Dental and Oral Surgical Procedures

UnitedHealthcare? Oxford Administrative Policy

Dental and Oral Surgical Procedures

Policy Number: DENTAL 002.33 T2 Effective Date: April 1, 2021

Instructions for Use

Table of Contents

Page

Purpose .......................................................................................... 1

Prior Authorization Requirements ................................................ 1

Policy .............................................................................................. 1

Procedures and Responsibilities .................................................. 2

Applicable Codes .......................................................................... 3

References ..................................................................................... 7

Policy History/Revision Information ............................................. 8

Instructions for Use ....................................................................... 8

Related Policies ? Orthognathic (Jaw) Surgery ? Temporomandibular Joint Disorders

Purpose

The purpose of this document is to outline the circumstances in which Oxford will reimburse dental or oral surgical services and related anesthesia.

Prior Authorization Requirements

Prior authorization is required in all sites of service.

Notes: Participating providers in the office setting: Prior authorization is required for services performed in the office of a participating provider. Non-participating/out-of-network providers in the office setting: Prior authorization is not required but is encouraged for out-of-network services. If prior authorization is not obtained, Oxford will review for out-of-network benefits and medical necessity after the service is rendered. Specialty review of all dental and oral surgical services is required when services are to be rendered by practitioners of the following specialties: o Endodontics o General Dentistry o Oral Surgery o Oral/Maxillofacial Surgery o Orthodontics o Pediatric Dentistry o Periodontics

Policy

Oxford will cover certain oral surgical and dental procedures when determined to be medical in nature.

In addition, under certain circumstances, coverage for anesthesia services in conjunction with dental or oral surgical services may be approved.

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 1 of 8 Effective 04/01/2021

Procedures and Responsibilities

Before using this policy, check the member specific benefit plan document and any federal or state mandates, if applicable. If there is a difference between this policy and the member specific benefit plan document, the member specific benefit plan document will govern.

Note: Members enrolled on Essential Health Benefit plans may have coverage for Pediatric Dental. Pediatric Dental coverage may provide additional coverage beyond what is outlined below.

Indications for Coverage

Coverage for dental and oral surgical procedures may qualify for coverage under a member's benefit plan when determined to be medical in nature.

Dental Services ? Accidental Only

Coverage may include: ? Oral surgical procedures for jaw bones or surrounding tissue and dental services for the repair (not replacement) of sound

natural teeth when both of the following are true: o Treatment is needed because of accidental damage. o You receive dental services from a Doctor of Medicine (for NJ plans only), Doctor of Dental Surgery or Doctor of

Medical Dentistry. ? Dental services for the repair or replacement of sound and natural teeth, maxilla, mandible, and surrounding tissues

following accidental injury (not including injuries caused by eating, biting, or chewing or intentional misuse of the teeth) when the following criteria have been met: o Documentation that may be requested:

Accidental injury must be documented. Pre- and post-accident x-rays are required. o Teeth were stable and functional immediately prior to the time of the accident without evidence of decay, periodontal disease, or endodontic pathology.

Note: Dental services to repair damage caused by accidental injury must be completed within 12 months of the accident, or if not a Covered Person at the time of the accident, within the first 12 months of coverage under the Policy.

Additional Dental Coverage Requirements Connecticut Members

Coverage must be provided for general anesthesia, nursing, and related hospital services provided in conjunction with inpatient, outpatient or one-day dental services when the dentist or oral surgeon and the physician determine that the services are medically necessary for the treatment of either of the following types of patient: o A person who is determined by a dentist, in conjunction with a physician who specializes in primary care, to have a

dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital or alternate facility. o A person who has a developmental disability, as determined by a physician who specializes in primary care that places the person at serious risk. Coverage will be provided for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders if such processes and appliances are prescribed by a craniofacial team recognized by the American Cleft PalateCraniofacial Association and are not required for cosmetic surgery.

New Jersey Members

Coverage must be provided to individuals who are severely disabled or a child age five or under for expenses incurred for: o General anesthesia and hospitalization for dental services; or o A medical condition covered by the contract which requires hospitalization or general anesthesia for dental services

rendered by a dentist regardless of where the dental services are provided.

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 2 of 8 Effective 04/01/2021

Oral Surgery

Coverage may include: ? Oral surgical procedures for the correction of a non-dental physiological condition which results in a severe functional

impairment. ? Oral surgical procedures for the excision of cysts and tumors requiring pathological examination jaws, cheeks, lips, tongue,

roof and floor of the mouth. ? Surgical and nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. ? Surgical removal of bony impacted teeth.* ? Removal of odontogenic cysts or tumors.* ? Removal of soft tissue neoplasms of the lips, tongue, palate, floor of mouth, and vestibule (e.g., fibromas, mucocoeles,

etc.).

