Prior authorization request form Form

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

EFFECTIVE DATE: 06|02|2009 POLICY LAST REVIEWED: 1|7|2026

OVERVIEW The policy documents the claim filing process for dental providers rendering an office visit or service for or medical conditions.

PRIOR AUTHORIZATION Not applicable
POLICY STATEMENT Medicare Advantage Plans: An oral or dental examination (not treatment) on an inpatient/outpatient basis performed as part of a comprehensive workup prior to kidney transplantation or heart valve replacement surgery is covered for all dental providers including an Oral Maxillofacial Surgeon (OMS), General Dentist, Periodontist, Endodontist, Orthodontist, Prosthodontist, and Pedodontist.

Dental providers are covered for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw under the member's medical benefit. 1,2 (See special claims filing instructions below in the Coding and Reimbursement section of the policy).

Commercial:
E & M services for oral examinations are covered for Oral Maxillofacial Surgeon (OMS) when rendered for a medical condition under the member’s medical coverage.

E & M services for dental examinations are not covered when reported by other dental providers (excluding OMS) such as, General Dentists, Periodontists, Endodontists, Orthodontists, Prosthodontist, and Pedodontics.

MEDICAL CRITERIA Not Applicable BACKGROUND Medical Conditions:
Medical conditions include but are not limited to malignancy or benign neoplasms of the lip, tongue, or floor of the mouth; diseases of salivary glands; or cyst removal from the area of the mouth.

Dental Conditions: Typically services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth (defined as the periodontium, including the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone [i.e., alveolar process and tooth sockets]) on which the procedure is performed are not covered as a medical benefit. However, certain medical conditions warrant the removal of teeth especially in preparation for radiation treatment for neoplastic diseases involving the jaw.

Medicare allows oral examinations for medical conditions such as prior to renal transplant and/or heart valve replacement surgery and not for the care of the teeth or structures directly supporting the teeth (for definition see above). The examination is for the identification, prior to a complex surgical procedure, of existing Payment Policy | Dental Providers Filing Evaluation and Management for Medical Reasons

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

medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery.

Medicare Advantage Plans

Despite the "dental services exclusion" in §1862(a)(12) of the Act (see the Medicare Benefit Policy Manual, Chapter 16, "General Exclusions from Coverage," §140), an oral or dental examination performed on an inpatient/outpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery. Such a dental or oral examination would be covered under Part A of the program if performed by a dentist on the hospital's staff, or under Part B if performed by a physician. (When performing a dental or oral examination, a dentist is not recognized as a physician under §1861(r) of the Act.) (See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," §70.2, and the Medicare Benefit and Entitlement Manual, Chapter 15, "Covered Medical and Other Health Services," §150.)

COVERAGE Medicare Advantage Plans and Commercial Products Benefits may vary. Please refer to the appropriate Evidence of Coverage, Subscriber Agreement, or Benefit Booklet for applicable benefits/coverage.

CODING Medicare Advantage Plans Special claims filing instructions for dental extractions for Medicare Advantage for Medicare members:
Dental providers: To ensure correct claims processing, the unlisted CPT code below should be filed on a CMS 1500 form. 41899 Unlisted procedure, dentoalveolar structure

Medicare Advantage Plans and Commercial Products The following Evaluation and Management service codes 99202-99205 and 99211-99215 are covered when filed by an OMS for a medical condition.

An Oral Maxillofacial Surgeon (OMS) can file an E&M service for a non-covered, non-medical condition by appending the E&M code with a GA modifier (Waiver liability statement on file). When this is filed, the claim will be denied as non-covered and the member will be liable.

For all other dental specialties (excluding OMS), E&M services are covered when performed as part of a comprehensive workup prior to kidney transplantation or heart valve replacement surgery only. The E&M service claim is to be filed with the ICD-10 code Z01.818 Encounter for other pre procedure in the primary position.

RELATED POLICIES Unlisted Procedures PUBLISHED Provider Update, February 2026 Provider Update, October 2025 Provider Update, September 2023 Provider Update, April 2020 Provider Update November 2018

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

REFERENCES 1.National Coverage Determination (NCD) for Dental Examination Prior to Kidney Transplantation (260.6) https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=194&ncdver=1&bc=AAAAgAAAAAAA&

2. CMS.GOV, Medicare Dental Coverage.
3. Letter from the ADA: 230911adamedicarepfsproposedrulenosigs.pdf
4. AAPC Article: Medicare Expands Dental Coverage in 2024 - AAPC Knowledge Center

5. CMS expands Medicare to cover medically necessary conditions requiring dental services | American
   Dental Association

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   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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