Dental Services for Accidental Injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders Form

Page 1 of 7

Medical Policy Number: 10.01.VT203

Dental Services for Accidental Injury, Gross Deformity,
Head and Neck Cancers and Congenital/Genetic Disorders Corporate Medical Policy

File Name: Dental Services for Accidental Injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders
File Code: 10.01.VT203 Origination: 01/01/2014 Last Review: 03/2025 Next Review: 03/2026 Effective Date: 07/01/2025

Description Dental services include those procedures which are performed on sound natural teeth and supporting structures, lips, tongue, roof and floor of the mouth, accessory sinuses, salivary glands or ducts, jaws (i.e., mandible and maxilla, including orthognathic services). Dental services may also be provided for treatment of sound natural teeth and supporting structures as mentioned above for the following: trauma, cancer-related treatment, infection, accidental injury, reduce a dislocation, repair a fracture, excise tumors, cysts or exostosis, or drain abscesses with cellulitis.

Policy

The intent of this policy is to communicate the medical necessity criteria for medical dental services.

Definitions: Accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.

Preventive dentistry is the branch of dentistry that deals with the preservation of healthy teeth and gums and the prevention of dental caries and oral disease. Primary (Deciduous) Dentition: Teeth developed and erupted first in order of time.

Page 2 of 7

Medical Policy Number: 10.01.VT203

Transitional Dentition: The final phase of the transition from primary to adult teeth, in which the deciduous molars and canines are in the process of shedding and the permanent successors are emerging.

Adolescent Dentition: The dentition that is present after the normal loss of primary teeth and prior to cessation of growth.

Permanent (Adult) Dentition: The dentition that is present after the cessation of growth.

Erupted tooth: Is characterized by the upward movement of a tooth through the jawbone and the breakthrough of the gum to project into the mouth1.

Impacted tooth: Is characterized by a tooth not being fully erupted into the oral cavity. This may be due to insufficient space in the dental arch to accommodate eruption of the tooth, ectopic or abnormal position of the tooth, the presence of associated pathology, or other reasons2.

Sound natural tooth: A sound, natural tooth is a tooth that is whole or properly restored using direct restorative dental materials (i.e. amalgams, composites, glass ionomers or resin ionomers)); is without impairment, untreated periodontal conditions or other conditions; and is not in need of the treatment provided for any reason other than accidental injury. A tooth previously restored with a dental implant, crown, inlay, onlay, or treated by endodontics, is not a sound natural tooth.

When a service or procedure may be considered medically necessary:

The following dental services are covered under the medical benefit when prior approval has been obtained, OR in the event of an emergency, you must contact The Plan as soon as reasonably possible for approval of continued treatment: • Treatment for or in connection with an accidental injury to the jaws, sound natural teeth, mouth or face provided a continuous course of dental treatment is started within six months of the accident and covers a reasonable course of treatment defined as not exceeding five years from the beginning of treatment. • Treatment including root canal procedures in connection to accidental injury. Root canal procedures may be necessary prior to crown installation, when related to accidental injury. • Treatment with dental implants or prostheses, when necessary due to accidental injury.
NOTE: For dental implant insertion the member should be at least 17 years of age, have permanent teeth and have met the above criteria. • Surgery to correct gross deformity resulting from major disease or surgery:
o In the setting of gross deformity resulting from major disease, surgical treatment must take place within six months of the onset of the gross deformity from the disease, or within six months of clinical stability after the onset of the gross deformity from the disease, when there is appropriate clinical documentation that the patient was not clinically stable enough for the corrective treatment prior to this point.

Page 3 of 7

Medical Policy Number: 10.01.VT203

o In the setting of gross deformity resulting from surgery, the corrective treatment must begin within six months after surgery and cover a reasonable course of treatment defined as not exceeding five years from the beginning of treatment except as otherwise required by law.
NOTE: Gross deformity is defined as readily visible and disfiguring and/or functionally disabling. Gross deformity does not include gum disease, absence of teeth or chronic or acute decay. This is usually extensive surgery, such as orthognathic procedures. It includes surgery to correct cleft palate or skeletal deformities. • Surgery related to head and neck cancer where sound natural teeth may be affected primarily or as a result of the chemotherapy or radiation treatment of that cancer. • Treatment related to a congenital or genetic disorder, such as but not limited to the absence of one or more teeth, up to the first molar, or abnormal enamel (example lateral peg). This treatment may include the surgical removal of teeth, if it is required to address sequelae of a congenital or genetic disorder. • Facility and Anesthesia Charges for members: o with phobias or mental illness documented by a licensed physician or mental health professional; OR o with disabilities that preclude office-based dental care due to safety considerations; OR o who are developmentally unable to safely tolerate office-based dental care • Diagnostic Imaging, including but not limited to, plain film radiographs and Cone Beam CT (CBCT), performed as part of evaluation of an accidental injury to the jaws, sound natural teeth, mouth or face, or as part of evaluation to correct gross deformity resulting from major disease or surgery.