*Note: These benefits are limited to specific benefit plans; refer to the member specific benefit plan document and any federal or state mandates, if applicable.

Additional Dental and Oral Surgery Coverage Requirements

New York Members

Oral surgical procedures for jaw bones or surrounding tissue and dental services for the repair (not replacement) of sound natural teeth when both of the following are true:

Treatment is needed due to congenital anomaly. Note: A congenital anomaly is defined as a physical developmental defect that is present at the time of birth. Dental services are received from a Doctor of Dental Surgery or Doctor of Medical Dentistry.

Note: Dental services for the replacement of sound natural teeth due to accidental injury is covered only when repair is not possible.

Coverage Limitations and Exclusions

Refer to the member specific benefit plan document and any federal or state mandates, if applicable. ? Dental damage that happens as a result of normal activities of daily living (such as biting or chewing) or intentional misuse

of the teeth is not considered an accidental injury. Benefits are not available for repairs to teeth that are damaged as a result of such activities. ? Removal of cysts related to teeth is not covered.

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.

CPT Code 21015 21016 21025 21026 21029 21030 21031 21032

Description Radical resection of tumor (e.g., sarcoma), soft tissue of face or scalp; less than 2 cm Radical resection of tumor (e.g., sarcoma), soft tissue of face or scalp; 2 cm or greater Excision of bone (e.g., for osteomyelitis or bone abscess); mandible Excision of bone (e.g., for osteomyelitis or bone abscess); facial bone(s) Removal by contouring of benign tumor of facial bone (e.g., fibrous dysplasia) Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage Excision of torus mandibularis Excision of maxillary torus palatinus

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 3 of 8 Effective 04/01/2021

CPT Code 21034 21040 21044 21045

21046

21047

21048

21049

21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100

21110

21116

21188

21206 21208 21209 21210 21215 21244 21245 21246 21248 21249

21255

Description Excision of malignant tumor of maxilla or zygoma Excision of benign tumor or cyst of mandible, by enucleation and/or curettage Excision of malignant tumor of mandible; Excision of malignant tumor of mandible; radical resection Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion[s]) Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (e.g., locally aggressive or destructive lesion[s]) Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion[s]) Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (e.g., locally aggressive or destructive lesion[s]) Impression and custom preparation; surgical obturator prosthesis Impression and custom preparation; orbital prosthesis Impression and custom preparation; interim obturator prosthesis Impression and custom preparation; definitive obturator prosthesis Impression and custom preparation; mandibular resection prosthesis Impression and custom preparation; palatal augmentation prosthesis Impression and custom preparation; palatal lift prosthesis Impression and custom preparation; speech aid prosthesis Impression and custom preparation; oral surgical splint Impression and custom preparation; auricular prosthesis Impression and custom preparation; nasal prosthesis Impression and custom preparation; facial prosthesis Unlisted maxillofacial prosthetic procedure Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) Application of interdental fixation device for conditions other than fracture or dislocation, includes removal Injection procedure for temporomandibular joint arthrography Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) Osteoplasty, facial bones; reduction Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Graft, bone; mandible (includes obtaining graft) Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate) Reconstruction of mandible or maxilla, subperiosteal implant; partial Reconstruction of mandible or maxilla, subperiosteal implant; complete Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); complete Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 4 of 8 Effective 04/01/2021

CPT Code 21296 21299 21421

21422 21423

21431 21432

21433

21435

21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470

21480 21485

21490 21497 21499 40530 40654 40700 40701 40702 40720

40761 40799

Description Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); intraoral approach Unlisted craniofacial and maxillofacial procedure Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint Open treatment of palatal or maxillary fracture (LeFort I type); Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation Open treatment of craniofacial separation (LeFort III type); complicated (e.g., comminuted or involving cranial nerve foramina), multiple surgical approaches Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (e.g., head cap, halo device, and/or intermaxillary fixation) Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) Closed treatment of mandibular fracture; without manipulation Closed treatment of mandibular fracture; with manipulation Percutaneous treatment of mandibular fracture, with external fixation Closed treatment of mandibular fracture with interdental fixation Open treatment of mandibular fracture with external fixation Open treatment of mandibular fracture; without interdental fixation Open treatment of mandibular fracture; with interdental fixation Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints Closed treatment of temporomandibular dislocation; initial or subsequent Closed treatment of temporomandibular dislocation; complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or subsequent Open treatment of temporomandibular dislocation Interdental wiring, for condition other than fracture Unlisted musculoskeletal procedure, head Resection of lip, more than one-fourth, without reconstruction Repair lip, full thickness; over one-half vertical height, or complex Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 stage procedure Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle Unlisted procedure, lips

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 5 of 8 Effective 04/01/2021

CPT Code 40800 40801 40804 40805 40806 40814

40816

40818 40819

40820

40840 40842 40843 40844 40845 40899 41000

41005

41006

41007

41008

41009

41010 41015 41016 41017 41018 41114 41115 41120 41130 41252 41512 41520 41530 41800 41805

