions in documented high caries risk Porcelain/Ceramic Crown D2929 5 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Stainless Steel Crown D2930, D2931, D2932, D2933, D2934 children. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver has active caries; o White spot lesions or enamel defects; o Visible caries or previous restorations; o Poor oral hygiene; o Sub-optimal systemic fluoride intake; o Frequent exposure to cavity-producing foods and drinks; o Patients with special health care needs; o Low socioeconomic status; o Xerostomia; o More than one interproximal lesion; o Other factors identified by professional literature; Cervical decalcification, and/or developmental defects (hypoplasia, hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.). Interproximal caries extending beyond line angles. Following pulpotomy or pulpectomy. For restoring a primary tooth that is to be used as an abutment for a space maintainer. For the intermediate restoration of fractured teeth. Restoration and protection of teeth exhibiting extensive tooth surface loss due to attrition, abrasion or erosion. In patients with impaired oral hygiene in which the breakdown of intracoronal restorations is likely. When the tooth cannot be effectively isolated for amalgam or composite restorations. Prefabricated Crowns are not indicated for the following: A primary molar that is close to exfoliation, with more than half the roots resorbed. Excessive tooth crown loss resulting in the inability for mechanical retention. Loss of space due to tipping of neighboring teeth into carious defect interfering with the ability to attain proper fit. As a definitive restoration on a permanent tooth. For low and moderate caries risk patients, when a more conservative restoration is indicated. Solely for cosmetic purposes. As a prophylactic measure for teeth with no evidence of pathology. Refer to clinical policy: Prefabricated Crowns (DCP012.01) 6 PROCEDURE Protective restoration D2940 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Documentation Recorded in member chart. Criteria Direct placement of a restorative material to protect tooth and/or tissue form. Used to relieve pain, promote healing, or prevent further deterioration. Covered as a separate procedure only if no other service other than radiographic images and exam were performed on the same tooth on the same day. Not to be used for endodontic access closure, or as a base or liner under a restoration Core buildup D2950 Documentation Bitewing unless tooth has had root canal therapy, then a periapical should be submitted. Note out of numerical order to keep code by crown procedures Criteria Evidence of extensive caries or at least three surfaces of the tooth have severe breakdown. Must be necessary for retention of the crown. Not covered when procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation. Vertical height of clinical crown must be adequate to support a prosthetic crown. Evidence of radiographic decay around an existing restoration and removal of the filling is clinically indicated. Not benefited with post/core. Pin retention per tooth D2951 Documentation in member record One per lifetime per tooth Post and Core D2952, D2953, D2954, D2957 Post-op endodontic radiographic image required showing adequate root canal treatment. Criteria Only for retention or reinforcement when inadequate tooth structure remains for retention or to resist masticatory forces. An anterior tooth with minimal access opening may not require a post/core. There must be sufficient tooth structure to support a crown. No periodontal disease and at least 50% bony support. No benefit for post preparation. Labial Veneer D2960–D2962 Documentation Radiographic image and narrative of medical necessity. Intraoral photo helpful. Criteria May be benefited if the destruction is such that a crown is not recommended but a direct restoration will not suffice. Not covered when strictly cosmetic. Coping D2975 Documentation Bitewing or periapical if tooth has had root canal therapy 7 Criteria Only if insufficient natural tooth structure remains to retain the crown or alignment is a problem. PROCEDURE Repairs necessitated by restorative material failure D2980–D2999 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Documentation Narrative required, radiographic images if indicated ENDODONTICS Endodontic therapy D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348 Documentation Pre and post-operative radiographic image and provider narrative if pathology is not evident on the film. Criteria for codes D3110–D3240, D3310–D3333, D3346–D3348, D3351–D3357 Endodontic codes: D3110–D3240 D3310–D3333 D3346–D3348 D3351–D3357 General documentation requirements Pre and post endodontic periapical radiographic images showing apex of tooth. For retreatment, surgical endodontics, cracked tooth syndrome and other procedures: pre and post-op images, taken within one year and narrative if the reason for treatment is not evident on films. Criteria for codes D3110–D3240, D3310–D3333, D3346–D3348, D3351–D3357 Diagnosis Diagnostic tests used to determine a diagnosis of irreversible pulpitis or periapical pathology must be documented in the record. Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01) Indications for Coverage – Vital Pulp Therapy Direct Pulp Cap Direct pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis All caries has been removed Mechanical exposure of a clinically vital and asymptomatic pulp occurs Bleeding is controlled at the exposure site Exposure permits the capping material to make direct contact with the vital pulp tissue Exposure occurs when the tooth is under dental dam isolation Adequate seal of the coronal restoration can be maintained Patient has been fully informed that endodontic treatment may be indicated in the future Direct Pulp capping is not indicated for the following: A carious exposure in primary teeth Indirect Pulp Cap Indirect pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation No history of subjective pretreatment symptoms Pretreatment radiographs should not show periradicular pathosis Coverage Limitations and Exclusions for Direct and Indirect Pulp Cap Limited to once every 36 months Not to be billed on same day as any definitive restoration Not to be billed when a liner or a base is placed Not to be billed as a liner or base when the likelihood of pulpal exposure is absent Therapeutic Pulpotomy Therapeutic pulpotomy is indicated for the following: 8 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Exposed vital pulps or irreversible pulpitis of primary teeth Any bleeding was controlled within several minutes As an emergency procedure in permanent teeth until root canal treatment can be accomplished As an interim procedure for permanent teeth with immature root formation to allow continued root development In primary teeth, where there is a reasonable period of retention expected (approximately one year) Therapeutic pulpotomy is not indicated for the following: Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor As the first stage of complete root canal therapy Removal of pulp apical to the dentinocemental junction For primary teeth that are near exfoliation or less than 50% of the tooth root remains Coverage Limitations and Exclusions for Therapeutic Pulpotomy Not to be billed on same day as root canal therapy Partial Pulpectomy for Apexogenesis A partial pulpotomy for Apexogenesis is indicated for the following: In a young permanent tooth for a carious pulp exposure When the pulpal bleeding is controlled within several minutes A vital tooth, with a diagnosis of normal pulp or reversible pulpitis Coverage Limitations and Exclusions for Partial Pulpectomy for Apexogenesis Not to be billed on same day as any definitive restoration Not to be billed on same day as a surgical endodontic procedure Apexification/Recalcification Apexification/recalcification is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs. When closure or repair is complete, nonsurgical root canal treatment should be completed: Incomplete apical closure in a permanent tooth root External root resorption or when the possibility of external root resorption exists. Necrotic pulp, irreversible pulpitis or periapical lesion For prevention or arrest of resorption Perforations or root fractures that do not communicate with oral cavity Apexification/recalcification is not indicated for the following: Tooth with a completely closed apex If patient compliance or long term follow up may be questionable 9 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Pulpal Regeneration Pulpal regeneration is indicated for the following and involves two or more separate appointments: Permanent tooth with immature apex Necrotic pulp Pulp space not needed for post/core or final restoration When tooth is not restorable Pulpal regeneration is not indicated for the following: Primary teeth The pulp space would be needed for final restoration Indications for Coverage – Non Vital Pulp Therapy Pulpal Debridement (Pulpectomy) Pulpal Debridement (Pulpectomy) is indicated for the following: For a restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified For the relief of acute pain prior to complete root canal therapy For a primary tooth, where there is a reasonable period of retention expected (approximately one year) Pulpal Debridement (Pulpectomy) is not indicated for the following: Complete root canal therapy of an infected or necrotic tooth For primary teeth that are near exfoliation or less than 50% of the tooth root remains Coverage Limitations and Exclusions for Pulpal Debridement (Pulpectomy) Not to be billed on same day as any definitive restoration Not to be billed on same day as a surgical or non-surgical endodontic procedure Pulpal Therapy (resorbable filling) – Primary Teeth Pulpal Therapy for primary teeth is indicated for the following and includes all appointments need to complete treatment, as well as intra-operative radiographs: For a restorable primary tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified The prognosis for keeping the tooth is up to one year and the tooth root lies in at least 25% bone Pulpal Therapy is not indicated for the following: For primary teeth that are near exfoliation or less than 50% of the tooth root remains For permanent teeth Coverage Limitations and Exclusions for Pulpal Therapy – Primary Teeth 10 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Indicated to age 15 Endodontic Therapy Endodontic Therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs: For a restorable mature, completely developed permanent or primary tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure For teeth with radiographic periapical pathology For primary teeth without a permanent successor Trauma When needed for prosthetic rehabilitation Endodontic Therapy is not indicated for the following: Teeth with a poor long term prognosis Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease Teeth with incompletely formed root apices Coverage Limitations and Exclusions for Endodontic Therapy Not for third molars, unless necessary as bridge abutment with a good prognosis, or if tooth will be in functional occlusion Not covered solely for cosmetic/aesthetic reasons Treatment of root canal obstruction; non-surgical access Treatment of a root canal obstruction is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs: When there is an obstruction of the root canal system, (biological, iatrogenic ledges or post removal) and endodontic retreatment is needed Removal of obstruction is complex and/or requires significant time Treatment of a root canal obstruction is not indicated for the following: When there is no obstruction evident Coverage Limitations and Exclusions for Treatment of root canal obstruction Limited to once per tooth per lifetime Not billable if tooth has a history of incomplete endodontic therapy or internal root repair of perforation defects Incomplete endodontic therapy: inoperable, unrestorable or fractured tooth Incomplete endodontic therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs: During endodontic treatment of a tooth, it becomes apparent that the procedure cannot be successfully completed The tooth will not be able to be restored, or the tooth fractures, 11 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION necessitating discontinuation of treatment Coverage Limitations and Exclusions for Incomplete endodontic therapy Limited to once per tooth per lifetime Internal root repair of perforation defects Internal root repair of perforation defects is indicated for the following and includes all appointments needed to complete treatment including intraoperative radiographs: There is a root perforation caused by pathology such as resorption or decay A communication between the pulp space and external root surface as a result of internal root resorption. Internal root repair of perforation defects is not indicated for the following: Teeth that are considered non-restorable Teeth with inadequate bone support or advanced untreated periodontal disease Coverage Limitations and Exclusions for Internal root repair of perforation defects Limited to once per tooth per lifetime Not billable for iatrogenic root perforation Retreatment of previous root canal therapy Retreatment of previous root canal therapy is indicated for the following and includes all appointments needed to complete treatment, including intraoperative radiographs: Canal fill appears to extend to a point shorter than 2millimeters from the apex, or extends significantly beyond the apex Fill appears to be incomplete Tooth is sensitive to pressure and percussion or other subjective symptoms The existing endodontics is poor Placement of a post has the potential to compromise the existing obturation or apical seal of the canal system The canal is accessible and allows for retreatment with a non-surgical procedure Coverage Limitations and Exclusions for Retreatment of previous root canal therapy Original treatment must be at least 8 weeks prior to the retreatment date Not benefited within 12 months of original treatment if by same dentist Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01) Surgical Endodontics D3410–D3950, D3999 Documentation Pre and post-operative radiograph image. Provider narrative may be requested if pathology is not visible. 12 Criteria for codes D3410–D3950, D3999 Apicoectomy Apicoectomy is indicated for the following: Failed retreatment of endodontic therapy PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Date of last root canal treatment if needed. When the apex of tooth cannot be accessed due to calcification or other anomaly Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked over extension of obturating materials interfering with healing Apicoectomy is not indicated for the following: Unusual bony or root configurations resulting in lack of surgical access The possible involvement of neurovascular structures 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 When a biopsy of periradicular tissue is necessary Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked overextension of obturating materials interfering with healing Periradicular surgery without apicoectomy is not indicated for the following: Unusual bony or root configurations resulting in lack of surgical access The possible involvement of neurovascular structures 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 13 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION not be obturated by nonsurgical root canal treatment Persistent periradicular pathosis resulting from an inadequate apical seal that cannot be corrected nonsurgically. Root perforations Resorptive defects Retrograde filling is not indicated for the following: When canals are successfully obturated and no evidence of radiographic pathology or clinical symptoms persist When a tooth has an overall poor prognosis with or without retrograde filling placement Root Amputation Root amputation is indicated for the following: Class III furcation involvement Untreatable bony defect (of one root) Root fracture Root caries Root resorption Persistent sinus tract or recurrent apical pathology When there is greater than 75% bone supporting remaining root(s) The tooth has had successful endodontic treatment on remaining root(s) Root Amputation is not indicated for the following: Teeth with an overall poor prognosis with or without root amputation Vital teeth Intentional Reimplantation Intentional replantation is indicated when all of the following clinical conditions exist: Persistent periradicular pathosis following endodontic treatment Nonsurgical retreatment is not possible or has an unfavorable prognosis Periradicular surgery is not possible or involves a high degree of risk to adjacent anatomical structures The tooth presents a reasonable opportunity for removal without fracture The tooth has an acceptable periodontal status prior to the replantation procedure Intentional replantation is not indicated when any of the above criteria are not met. Hemisection Hemisection of multirooted teeth is indicated for the following: Class III or Class IV periodontal furcation defect Infrabony defect of one root of a multi-rooted tooth that cannot be successfully treated periodontally. Coronal fracture