Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 07|19|2007 POLICY LAST UPDATED: 08|17|2022

OVERVIEW This policy addresses the initial dental care/services provided by dental providers specifically relating to injuries of sound natural teeth due to trauma or accident that are covered under the member’s medical benefit.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Prior authorization is not required.

POLICY STATEMENT Medicare Advantage Plans Non-routine dental care required to treat illness or injury may be covered as inpatient or outpatient care. Covered services are limited to surgery of the jaw or related structures and setting fractures of the jaw or facial bones.

Note: Blue Cross & Blue Shield of Rhode Island (BCBSRI) must follow Centers for Medicare and Medicaid Services (CMS) guidelines, such as national coverage determinations or local coverage determinations for all Medicare Advantage Plan policies. Therefore, Medicare Advantage Plan policies may differ from Commercial products. In some instances, benefits for Medicare Advantage Plans may be greater than what is allowed by the CMS.

Commercial Products Treatment of an accidental injury to sound natural teeth when received within seventy-two (72) hours of the onset of an accidental injury is considered medically necessary for the diagnosis codes listed below.

Treatments include the following: • Extraction of teeth needed to avoid infection of teeth damaged in the injury; • Suturing; • Reimplanting and stabilization of dislodged teeth; • Repositioning and stabilization of partly dislodged teeth;
• Dental X-rays.

Any dental services, other than those listed above, are considered a contract exclusion.

COVERAGE

Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable Emergency Dental Condition, and Dental Services benefits/coverage.

BACKGROUND Payment Policy | Dental Services for Accidental Injury d

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

Coverage under the medical benefit is typically provided when there is accidental injury to the sound natural teeth, caused by unexpected and unintentional means. It does not include injury sustained while biting or chewing. Sound natural teeth are defined as teeth that are free of active or chronic clinical decay, have at least 50% bone support and are functional in the arch.

Treatment for an accidental injury to sound natural teeth, and/or any facial fractures will be covered in the hospital or emergency room, along with the doctor’s or dentist’s services, when the accidental injury is the direct cause for the treatment, independent of other disease or bodily injury.

If dentally necessary services are received in a doctor’s or dentist’s office due to an accidental injury to sound natural teeth, the member is responsible for any applicable office visit copayment.

Because services for treatment of accidental injury to sound natural teeth are covered under the medical benefit, the provider should file the claim using the CMS 1500 form.

CODING Commercial Products The following dental codes are typically covered for the treatments mentioned above. X-rays D0210 Intraoral-complete series (radiographic image) D0220 Intraoral-periapical-first radiographic image D0230 Intraoral-periapical-each additional radiographic image D0240 Intraoral-occlusal radiographic image
D0250 Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector
D0270 Bitewing-single radiographic image D0272 Bitewings-two radiographic image D0273 Bitewings-three radiographic image D0274 Bitewings-four radiographic image D0277 Vertical bitewings - 7 to 8 radiographic images

The following is a list of procedure codes typically used by dentists for accidental injury to sound teeth: D7210 Surgical removal of erupted tooth requiring removal of bone and/or section of tooth, and elevation of mucoperiosteal flap
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue
D7540 Removal of reaction-producing foreign bodies, musculoskeletal system

D7910 Suture of recent small wounds up to 5 cm
D7911 Complicated suture - up to 5 cm
D7912 Complicated suture - greater than 5 cm

The following is a list of ICD-10-CM diagnoses codes typically used by dentists for accidental injury to sound teeth: S01.532A S01.542A S01.552A S02.5XXA S02.5XXB S03.2XXA

RELATED POLICIES

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Oral Surgeons Filing Anesthesia Services
Dental Providers Filing Evaluation and Management Services for Medical Reasons Dental Services Rendered in the Outpatient Setting

PUBLISHED Provider Update, October 2022 Provider Update, February 2020 Provider Update, January 2018 Provider Update, January 2017

REFERENCES

1. Blue Cross & Blue Shield of Rhode Island Subscriber Agreement.
2. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) for DENTAL Examination Prior to Kidney Transplantation (260.6)
3. Medicare Dental Coverage - Centers for Medicare & Medicaid Services http://cms.hhs.gov/Medicare/Coverage/MedicareDentalCoverage/index.html

4. Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services 150 - Dental Services i

   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. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS