Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 06/01/2011 Title: Medical Services That RequireDental Services
Revision Date: Document: BI290:00
CPT Code(s): 21010-21116, 21141-21160, 21193-21296, 21421-21490, D0120-D0999
Public Statement
  1. Dental services provided for the routine care, treatment, or replacement of teeth or structures (e.g., root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, and extensive dental restoration) or structures directly supporting the teeth are generally excluded from coverage under QualChoice`s medical plans.
  2. Dental services for other problems may be covered after pre-authorization.

3.    Members should refer to their plan documents for information regarding applicable terms and limitations of coverage.


Medical Statement

1.     Treatment of Jaw and Contiguous Structures:

Some QualChoice medical plans provide coverage for some dental related services, and for certain "dental-in-nature" oral and maxillofacial surgery (OMS) services that are related to the jaw or facial bones. Reduction of any facial bone fracture is covered under all QualChoice medical plans, as well as the removal of tumors, treatment of dislocations, facial and oral wounds/lacerations, and removal of cysts or tumors of the jaws or facial bones, or other diseased tissues.

 

2.     Medical Services Provided by a Dentist:

Medically necessary medical services that could be performed by a physician (M.D. or D.O.) but are performed by a dentist are covered if performance of those services is within the scope of the dentist`s license, according to state law. These services may include, but are not limited to, the following:

    1. Dental examinations to detect infection prior to certain surgical procedures;
    2. Diagnostic x-rays in connection with services covered under the medical plan;

C.    Treatment of oral infections in connection with services covered under the medical plan.

 

3.     Removal of Impacted Teeth:

QualChoice plans usually exclude coverage of services related to the care, filling, removal, or replacement of impacted teeth. See BI207 Dental Impacted Teeth.

Note: In general, placement of bone grafts into extraction sites is considered not medically necessary.

4.     Repair of Cleft Palate:

Medical management of children with cleft palate may involve what might otherwise be considered dental care. The following policies apply to the correction of this congenital defect.

    1. Alveolar ridge closure is covered under QualChoice medical plans as part of the cleft palate repair.
    2. An appliance for palatal expansion in preparation for bone graft surgery of the alveolar cleft may be covered in the pre-surgical and post-surgical period for primary and mixed dentitions. Later orthodontic care, including full braces for the permanent dentition, is not covered.

C.    Orthognathic surgery is covered for these members if the functional impairment to be corrected results from the cleft palate and/or its treatment. For plans with precertification provisions, a proposed treatment plan must be submitted to QualChoice for review.

 

5.     Dental Services that are Integral to Medical Procedures:

A dental service that would otherwise be excluded from coverage under QualChoice`s medical plans may be a covered medical expense if the dental service is medically necessary and is incident to and an integral part of a service covered under the medical plan. Coverage requires prior authorization by QualChoice.

Examples of dental services that are integral to medical procedures include the following:

    1. Extraction of teeth prior to radiation therapy of the head and neck. Note: Dental reconstruction for the replacement of extracted teeth is not covered by the medical plan.
    2. Reconstruction of a dental ridge distorted as a result of removal of a tumor (including bone grafting and dental implants if necessary to stabilize a maxillofacial prosthesis such as an obturator).

C.    Removal of broken teeth necessary to reduce a jaw fracture.

In these examples, the dental or OMS service is either a part of the medical procedure or is done in conjunction with and made necessary solely because of the medical procedure and the dental or OMS service does not treat dental.

6.     Diagnostic Services:

Whether ancillary services and procedures, such as diagnostic x-rays, are covered under the medical plan depends upon whether the primary procedure is covered under the medical plan.

7.     Dental Services Not Integral to Medical Services:

Dental services and dental-in-nature OMS services do not become eligible for medical coverage merely by virtue of their being performed prior to a covered medical service for the treatment of systemic disease, even if the medical service makes the dental service medically necessary. Removal of teeth at risk of infection, periodontal therapies, and subsequent oral rehabilitation reconstruction (i.e., the replacement of teeth) are not covered under medical plans even where these services are medically necessary prior to major surgical procedures such as open heart surgery, organ transplantation, joint reconstructive surgery or other types of surgery.