extending into the furcation 14 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Vertical root fracture confined to the root to be separated and removed Carious, resorptive root or perforation defects that are inoperable or cannot be corrected without root removal Persistent periradicular pathosis where nonsurgical treatment or periradicular surgery is not possible and the problem is confined to one root The tooth has had successful endodontic treatment on remaining portion of tooth Hemisection of multirooted teeth is not indicated for the following: Teeth with overall poor prognosis with or without hemisection Vital teeth Bone Graft in Conjunction With Periradicular Surgery Bone Graft in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Biologic Materials to Aid In Soft and Osseous Tissue Regeneration in Conjunction With Periradicular Surgery Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery are unproven for the treatment of lesions that are endodontic in origin. Guided Tissue Regeneration Resorbable Barrier in Conjunction with Periradicular Surgery Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Refer to coverage guideline: Surgical Endodontics (DCG010.01) PERIODONTICS Surgical Periodontics – Resective Procedures D4210 D4211 D4212 D4230 D4231 D4240 D4241 D4245 D4249 D4261 D4274 Documentation/Other for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261 Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. 15 Criteria for codes D4210–D4261, D4274 Gingivectomy/Gingivoplasty Gingivectomy/Gingivoplasty is indicated for the following: Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is fibrous and firm and there is an adequate zone of keratinized tissue; Elimination of gingival enlargements/overgrowth due to medications, medical conditions or tooth position; Elimination of suprabony periodontal abscesses; For exposure of soft tissue impacted teeth to aid in eruption; To reestablish gingival contour following an episode of acute necrotizing ulcerative gingivitis; To allow restorative access, including root surface caries. PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Documentation for code D4274 Pre-surgical radiograph images. Grafts: One soft tissue graft per two contiguous teeth. Bone graft and guided tissue regeneration: only one or the other allowed. Evidence of mobility, bruxism and/or hyperocclusion may contraindicate grafting Gingivectomy/Gingivoplasty is not indicated for the following: When bone surgery is required for infrabony defects, or for the purpose of examining bone shape and morphology; Situations in which the bottom of the pocket is apical to the mucogingival junction; Areas where aesthetics are a concern (particularly in the anterior maxilla); In areas with a shallow palatal vault or prominent external oblique ridge; Severely edematous or inflamed tissue; Patients with poor plaque control or non-compliance with non-surgical procedures; Patients with an uncontrolled underlying medical condition; Solely for cosmetic/aesthetic purposes. Anatomical Crown Exposure Anatomical Crown exposure is indicated for the following: In an otherwise periodontally healthy area to facilitate the restoration of subgingival caries; In an otherwise periodontally healthy area to allow proper contour of restoration; In an otherwise periodontally healthy area to allow management of a fractured tooth in which the fracture extends subgingivally. Anatomical Crown exposure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition. Gingival Flap Procedure Gingival flap procedure is indicated for the following (includes root planing): The presence of moderate to deep probing depths; Loss of attachment; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful; The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods. Gingival flap procedure is not indicated for the following: 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; 16 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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 on a tooth with little to no crown exposure. Clinical Crown Lengthening-Hard Tissue is not indicated for the following: As treatment for periodontal disease; 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 17 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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 (DCP013.01) Surgical Periodontics – Regenerative Procedures D4263 D4264 D4265 D4266 D4267 D4268 D4999 Codes D4265, D4266, D4267 and D4999 are each addressed in the Regenerative, Mucogingival and Resective Surgical Periodontics clinical policies. Documentation Full radiographic images (panoramic image) with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Criteria for codes D4263–D4268, D4999 Bone Replacement Grafts Bone Replacement Grafts are indicated for the following: Infrabony/Intrabony vertical defects; Class II furcation involvements. Bone Replacement Grafts are not indicated for the following: Class I furcation involvement; Class III or higher furcation involvement; Non-vertical defects; Patients with 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). 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). 18 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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; Class III or higher furcation involvement; Horizontal bone loss; 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 (DCP014.01) Surgical Periodontics – Mucogingival Procedures D4270 D4273 D4275 D4276 D4277 D4278 D4283 D4285 Codes D4265, D4266, D4267 and D4999 are each addressed in the Regenerative, Mucogingival and Resective Surgical Periodontics clinical policies. Documentation/Other Criteria for codes D4265–D4267, D4270–D4273, D4275–D4278, D4283, D4285, D4999 Pedicle soft tissue graft (D4270) is not benefited at the same time with other periodontal surgery. Soft tissue grafts are benefitted once per two contiguous teeth Documentation (see Note) Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. 19 Pedicle Soft Tissue Graft Procedure Pedicle Soft Tissue Graft Procedure is indicated for the following: Areas with less than 2 mm of attached gingiva; Unresolved sensitivity in areas of recession; Progressive recession or chronic inflammation; For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control; Ridge augmentation; To increase vestibular depth for the correct fit of prosthesis; To widen zone of attached gingiva for prosthetic abutment teeth; To increase vestibular depth to allow proper oral hygiene techniques; Gingival clefting. PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Periodontal charting performed within 12 months, including six point 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; Patients with an untreated medical condition. Note 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 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. 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; 20 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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: Roots covered with thin bony plates; Patients with an untreated medical condition. 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. 21 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Guided Tissue Regeneration is not indicated for the following: Multiple adjacent tooth sites of root coverage required; Solely for cosmetic/aesthetic purposes. Refer to clinical policy: Surgical Periodontics: Mucogingival Procedures (DCP015.01) Provisional Splinting D4320, D4321 Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Criteria for codes D4320–D4321 Tooth numbers or site designations. Provisional Splinting using these codes is not indicated for the following: Tooth transplantation; Trauma resulting in the reimplantation of completely avulsed tooth/teeth; Trauma resulting in displacement or fracture of tooth/teeth. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Provisional Splinting using these codes is indicated for the following: Multiple teeth that have become mobile due to loss of alveolar bone loss and periodontium; During surgical and healing phases of regenerative periodontal therapy. Coverage Limitations and Exclusions for Provisional Splinting Limited to once per 36 months per same tooth/teeth. Not to be billed on same day as any restoration, prostheses or implant for same tooth/teeth. Refer to coverage guideline: Provisional Splinting (DCG011.01) Non-Surgical Periodontal Therapy D4341, D4342, D4381, D4910 Documentation Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Criteria for codes D4341, D4342, D4381, D4910 Scaling and Root Planing Scaling and Root planing is indicated for any of the following: Localized or generalized mild chronic periodontal disease-characterized by 1-2 millimeters of clinical attachment loss (CAL). Localized or generalized moderate chronic periodontal diseasecharacterized by 3-4 millimeters clinical attachment loss (CAL). In molars, furcation involvement not to exceed Class 1. Localized or generalized severe periodontal disease-characterized by more than 5 millimeters of CAL. Chronic refractory mild or moderate periodontal disease-characterized by patients who demonstrate additional attachment loss despite being longitudally monitored with periodontal maintenance. Periodontal abscess characterized by localized swelling and/or increased probing depth and loss of periodontal attachment. Scaling and root planing is not indicated for the following: In the absence of diagnosed periodontal disease. For the removal of heavy deposits of calculus and plaque. Gingivitis defined as inflammation of the gingival tissue without loss of 22 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION attachment (bone and tissue). As a sole treatment for chronic periodontitis with advanced loss of support demonstrated by pockets greater than 6 millimeters with CAL greater than 4 millimeters, and radiographic bone loss. Mobility may or may not be present. As a sole treatment for refractory chronic, aggressive or advanced periodontal diseases. Localized Delivery of Antimicrobial Agents Localized Delivery of Antimicrobial Agents is indicated as an adjunct to scaling and root planing in cases of refractory disease and/or residual probing depths greater than or equal to 5 millimeters with inflammation that are still present following conventional therapies. Localized Delivery of Antimicrobial Agents is unproven and not indicated in the absence of periodontal scaling and root planing (SRP) procedure. Periodontal Maintenance Periodontal Maintenance is indicated for the following: To maintain the results of non-surgical periodontal scaling and root planing therapy and prevent recurrent disease. As an extension of active periodontal therapy at selected intervals. Periodontal Maintenance is not indicated for the following: No history of scaling and root planing (SRP) or surgical procedures. Gingivitis – defined as inflammation of the gingival tissue without loss of attachment (bone and tissue). Gingival Irrigation Per Quadrant Gingival Irrigation per quadrant is unproven. There is limited evidence to support the efficacy of a single episode or multiple in office irrigation appointments. The available studies show the greatest problem with irrigation as an adjunctive therapy is that the antimicrobials are quickly eliminated. Refer to clinical policy: Non-Surgical Periodontal Therapy (DCP.004.01) Full Mouth Debridement D4355 Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral 23 Criteria for codes D4355 Indications for Coverage Full Mouth Debridement is a covered dental service and indicated when the following criteria have been met: Heavy calculus is present on teeth and usually visible on radiographs. Due to the amount of calculus, plaque and debris, a comprehensive examination and diagnosis is not possible. Coverage Limitations and Exclusions Limited to once every 36 months. PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION hygiene status. Not to be billed on same day as any exam code or non-surgical periodontal therapy code. Not to be billed within 12 months of prophylaxis or periodontal maintenance. Not to be used as a therapeutic or preventive procedure such as scaling and root planing or prophylaxis. Refer to coverage guideline: Full Mouth Debridement (DCG.001.01) Unscheduled Dressing Change D4920 Gingival Irrigation – per quadrant D4921 REMOVABLE PROSTHETICS Removable Prosthodontics D5110–D5899 Documentation Full mouth radiographic images. Criteria for codes D5110–D5140, D5211–D5281, D5410–D422, D5510, D5520, D5610–D5671, D5710–D5721, D5730–D5761, D5810–D5821, D5850–D5875 Complete dentures D5110–D5140 Tooth numbers for missing teeth to be replaced, and other missing teeth. Partial dentures D5211–D5281 Date of extractions if indicated. Removable prosthodontic appliances are indicated for replacement of missing teeth loss to disease or injury. The following outlines indications and coverage guidelines for complete and partial removable prosthodontics. Adjustments to Dentures D5410–D5422 Age of existing prosthesis. Immediate denture: X-rays showing at least one tooth present and severe periodontal disease or caries. Repair to Complete Dentures D5510, D5520 Repair to Partial Dentures D5610–D5671 Complete Dentures Complete dentures are indicated for the following: To replace teeth that are non-restorable due to gross caries and/or advanced periodontal disease To replace teeth lost due to orofacial trauma To replace teeth lost due to oral cancer surgery and subsequent reconstruction Complete Dentures are not indicated for the following: When there is no evidence of dental disease When teeth appear to be restorable When there has been extensive bone atrophy resulting in an inadequate edentulous ridge for retention of appliance Patient convenience Denture Rebase Procedures D5710–D5721 Denture Reline Procedures D5730–D5761 Coverage Limitations Limited to once per 60 months from initial or supplemental placement Not allowed if within 60 months of an existing partial denture, interim partial denture, removable partial denture, pontic, retainer, inlay abutment, crown abutment, onlay abutment, or an interim retainer crown for same tooth Not allowed if there is a history of an implant, implant abutment, denture, or interim partial for the same tooth Interim partial dentures D5810–D5821 Other Removable Prosthetic Services D5850–D5875 24 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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 Limited to once per 60 months Not allowed if within 60 months of an existing partial denture, interim partial denture, removable partial denture, pontic, retainer, inlay abutment, crown abutment, onlay abutment, or an interim retainer crown for same tooth Not allowed if there is a history of an implant, implant abutment, denture, or interim partial for the same tooth Complete and Partial Denture Rebase Procedures Rebasing of removable appliances is considered inclusive for the first 6 months, and then subject to frequency limitations. For immediate dentures, one rebase covered in the first six months; then additional rebasing subject to frequency limitations. Denture Rebasing is indicated for the following: When there is a space between base and residual ridge When appliance has become mobile or unstable When replacing or rearranging teeth on the appliance When the base has fractured or cracked Denture Rebasing is not indicated for the following: When the appliance is broken or worn to the extent that replacement is warranted When the occlusion or structural integrity of the denture teeth are no longer functional When reline is sufficient Complete and Partial Denture Reline Procedures Relining of removable appliances is considered inclusive for the first 6 months, and then subject to frequency limitations. For immediate dentures, one reline covered in the first six months; then additional relining subject to frequency 25 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION limitations. Denture Relining is indicated for the following: When appliance has become mobile or unstable To reestablish a soft tissue base for a distal extension appliance when denture rotation is evident When there has been loss of occlusal contact with opposing arch Denture Relining is not indicated for the following: When the appliance is broken or worn to the extent that replacing the appliance is warranted When the occlusion or structural integrity of the denture teeth are no longer functional Interim Prosthesis Interim Prostheses are indicated for the following: While tissue is healing following extractions For the maintenance of a space for future permanent treatment such as an implant, bridge or definitive fixed appliance To condition teeth and ridge tissue for optimum support of a definitive removable partial denture To maintain established jaw relation until all restorative treatment has been completed and a definitive partial denture can be constructed Interim Prostheses are not indicated for the following: As a permanent, definitive prosthesis Overdentures Overdentures are indicated for the following: To preserve the integrity of the edentulous ridge When there are teeth available as abutments that have a good long term prognosis Overdentures are not indicated for the following: When there