MEDICAL POLICY POLICY TITLE DENTAL AND ORAL SURGERY SERVICES AFTER AN ACCIDENT POLICY NUMBER MP

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1 Original Issue Date (Created): July 1, 2005 Most Recent Review Date (Revised): Effective Date: June 29, 2010 May 25, RETIRED I. POLICY II. Dental and/or oral surgery services (on a limited basis) may be considered medically necessary as a result of an accident. Accidental injury would include unintentional traumatic injury to the jaw or structures contiguous to the jaw, including injury to the teeth, and does not include conditions resulting from dental disease or occurring during the normal chewing process. Only those medically necessary services immediately required in response to the emergency and to stabilize the medical condition of the member will be covered. Oral surgery services provided for the care, filling, treatment, removal or replacement of teeth (e.g., root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, extensive dental restoration, dental implants) or structures directly supporting the teeth are generally excluded from coverage. Also, all dental services rendered after stabilization of a member in an emergency following an accidental injury, including but not limited to, oral surgery for replacement teeth, oral prosthetic devices, bridges, or orthodontics are excluded from coverage under the medical plan. Cross-references MP Cosmetic and Reconstructive Surgery MP Dental and Oral Surgery Procedures Including Bony Impacted Teeth Performed in a Facility PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [Y] CHIP* [Y] PPO* [N] HMO [Y] SeniorBlue HMO* [Y] Indemnity* [N] Special Care [Y] POS* [N] FEP PPO Page 1

2 III. IV. [Y] SeniorBlue PPO* * Dental and oral surgery services are eligible for coverage when performed incidental to and as an integral part of a covered service (e.g., removal of broken teeth in order to reduce a jawbone fracture). DESCRIPTION/BACKGROUND Oral Surgery is a branch of dentistry that deals with the extraction of teeth, with the treatment of fractures of the jaw and adjacent bones, and with other surgical procedures on the jaw, oral tissue, and adjacent tissue to correct disease. Generally, dental and oral surgery procedures are usually provided in an office setting. Inpatient, outpatient, or ambulatory surgery facilities may be indicated for some situations. DEFINITIONS ACCIDENTAL INJURY refers to any unintentional injury. V. BENEFIT VARIATIONS VI. The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES American Academy of Pediatric Dentistry (AAPD). Guideline on Management of Acute Dental Trauma. Revised [Website]: Accessed April 1, Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. Section 150: Dental Services. Page 2

3 [Website]: Accessed April 1, Flores MT, Andersson L, Andreasen JO, et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol. Apr 2007; 23(2): McTigue D. Evaluation and management of dental injuries in children In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated January [Website]: Accessed April 1, VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. ICD-9-CM Diagnosis Code* LOSS OF TEETH DUE TO TRAUMA CLOSED FRACTURE OF UNSPECIFIED SITE OF MANDIBLE CLOSED FRACTURE OF ANGLE OF JAW OPEN FRACTURE OF UNSPECIFIED SITE OF MANDIBLE Page 3

4 ICD-9-CM Diagnosis Code* OPEN FRACTURE OF ANGLE OF JAW MALAR AND MAXILLARY BONES, CLOSED FRACTURE OPEN WOUND OF TOOTH (BROKEN), WITHOUT MENTION OF COMPLICATION OPEN WOUND OF TOOTH (BROKEN), COMPLICATED *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. The following services are not covered: HCPCS Code D7270 D7610 D7620 D7630 D7640 D7670 D7671 D7680 D7910 TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED TOOTH MAXILLA - OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT MAXILLA - CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT) MANDIBLE - OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT) MANDIBLE - CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT) ALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETH ALVEOLUS - OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETH FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 4

5 IX. POLICY HISTORY MP CAC 9/28/04 CAC 9/27/05 CAC 7/25/06 CAC 6/26/07 CAC 5/27/08 CAC 5/26/09 CAC 5/25/10 Consensus Policy approved for retirement effective 5/25/2011. Page 5