NOTE: Professional charges for dental services may not be covered

When a service is considered a benefit exclusion and therefore not covered • Surgical removal of teeth, including removal of bony impacted wisdom teeth. (This exclusion does not apply when surgical removal of teeth is medically necessary to address sequalae of a congenital or genetic disorder as above); • Gingivectomy; • Tooth implants including those for the purpose of anchoring oral appliances that are not listed as medically necessary with prior approval above. (This exclusion does not apply to the treatment of an accidental injury, trauma, cancer-related treatment or diagnosis for which a member has received a prior approval);
• Care for periodontitis; • Injury to teeth or gums as a result of chewing or biting; • Orthodontics (including orthodontics performed as adjunct to orthognathic surgery or in connection with an accidental injury); • Pre- and post-operative care (most pre-and post-operative visits are considered part of the surgical benefit, and additional benefits are not provided for these services); • Procedures designed primarily to prepare the mouth for dentures (including alveolar augmentation, bone grafting, frame implants, ramus mandibular stapling); • Dental services and dental related Oral Surgery, unless specifically outlined as

Page 4 of 7

Medical Policy Number: 10.01.VT203

eligible in the member’s contract; • Charges related to Non-Covered dental procedures or anesthesia (for example, facility charges, except when medically necessary as listed above); • Fluoride treatments performed in the school setting; • Cosmetic procedures and supplies that are not Reconstructive.

Reference Resources

• http://meddict.org/term/eruption-of-teeth/ • www.aaoms.org/docs/practicemgmt/.../impactedthirdmolars.pdf • http://www.aaoms.org http://www.surgical-dentistry.info/files/DentalUpdate- TheSurgicalManagementoftheOralSoftTissues- Biopsy.pdf • http://www.dentistry.utoronto.ca/dpes/oral-maxillofacial- surgery/patients/surgical- incision-and-drainage-patient • http://www.charlotteoralsurgery.com/oral-surgery-charlotte-nc/bone- grafting- charlotte-nc.html • http://www.rightdiagnosis.com/surgery/vestibuloplasty.htm and http://www.ffofr.org/education/lectures/complete-dentures/complete- dentures- reconstructive-preprosthetic- surgery/ • http://www.cosmeticdentistryguide.co.uk/articles/tuberosity-reduction.html

Related Policies

Dental Services Pediatric for (Qualified Health Plan and Applicable Plans) Temporomandibular Joint Dysfunction

Document Precedence

Blue Cross and Blue Shield of Vermont (Blue Cross VT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language, or employer’s benefit plan if an ASO group, determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, Blue Cross VT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract/employer benefit plan language, the member’s contract/employer benefit plan language takes precedence.

Audit Information

Blue Cross VT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, Blue Cross VT reserves the right to recoup all non- compliant payments.

Page 5 of 7

Medical Policy Number: 10.01.VT203

Administrative and Contractual Guidance Benefit Determination Guidance

Prior approval may be required and benefits are subject to all terms, limitations and conditions of the subscriber contract.

Incomplete authorization requests may result in a delay of decision pending submission of missing information. To be considered compete, see policy guidelines above.

NEHP/ABNE members may have different benefits for services listed in this policy. To confirm benefits, please contact the customer service department at the member’s health plan.

Federal Employee Program (FEP): Members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. It is important to verify the member’s benefits prior to providing the service to determine if benefits are available or if there is a specific exclusion in the member’s benefit.

Coverage varies according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict.

If the member receives benefits through an Administrative Services Only (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member’s employer benefit plan documents or contact the customer service department. Language in the employer benefit plan documents takes precedence over medical policy when there is a conflict.