has been significant deterioration of the edentulous ridge When the teeth available as abutments do not have a good long term prognosis For patients with poor oral hygiene and non-compliance Tissue Conditioning Tissue Conditioning is considered inclusive for the first 12 months, and is then subject to frequency limitations. Tissue Conditioning is indicated for the following: In the presence of inflammation and irritation of the mucosa covering denture-bearing areas When there is distortion of normal anatomic structures, such as incisive 26 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION papillae, rugae, and retromolar pads A burning sensation in residual ridge areas, the tongue, and the cheeks and lips not related to a systemic medical condition Subsequent to placement of immediate dentures to facilitate short term denture retention Tissue Conditioning is not indicated for the following: For long term appliance stability and/or comfort Repairs and Adjustments Repairs and adjustments of removable appliances are considered inclusive for the first 12 months, and are then subject to frequency limitations. Adding teeth to appliances is also subject to frequency limitations. Maxillofacial Prosthetics These are removable appliances for the loss of orofacial structures due to trauma, congenital deformity or destruction of structures due to cancer and resection. This code section also includes radiation shields, carriers for fluoride, radiation carriers, as well as specific medicaments. These removable prosthetics are considered to be medical in nature and are typically covered under the member’s medical plan. Please see appropriate medical policy. Exclusions The following are excluded from coverage: Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). Placement of fixed partial dentures solely for the purpose of achieving periodontal stability. 27 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Clinical situations that can be effectively treated by a less costly dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure. Refer to coverage guideline: Removable Prosthodontics (DCG020.01) MAXILLOFACIAL PROSTHETICS Maxillofacial Prosthetics D5900–D5999 Documentation Narrative Radiographic images if indicated IMPLANTS D6010–D6013, D6040–D6050, D6104, D6199 Documentation Single implant: periapical acceptable; request full mouth images or panoramic image if needed. More than one implant: full mouth images or panoramic image required. Bone graft at time of implant placement: periapical pre-op radiograph, request full mouth images or panoramic image if needed. Criteria for codes D6010–D6013, D6040–D6050, D6104, D6199 A dental implant is an artificial tooth root that is placed into the jaw to hold a replacement tooth or bridge. Adequate bone in the jaw is needed to support the implant, and recipients should have healthy gum tissues that are free of periodontal disease. For most plans, implants are not covered, but for those plans that do have coverage, the following identify guidelines for implant placement: The implant site must be osseointegrated prior to loading. Implant must have adequate crown/root ratio. Must not have more than two threads above the alveolar crest. Implant must not be closer than 1-1.5mm to adjacent roots. Same day implant placement at time of extraction considered acceptable. No direct loading of abutment and/or fixed prosthesis on date of implant placement. Periodontal health of existing dentition must be favorable. Long term prognosis must be favorable. Site is free of acute infection. Factors to consider in treatment planning for implants: Location of tooth/teeth; Bone quality/quantity; Periodontal status; Restorability; Patient cost; Patient age (implants not appropriate for patients under age 15); Patients undergoing strong chemotherapy; Myocardial infarction: within 6 months of an attack; Anticoagulant therapy; Severe neuropsychiatric disease, mental disability, and narcotic drug addicts ; Severe blood diseases; 28 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Systemic Risk Factors: o Smoking o Diabetes o Hypertension o Decreased estrogen levels in postmenopausal women o Use of IV bisphosphonates Refer to coverage guideline: Implant Placement (DCG.007.01) D6101–D6103 Interim abutment D6051 Documentation Pre-op periapical; request full mouth images or panoramic image if needed. Review for medical necessity Documentation/Criteria Post of radiograph to confirm interim abutment. Includes placement and removal. Healing cap is not an interim abutment. Loading of interim abutment on the same day as implant placement is acceptable for anterior teeth to allow for an esthetic temporary crown/bridge. FIXED PROSTHETICS Fixed Prosthodontics D6205–D6999 Documentation Radiographic images: full periapical set with bitewings. Panoramic with bitewings and PA of area (not preferable/panoramic needs to be high quality) of involved teeth, as well as contralateral and opposing sites. Pontic must be at least 2/3 the size of the tooth being replaced. Repair: Reviewer may request narrative if needed. Replacement: Reviewer may request narrative if needed. Criteria for codes D6205–D6999 Fixed Partial Dentures (FPD) Fixed partial dentures are indicated for the following: For the replacement of missing teeth in which the retainer teeth have a favorable long term prognosis For the replacement of one to two missing posterior teeth in a tooth bounded space In addition to the above, the following applies: Resin bonded appliances are indicated for the replacement of one missing tooth and an unrestored abutment tooth with significant clinical crown length Fixed partial dentures are not indicated for the following: Patients with rampant caries Patients with poor oral hygiene When retainer teeth have untreated endodontic pathology or periodontal disease or an unfavorable crown: root ratio When teeth intended as retainers have inadequate remaining tooth structure For the primary dentition When an arch or dentition is deemed terminal When tooth to be used as a retainer has tipped or drifted into edentulous 29 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION space, rendering seating of retainer difficult or impractical In addition to the above, the following applies: Cantilever FPD is not indicated in an area with significant malocclusion, heavy occlusion or parafunctional habits (e.g., nail biting, bruxism, clenching) Resin bonded FPD is not indicated when there is a pontic width discrepancy, in patients with parafunctional habits (e.g., nail biting, bruxism, clenching), in an area with significant malocclusion or heavy occlusion Resin bonded FPD is not indicated as a temporary prosthesis Provisional Fixed Partial Dentures Provisional Fixed Partial Dentures are indicated for the following: When the prognosis of a permanent fixed partial denture is questionable due to periodontal involvement, endodontic pathology or patient compliance To replace a lost tooth in young patients to allow maturity of the dentition and jaws before constructing a definitive fixed prosthetic appliance When a systemic medical condition prohibits the placement of a definitive fixed prosthetic appliance Provisional Fixed Partial Dentures are not indicated for the following: As a definitive fixed partial denture unless indicated by above criteria Fixed Partial Denture Repair (Necessitated by Restorative Material Failure) Fixed partial denture repair is indicated for the following: When the appliance to be repaired is functional and has a favorable long term prognosis Fixed partial denture repair is not indicated for the following: For porcelain fracture if margins are intact and functional area not involved Precision Attachments Precision attachments are indicated for the following: When aesthetics need to be considered For the redistribution of occlusal forces To minimize trauma to soft tissue For the control of loading and rotational forces When it is not possible to prepare two abutments with a common path of placement When the prognosis of an abutment is uncertain Connector Bar Connector bars are indicated to brace individual abutment teeth with considerable coronal length for enhances stabilization of removable partial dentures, complete dentures and overdentures. 30 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Stress Breaker (a non-rigid connector) Stress Breakers are indicated for the following: When it is not possible to prepare two abutments with a common path of placement When the prognosis of an abutment is uncertain Control of loading and rotational forces For the redistribution of occlusal forces Exclusions The following are excluded from coverage: Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). Placement of fixed partial dentures solely for the purpose of achieving periodontal stability. Coverage Limitations Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement. Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months. Limited to 1 time per tooth per consecutive 60 months. Stress breakers, and connector bars are not covered Clinical situations that can be effectively treated by a less costly alternative procedure will be assigned a benefit based on the least costly procedure. Refer to coverage guideline: Fixed Prosthodontics (DCG017.01) 31 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION ORAL SURGERY D7111–D7999 Documentation Dated and labeled radiographic images including panoramic image or periapicals usually taken within one year and appropriate to document the case. Alternate benefit permitted if submitted code is not supported by documentation. Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Narrative: If reason for extraction is not apparent For bicuspid with no apparent pathology, to determine if orthodontic extractions D7241, full bony impaction with complications D7260, oroantral closure D7270, reimplantation (copy of accident report helpful) D7340, 7350, vestibuloplasty D7953, bone graft for ridge preservation D7970, excision of hyperplastic tissue Cyst removal (D7450, 7451, 7460, 7461): Documentation of special services; size greater than 1.25mm and/or unrelated to tooth removal; operative notes and pathology report. Treatment notes if radiographic information not conclusive. Extractions D7210–D7250 Criteria Inappropriate removal of teeth to construct full dentures is excluded. Patient preference in the absence of clinical indications, is not sufficient Must be pathology involved (non-restorable caries, untreatable periodontal disease, untreatable endodontic disease) Exception to above may be made based on underlying medical condition Extraction of bicuspids may be ortho-related and fall under that benefit Bone graft with extraction is not a benefit unless a significant residual defect is present Inclusive components Sutures, local anesthesia, normal post-op care Third molar removal Classification is based on anatomic position of the tooth, not the technique required for its removal. Classification is based on ADA CDT descriptor for the 32 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION code submitted. See codes for specific guidelines. Extraction includes removal of soft tissue including but not limited to granulomatous, follicular or minor cystic tissue associated with the tooth. No bone graft is allowed unless a significant residual defect remains and is radiographically documented post op. ERUPTED THIRD MOLAR – one that is so positioned that the entire clinical crown in visible PARTIALLY ERUPTED THIRD MOLAR – one that is so positioned that only a portion of the clinical crown is visible UNERUPTED/IMPACTED THIRD MOLAR – one that has not penetrated through bone and/or soft tissue and entered the oral cavity. Non-Surgical Extractions D7111, D7140 Documentation Pre-operative radiographic images Criteria for codes D7111, D7140 Non-Surgical Extractions Non-surgical extractions are indicated for the following: For non-restorable teeth For teeth in which previous restorative, endodontic or periodontal treatment has failed Teeth with periapical pathology evident Supernumerary teeth Crowding/nonfunctional teeth Orthodontic considerations For primary teeth with roots retained in bone or soft tissue that is interfering with eruption of permanent teeth For primary canines to correct eruption pattern of a permanent canine that is palatally displaced Interference with prosthodontic needs Non-surgical extractions are not indicated when the clinical condition requires a surgical procedure (e.g., tooth impaction). Please refer to the Surgical Extraction of Impacted Teeth and Surgical Extraction of Erupted Teeth and Retained Roots dental policies. Coverage Limitations Limited to one extraction per tooth, per lifetime Refer to coverage guideline: Non-Surgical Extractions (DCG022.01) Surgical Extraction of Erupted Teeth and Retained Roots D7210, D7250 Documentation Dated and labeled radiographic images including panoramic image or periapicals usually taken within one year and appropriate to document the case. 33 Criteria for codes D7210, D7250 Surgical Extraction of an Erupted Tooth Surgical extraction of an erupted tooth is indicated for any of the following: No clinical crown is visible in the mouth; PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Treatment notes if radiographic information not conclusive. There is insufficient remaining clinical crown to allow a non-surgical extraction; The fracture of a tooth or roots during a non-surgical extraction procedure; Erupted teeth with unusual root morphology (dilacerations, cementosis); Erupted teeth with developmental abnormalities that would make nonsurgical extraction unsafe or cause harm; When fused to an adjacent tooth; In the presence of periapical lesions; For maxillary posterior teeth whose roots extend into the maxillary sinus; When severe crowding or ectopic position of the tooth is present; When tooth has been crowned or been treated endodontically; Other conditions as deemed necessary by a licensed dentist. Surgical extraction is not proven or indicated for the following: When a conservative non-surgical procedure is possible; When the Indications for Coverage criteria above are not met. Surgical Removal of Residual Tooth Roots Surgical removal of residual tooth roots is indicated for the following: When tooth roots, or fragments of tooth roots remain in the bone following a previous incomplete tooth extraction; Extreme tooth decay resulting in the destruction of the dentition to the extent that only root tips remain. Refer to coverage guideline: Surgical Extraction of Erupted Teeth and Retained Roots (DCG.005.01) Surgical Extraction of Impacted Teeth D7220 D7230 D7240 D7241 D7251 Documentation Dated and labeled radiographic images including panoramic image or periapicals usually taken within one year and appropriate to document the case. Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Narrative: If reason for extraction is not apparent For bicuspid with no apparent pathology, to determine if orthodontic extractions D7241, full bony impaction with complications Cyst removal (D7450, 7451, 7460, 7461): Documentation of special services; size greater than 1.25mm and/or unrelated to tooth removal; operative notes and pathology report. Treatment notes if radiographic information not conclusive. 34 Criteria for codes D7220, D7230, D7240–D7241, D7251 The prophylactic extraction of impacted third molars that are asymptomatic and disease free remains highly controversial. In the absence of strong clinical evidence to support or refute prophylactic extractions of asymptomatic and disease free third molars, the following coverage rationale has been adopted. Surgical extraction of soft tissue impacted teeth Surgical extraction of soft tissue impacted teeth is indicated for the following: Extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted; For a tooth/teeth in the line of a jaw fracture or complicating fracture management; As part of comprehensive treatment in orthognathic surgery; Moderate to severe or acute pain, or recurrent episodes that do not respond to conservative treatment (i.e. pain medication or antibiotics); Non-restorable caries; Management of, or limiting the progression of periodontal disease; PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION In the case of acute/chronic infection (abscess, cellulitis, pericoronitis); Pulpal exposure; Non-restorable pulpal or periapical lesion; Internal resorption; As a prophylactic procedure for an underlying medical or surgical condition (e.g. organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer ); Tumor resection; Ectopic position; For purposes of prosthetic rehabilitation (partial dentures and complete dentures). Surgical extraction of soft tissue impacted teeth is not indicated for the following: For prophylactic reasons other than an underlying medical condition; When a more conservative procedure can be performed; For pain or discomfort related to normal tooth eruption. Surgical extraction of partially bony impacted teeth Surgical extraction of partially bony impacted teeth is indicated for the following: Extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted; Tooth/teeth in the line of a jaw fracture or complicating fracture management; 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; 35 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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 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 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 36 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 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; As a prophylactic procedure for an underlying medical condition (e.g. organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer); Tumor resection; Ectopic position; For purposes of prosthetic rehabilitation (partial dentures an complete dentures); When complicated procedures are anticipated such as nerve dissection, sinus closure, aberrant tooth position or anatomy, or are unanticipated and arise during surgical extraction. Surgical extraction of completely bony impacted teeth with unusual surgical complications is not indicated for the following: 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 (DCP006.01) Oroantral fistula closure D7260 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. 