Description Drainage of abscess, cyst, hematoma, vestibule of mouth; simple Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated Removal of embedded foreign body, vestibule of mouth; simple Removal of embedded foreign body, vestibule of mouth; complicated Incision of labial frenum (frenotomy) Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle Excision of mucosa of vestibule of mouth as donor graft Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Destruction of lesion or scar of vestibule of mouth by physical methods (e.g., laser, thermal, cryo, chemical) Vestibuloplasty; anterior Vestibuloplasty; posterior, unilateral Vestibuloplasty; posterior, bilateral Vestibuloplasty; entire arch Vestibuloplasty; complex (including ridge extension, muscle repositioning) Unlisted procedure, vestibule of mouth Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space Incision of lingual frenum (frenotomy) Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space Excision of lesion of tongue with closure; with local tongue flap Excision of lingual frenum (frenectomy) Glossectomy; less than one-half tongue Glossectomy; hemiglossectomy Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex Tongue base suspension, permanent suture technique Frenoplasty (surgical revision of frenum, e.g., with Z-plasty) Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session Drainage of abscess, cyst, hematoma from dentoalveolar structures Removal of embedded foreign body from dentoalveolar structures; soft tissues

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 6 of 8 Effective 04/01/2021

CPT Code 41806 41820 41821 41822 41823 41825 41826 41827 41828 41830 41850 41870 41872 41874 41899 42000 42107 42120 42140 42145 42182 42200 42205

42210

42215 42220 42225 42226 42227 42235 42280 42281 42299

Description

Removal of embedded foreign body from dentoalveolar structures; bone

Gingivectomy, excision gingiva, each quadrant

Operculectomy, excision pericoronal tissues

Excision of fibrous tuberosities, dentoalveolar structures

Excision of osseous tuberosities, dentoalveolar structures

Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair

Excision of lesion or tumor (except listed above), dentoalveolar structures; with simple repair

Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair

Excision of hyperplastic alveolar mucosa, each quadrant (specify)

Alveolectomy, including curettage of osteitis or sequestrectomy

Destruction of lesion (except excision), dentoalveolar structures

Periodontal mucosal grafting

Gingivoplasty, each quadrant (specify)

Alveoloplasty, each quadrant (specify)

Unlisted procedure, dentoalveolar structures

Drainage of abscess of palate, uvula

Excision, lesion of palate, uvula; with local flap closure

Resection of palate or extensive resection of lesion

Uvulectomy, excision of uvula

Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty)

Repair, laceration of palate; over 2 cm or complex

Palatoplasty for cleft palate, soft and/or hard palate only

Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only

Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft)

Palatoplasty for cleft palate; major revision

Palatoplasty for cleft palate; secondary lengthening procedure

Palatoplasty for cleft palate; attachment pharyngeal flap

Lengthening of palate, and pharyngeal flap

Lengthening of palate, with island flap

Repair of anterior palate, including vomer flap

Maxillary impression for palatal prosthesis

Insertion of pin-retained palatal prosthesis

Unlisted procedure, palate, uvula

CPT? is a registered trademark of the American Medical Association

References

American Medical Association. Current Procedural Terminology: CPT, Professional Edition. CT P.A. No. 03-37 An act requiring health insurance coverage for craniofacial disorders. CT P.A. No. 03-58 codified under C.G.S.A ? 38a-517a and C.G.S.A ? 38a-491a. N.J. Stat. Ann. ?26:2J-4.19 New York Insurance Laws: Regulation 62, NYCRR Title 11 Section 52.16(c) (9).

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 7 of 8 Effective 04/01/2021

Oxford Certificate of Coverage and Member Handbook.

Policy History/Revision Information

Date 04/01/2021

Summary of Changes

Related Policies Added refereince link to the Clinical Policy titled Orthognathic (Jaw) Surgery

Procedures and Responsibilities Oral Surgery

Removed notation indicating surgical and nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery treatment, in general, must be rendered within 12 months of the injury; check the member specific benefit plan document for coverage limitations Added notation to indicate surgical removal of bony impacted teeth and removal of odontogenic cysts or tumors are limited to specific benefit plans; refer to the member specific benefit plan document and any federal or state mandates, if applicable

Additional Dental and Oral Surgery Coverage Requirements: New York Members

? Added notation to indicate dental services for the replacement of sound natural teeth due to accidental injury is covered only when repair is not possible

Supporting Information

? Archived previous policy version DENTAL 002.32 T2

Instructions for Use

The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document or Certificate of Coverage will govern.

Dental and Oral Surgical Procedures UnitedHealthcare Oxford Administrative Policy

?1996-2021, Oxford Health Plans, LLC

Page 8 of 8 Effective 04/01/2021

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