Policy Implementation/Update information

06/2013 Policy developed to comply with the Affordable Care Act and the State of VT RFP. 03/2014 Added CDT code: D1110 for adult prophylaxis. Approved by DHVA on 3/21/14 performed on children as young as 13 yrs of age. RLJ. 01/2015 Definition “sound natural tooth” updated. Exclusions clarified. Facility and anesthesia charges clarified. MPC approved policy on 1/19/15. 06/2015 Part A- under medically necessary “Surgery related to head and neck cancer where sound natural teeth may be affected primarily or as a result of the chemotherapy or radiation treatment of that cancer”. 10/2017 Clarifying language added absent (tooth /teeth), Trauma, infection, cancer-related treatment. Examples: Added, services may be covered (trauma, infection, cancer- related treatment. External provider feedback received. Coding changes: D0260- deleted 01/01/2016, D9220- deleted 01/01/2016, D9221- deleted 01/01/2016, D9241- deleted 01/01/2016, D9242- deleted 01/01/2016

Page 6 of 7

Medical Policy Number: 10.01.VT203

01/2018 CDT Yearly adaptive maintenance changes: D0260, D9220, D9221, D9241, D9242- the codes were deleted effective 01/01/2016. Deleted D5510, D5610 & D5620 the codes were deleted effective 01/01/2018. Revised the following codes to be effective 01/01/2018; D2740, D3320, D3330, D4321, D4326, D4355, D7111. Added the following codes effective 01/01/2018: D1354, D5511, D5512, D5621, D5622, D8695, D9222, D9223, D9239 01/2019 CDT Yearly Adaptive Changes Effective 01/01/2019: D1515 deleted replaced with D1516&D1517. D1525 deleted replaced with D1526 & D1527. D5211, D5212 & D5630 Edit to descriptor. D9404 deleted replaced with D9944, D9945 & D9946. 10/2019 Removed dental instructions regarding age, limit and guidance for benefit within body of document and placed in coding table. New coding table added to medical policy for ease of reading. 01/2020 CDT Yearly Adaptive Changes Effective 01/01/2020: Revised Codes: D1510 & D1575. Deleted Codes: D1550, D8692, D8694. Editorial Changes to Codes: D5213, D5214, D6214. New Codes: D1551, D1552, D1553, D2753, D6243, D6753, D7922, D8698, D8699, D8701, D8702. Non-Covered Codes: D0419, D1556, D1557, D1558, D5284, D5286, D6083, D6084, D6086, D6087, D6088, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6195, D6784, D8696, D8697, D9997 05/2020 Updates to teledentistry for synchronous and asynchronous services. Removed D9996 from non- covered to medically necessary. Added Code D9995 as medically necessary. Added section for teledentistry with language and documentation guidance to policy. Added code D0190 to be used in conjunction with teledentristy code D9996 to be eligible for asynchronous teledentistry. 01/2021 CDT Yearly Adaptative Maintenance Changes Effective 01/01/2021: Added codes to coding table as eligible services with applicable criteria: D0701, D0702, D0703, D0705, D0706, D0707, D0708, D0709, D2928, D3471, D3472, D3473, D3501, D3502, D3503, D7961, D7962. Added codes to Non-Covered coding table: D0704, D1321, D1355, D5995, D5996, D6191, D6192, D7993, D7994. Revised Descriptors: D0120, D0150, D1110, D1120, D1557, D1558, D2960, D5225, D5226, D5284, D5286, D5750, D5751, D5760, D5761, D5820, D5821, D6098. Deleted Codes: D3427, D7960. Codes that will not require prior approval: D2981, D2982, D2983. 04/2021 Policy renamed and separated Part A and Part B of the policy for clarification of services. Policy name change+++ Changed from Dental Services to Dental Services for Accidental Injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders. Updated timeframe and duration statements of treatment. 04/2022 Policy reviewed. Minor language and formatting changes. Clarification of benefit for root canal procedure. 02/2023 Policy reviewed. Removed reference to age under facility and Anesthesia Charges section of policy. Added Diagnostic Imaging section to add medical necessity criteria for services. 02/2024 Policy reviewed. Clarification around coverage for extraction of teeth when related to sequelae of congenital or genetic deformity. Minor formatting changes.

Page 7 of 7

Medical Policy Number: 10.01.VT203

03/2025 Policy reviewed. Clarification around surgery to correct gross deformity resulting from major disease.

Eligible providers

Qualified healthcare professionals practicing within the scope of their license(s).

Approved by Blue Cross VT Medical Directors

Tom Weigel, MD, MBA Vice President & Chief Medical Officer

Tammaji P. Kulkarni, MD
Senior Medical Director