37 Criteria Benefitted if the condition cannot be treated by approximating the soft tissue and suturing and requires excision of fistulous tract with closure by advancement flap. PROCEDURE Primary closure of sinus perforation D7261 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Criteria Subsequent to surgical removal of tooth, exposure of sinus requiring repair in absence of fistulous tract. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Tooth reimplantation D7270 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Surgical exposure of unerupted tooth D7280 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Criteria Recent history of facial trauma. Avulsion of tooth. Performed within 3 hours of accident. Includes splinting/stabilization. Criteria Tooth developing normally and in good position. Adequate space to erupt. Dense, fibrotic tissue appears to prevent eruption. Part of orthodontic treatment plan. Supernumeraries and third molars not benefited. Mobilization of erupted or malpositioned tooth to aid eruption D7282 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Tooth developing normally and in good position. Adequate space to erupt.. Hx. Of 7280 Treatment notes if radiographic information not conclusive or radiographs are not applicable. Placement of device to aid eruption of impacted tooth D7283 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Tooth developing normally and in good position. Adequate space to erupt.. Hx. Of 7280 Treatment notes if radiographic information not conclusive or radiographs are not applicable. Surgical placement of temporary anchorage device D7279, D7293, D7294 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. 38 Tooth developing normally and in good position. Adequate space to erupt.. Hx. Of 7280 PROCEDURE Alveoloplasty with extractions D7310, D7311 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Alveoloplasty without extractions D7320, D7321 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Vestibuloplasty D7340, D7350 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Excision of benign lesions D7411, D7412 Narrative of procedure Removal of benign odontogenic cyst or tumor D7450, D7451 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Criteria Bone requires osteoplasty as preparation for prosthesis beyond that expected during healing. For full quad: at least four contiguous extractions. Can be done up to 6 months post extraction of >4 teeth if indicated. Criteria Teeth removed sometime in the past. Narrative that current prosthesis is causing irritation, sore spots or inflammatory lesions due to thin or irregular alveolar crest. Needed to remove spicules or exostoses that result in chronic irritation or pathology. Criteria Sometimes performed for periodontal purposes when an abnormally shallow vestibule threatens the attached gingiva. May be performed to prepare an area for a denture. Should be reviewed if on the same date as a soft tissue graft or periodontal surgery. Criteria Cyst is not attached to or removed with tooth. Size, color or consistency indicates need for pathology examination. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Removal of benign nonodontogenic cyst or tumor D7460, D7461 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Criteria Presence of hard, attached or freely movable raised or erythematous lesion. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Removal of exostoses or tori D7471, D7472, D7473 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. 39 Criteria Impinges on speech or freeway space of tongue. Prevents adequate extension of denture. Frequent sore spots from denture. PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Prevents fabrication of denture. Factor in periodontal disease. Not with osseous surgery or alveoloplasty. Incision and drainage D7510, D7520 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Criteria Not usually benefited when at same time as extraction. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Collection and application of autologous blood concentrate product D7921 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Criteria Must be history of extraction on same day Treatment notes if radiographic information not conclusive or radiographs are not applicable. Sinus augmentation via lateral open approach D7951 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Criteria Usually for purposes of placement of an implant. Narrative and radiographic images to document the clinical need. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Sinus augmentation via a vertical approach D7952 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Criteria Medically necessary Treatment notes if radiographic information not conclusive or radiographs are not applicable. Bone graft for ridge preservation D7953 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Criteria The healing process normally repairs the defect following an extraction. In cases such as a large defect after lesion removal, the graft may be allowed. Implant note: if an implant is a covered procedure, this does not automatically imply approval of a bone graft. Radiographic images and narrative should be reviewed. SEE IMPLANT CRITERIA If implant is placed at time of bone graft then use code D6104 40 PROCEDURE Frenectomy or frenotomy D7960 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Documentation Narrative if applicable Criteria/Documentation Narrative may be requested from reviewer Apparent cause of diastema. Frenuloplasty D7963 Causing recession. Tissue hinders home care. Pre-prosthetic. Tongue movement limited. Denture lacerates or irritates frenum and cannot be resolved by denture adjustment. Excision of hyperplastic tissue D7970 Documentation Narrative if applicable Criteria (see also D4210) Severe or gross overgrowth of tissue associated with ill-fitting denture. Tissue not responsive to non-invasive therapy (conditioning, liners). Pre-prosthetic purposes. Hinders fit of existing prosthesis. Tissue hinders home care. Must be in an area of missing teeth where a full or partial denture or pontic will rest. Excision of periocoronal gingival D7971 Narrative and radiographic images to document the clinical need Medically necessary Surgical reduction of fibrous tuberosity D7972 Narrative and radiographic images to document the clinical need Medically Necessary All of the following documentation must be received: Panoramic imaging; Cephalometric imaging; 5-7 intraoral photographs; Other forms as required by the state. Criteria for codes D8050–D8090, D8220, D8660–D8680, D8690–D8691, D8999 ORTHODONTICS Medically Necessary Orthodontic Treatment D8050–D8090, D8220, D8660–D8680, D8690–D8691, D8999 Indications for Coverage Orthodontic treatment is a covered dental service and medically necessary when the following criteria have been met: All services must be approved by the plan; and The member is under the age 19 (through age 18, unless the benefit plan document indicates a different age); and Services are related to one of the following conditions: o Cleft lip and/or cleft palate; o Crouzon’s Syndrome; o Treacher-Collins Syndrome; 41 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION o o o o o Pierre-Robin Syndrome Hemi-facial atrophy; Hemi-facial hypertrophy Severe craniofacial deformities that result in a physically handicapping malocclusion; OR Other clinical criteria based on state specific language. All of the following documentation must be received: Panoramic imaging; Cephalometric imaging; 5-7 intraoral photographs; Other forms as required by the state. Coverage Limitations