Dental Procedures in the Outpatient Setting Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 01|01|2014 POLICY LAST REVIEWED: 03|05|2025 OVERVIEW This policy addresses guidelines relating to facility charges when a dental procedure is rendered in a setting other than the dental office for members with a qualifying medical condition.
MEDICAL CRITERIA While most dental treatment may be performed in an office setting, some members needing dental treatment may have a qualifying medical condition that requires the procedure be provided at an inpatient/outpatient hospital setting or ambulatory surgical center. Such documented medical conditions are as follows, but are not limited to: • Heart disease, including congenital defects and prosthetic heart valve that require strict anticoagulation • Endocrine disturbances, including brittle diabetes and adrenal insufficiency • Blood dyscrasias, including coagulation defects • Neuromuscular disease, including spastic paralysis and muscular dystonias • Pulmonary disease including asthma that cannot safely be managed in an office setting • Genetic disease, including cystic fibrosis and cleft palate • Mental retardation complicated by seizure disorders, cerebral palsy, or behavior disorders • Documented severe emotional disturbance/behavioral disorders • Rampant caries in a patient less than forty-eight (48) months of age (Baby Bottle Syndrome) • Extreme apprehension in children with documentation of unsuccessful attempt(s) at office treatment with sedation PRIOR AUTHORIZATION Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. POLICY STATEMENT Medicare Advantage Plans and Commercial Products When a member has a significant qualifying medical condition, a dentist may request preauthorization to perform the dental service in a setting other than the dental office.
Facility charges (e.g., operating room, anesthesia, medical consults) are eligible for coverage under the member’s medical benefit when the criteria below are met. Any fees and charges specific to the dental procedure or service performed are eligible for coverage under the member’s dental benefit. If the member does not have dental coverage, any resulting charges are the member’s responsibility.
COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable Dental and Inpatient/Outpatient/Free-Standing Ambulatory Surgery benefits/coverage.
Coverage for dental services performed by the oral surgeon/dentist will be provided through the dental benefit. If the member has no dental coverage, payments for the dental services are the member's responsibility.
Medical Coverage Policy | Dental Procedures in the Outpatient Setting

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

BACKGROUND Not applicable

CODING HCPCS Dental Procedure Codes:
The following is a list of HCPCS dental procedure codes typically used for dental procedures rendered in the outpatient setting. This is NOT an all-inclusive list.

Examples of HCPCS dental procedure codes

RELATED POLICIES None

PUBLISHED Provider Update, May 2025 Provider Update, April 2024 Provider Update, April 2023 Provider Update, March 2021 Provider Update, April 2020

REFERENCES Not applicable i ii

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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