and Exclusions Orthodontic services that do not meet the criteria listed above. Orthodontic services that are specifically excluded. Orthodontic services for crowded dentitions (crooked teeth), excessive spacing between teeth, temporomandibular joint (TMJ) conditions and/or horizontal/vertical discrepancies (overjet/overbite). Refer to coverage guideline: Medically Necessary Orthodontic Treatment (DCG.003.01) ANESTHESIA SERVICES General Anesthesia and Conscious Sedation D9210–D9212, D9215, D9219, D9223, D9230, D9243, D9248 Documentation & Time Recommendations & Nitrous/Extraction Recommendations Provider notes including: duration, type of anesthetic, dosage. If restorative/surgical procedures and age do not meet criteria: Narrative documenting medical necessity, including description of underlying medical problem; description of behavior problem and age of patient. Criteria for codes D9210–D9212, D9215, D9219, D9223, D9230, D9243, D9248 Sedation for dentistry is proven to help decrease anxiety, diminish fear and increase tolerance for dental procedures. It is necessary for the safe and comprehensive dental treatment of patients that meet selection criteria. Local anesthesia is not covered in conjunction with operative or surgical procedures. Nerve blocks are not addressed in this coverage guideline; please refer to appropriate medical policy. Anesthesia time is defined as the period between the beginning of the administration of the agent and the time that the anesthetist is no longer in personal attendance. Local Anesthesia is considered an inclusive component of any dental procedure unless used for pain relief or if pain relief is required to make an accurate diagnosis. General Time Guidelines for IV sedation & General Anesthesia: Regional and trigeminal block anesthesia is not a covered service. 3-4 Teeth D7230, D7240 1.5 hours 1-2 Teeth D7230, D7240 45 min 3-4 Teeth D7210, D7220 1 hour 1-2 Teeth D7210, D7220 45 min Full Mouth Extractions or + Teeth D7111, D7140 1.5 hours 42 Nitrous Oxide Coverage Limitations/Exclusions o Limited to once per day o Excluded when reported on same date of service as IV sedation, nonIV sedation or General Anesthesia o Patient convenience Nitrous Oxide is proven effective for sedation in adults and children for the following: PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION 3-6 Teeth D7111, D7140 45 min. 1-3 Teeth D7111, D7140 30 min. Nitrous Oxide: Extraction Coverage Recommendations: More than one soft tissue impacted tooth D7220 One or more partial or full bony D7230, D7240 More than six simple extractions D7140 Multiple surgical extractions D7210 o Ineffective local anesthesia o Anxiety o Special needs patients o Lengthy procedures for special needs patients and children o Behaviorally challenged or uncooperative patients Nitrous Oxide is contraindicated for patients with but not limited to the following: o Severe underlying medical conditions ( e.g., severe chronic obstructive pulmonary diseases, congestive heart failure, sickle cell anemia, acute otitis media, recent tympanic membrane graft, acute severe head injury) o Severe emotional disturbances o Drug related dependencies o Pregnancy – first trimester o Treatment with bleomycin sulfate (injection used in cancer patients) o Methlenetetrahydropfolate reductase deficiency o Vitamin B12 deficiency Intravenous (IV) Sedation Coverage Limitations/Exclusions o Limited to once per day IV sedation is proven and effective for the following: o Anxiety/Fear o Pain Control o Oral Surgery o Medically compromised patients or those with special needs IV sedation is contraindicated for patients with but not limited to the following: o Allergy to IV medications o Certain prescribe pharmaceuticals o In any patient where IV sedation has been considered unsafe Non-IV Sedation Coverage Limitations/Exclusions o Not allowed on same day as general anesthesia Non-IV sedation is proven and effective for the following: o Anxiety o Uncooperative or unmanageable patient Non-IV sedation is contraindicated for patients with but not limited to the following: o Patient or dentist convenience Nerve Blocks are not covered for dental services; please refer to appropriate medical policy for specifics regarding coverage for nerve blocks. 43 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION General anesthesia General anesthesia is proven and effective. The decision to administer should be made on an individual patient basis and should be limited to: o Clinical procedures of extensiveness or complexity or situations that require more than a local anesthetic o At least 2 attempts using office technique and the failure documented o Uncooperative or Unmanageable Patient o Physical, Cognitive or Developmental Disabilities o Significant underlying medical condition o Allergy or sensitivity to local anesthesia o Lengthy restoration procedures for pediatric patients o A child who has resisted all other conventional management procedures General anesthesia is contraindicated for patients with but not limited to the following: o Patients with predisposing medical and/or physical conditions that potentially make general anesthesia unsafe o Cooperative patients with minimal dental needs o Choice of an alternative option for treatment o Language or cultural barriers o Parental objection Refer to coverage guideline: General Anesthesia Conscious Sedation Services (DCG.016.01) ADJUNCTIVE SERVICES Palliative treatment D9110 Criteria Not payable with other services such as extraction, incision/drainage, sedative on same date-of-service, with the exception of x-rays and exam (usually D0140). For immediate relief of pain and not a definitive procedure Bridge sectioning D9120 Radiographic image required. Code for both preparing teeth for extraction and for retaining part of fixed prosthesis. Consultation D9310 Criteria A diagnostic service not by the practitioner providing the specific or on-going treatment. The condition may be out of the scope of practice, requiring second opinion. Professional Visits D9410–D9450 Documentation Narrative from member record. 44 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Therapeutic parenteral drugs D9610, D9612 Criteria Inclusive when administered through the IV during IV sedation. Covered when administered as a separate IV or intramuscular injection. Other drugs D9630 D9610 Single administration of antibiotics, steroids, anti-inflammatory drugs, or other therapeutic medications. NOT to be used to report administration of sedative, anesthetic or reversal agents. D9612 Multiple administrations of drugs listed for D9610. Only used when two or more drugs are used and no to be reported in addition to code D9610. D9630 Dispensing of oral antibiotics/home fluoride, oral analgesics, not limited to these drugs. Does not include writing of a prescription. Application of Desensitizing Medicament D9910 Documentation Narrative with explanation of symptoms. Criteria Typically used for root sensitivity per tooth. Not covered for bases/liners. Desensitizing Resin D9911 Documentation Narrative with explanation of symptoms. Criteria Adhesive application for root sensitivity per tooth. Not covered for bases/liners/adhesives under restorations. Behavior management D9920 Criteria Appropriate in cases where substantial time and effort is expended in allaying the patient’s fear and apprehension. Narrative required. Treatment of complication D9930 Criteria Narrative and/or radiographic images required. Examples: dry socket, extensive hemorrhage. Occlusal guard D9940 Documentation/Criteria Provider narrative which includes a history of bruxism, grinding, &/or clenching resulting in excessive wear. Should include occlusal analysis and symptoms. Athletic guard D9941 Documentation Narrative Repair/Reline of Occlusal Guard D9942 Documentation Narrative Not for temporomandibular joint treatment. Indications: bruxism, grinding, clenching, excessive wear &/or myofascial pain due to bruxing, grinding, clenching, Occlusal analysis D9950 Criteria Not for TMJ treatment. Occlusal adjustment D9951, D9952 Criteria Not for TMJ treatment, completed prosthetic appliance or with endodontic therapy. 45 PROCEDURE CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DOCUMENTATION Enamel Microabrasion D9970 Documentation Narrative, intraoral photos helpful. Criteria Discolored surface enamel from altered mineralization/decalcification. Per visit basis. Odontoplasty D9971 Documentation Narrative, intraoral photos helpful. Criteria 1-2 teeth –includes removal of enamel projections. Bleaching and unspecified report D9972–D9999 Documentation Narrative, intraoral photos, images. 46