8.     Dental Services Accompanying Reconstructive Surgery:

Dental services performed in conjunction with medically necessary reconstructive surgery (e.g., reconstructive surgery following ablative surgical procedures) are covered according to the guidelines below:

The following dental services are covered in conjunction with medically necessary reconstructive surgery:

    1. Nasal, aural, orbital, and ocular prostheses;
    2. Radiation stents;
    3. Some medical plans include optional coverage for preventive or other dental services. The Preventive Dental Care Benefit (for members under 12 years of age) is a standard benefit in many QualChoice plans. In addition, some medical plans include a dental services rider. Refer to the individual plan documents for a description of covered services;
    4. Surgical, intermediate, and permanent obturators;

E.    Surgical splints.

 

9.     Other coverage options:

QualChoice medical plans generally provide medical coverage for the following dental and oral and maxillofacial surgery services;

A.    Surgery needed:

      1. To alter the jaw, jaw joints or bite relationships by a cutting procedure when non-surgical management (including appliance, medical, physical, and behavioral therapies) cannot result in functional improvement, not related to TMJ treatment, See BI231 TMJ.
      2. To remove cysts, tumors or other diseased tissues;
      3. To surgically remove teeth that will not erupt through the gum, teeth partly or completely impacted in the bone of the jaw, and teeth that cannot be removed without cutting into bone; charges for routine tooth removal not needing cutting of bone is specifically excluded under standard traditional plans;

4.     To treat a fracture, dislocation or wound.

 

    1. Charges for repairing or replacing the first free standing crown or abutment for fixed bridge prostheses, but only when accidental injury requires re-preparation of the natural tooth. Note: Charges to remove, repair, replace, restore, or reposition teeth lost or damaged in the course of biting or chewing are not covered medical expenses. Sound natural teeth are defined as teeth that were stable, functional, and free from decay and advanced periodontal disease, and in good repair at the time of the accident.

 

    1. Dental treatment needed to remove, repair, replace, restore, or reposition natural teeth damaged, lost, or removed due to an injury occurring while the person is covered under the medical plan. Standard traditional plans also cover dental work to restore, repair, remove, reposition, or replace other body tissues of the mouth fractured or cut. Any such teeth must be free from decay, in good repair and firmly attached to the jawbone at the time of injury. In general, most plans require restoration or replacement in the calendar year of the accident or the next calendar year. Coverage requires prior authorization. The cost of installing the first denture, crown, in-mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury is covered.
      Charges for repairing or replacing the first free standing crown or abutment for fixed bridge prostheses, but only when accidental injury requires re-preparation of the natural tooth.

      Note: Charges to remove, repair, replace, restore, or reposition teeth lost or damaged in the course of biting or chewing are not covered medical expenses.

      Sound natural teeth are defined as teeth that were stable, functional, and free from decay and advanced periodontal disease, and in good repair at the time of the accident.

 

    1. Orthodontic therapy used in the first course of treatment to correct a malocclusion caused by accidental injury (this does not include benefits for full mouth orthodontic therapy).

 

E.    The cost of installing the first denture, crown, in-mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury.

 

10. General Anesthesia Accompanying OMS and Dental Services:

QualChoice medical plans cover the use of general anesthesia for OMS and dental services if the member meets the selection criteria (See BI104 Dental Anesthesia).

11. Bone Grafting of Extraction Sites:

In general, placement of bone grafts into extraction sites is considered not medically necessary. Exception can be made for bone grafting of impacted third molar extraction sites when bony defects are clinically significant and the patient is 26 years of age or older (American Association of Oral and Maxillofacial Surgeons, 2006).

Codes Used In This BI:

 

21010

Incision of jaw joint

21011

Exc face les sc < 2 cm

21012

Exc face les sbq 2 cm/>

21013

Exc face tum deep < 2 cm

21014

Exc face tum deep 2 cm/>

21015

Resect face tum < 2 cm

21016

Resect face tum 2 cm/>

21025

Excision of bone lower jaw

21026

Excision of facial bone(s)

21029

Contour of face bone lesion

21030

Excise max/zygoma b9 tumor

21031

Remove exostosis mandible

21032

Remove exostosis maxilla

21034

Excise max/zygoma mal tumor

21040

Excise mandible lesion

21044

Removal of jaw bone lesion

21045

Extensive jaw surgery

21046

Remove mandible cyst complex

21047

Excise lwr jaw cyst w/repair

21048

Remove maxilla cyst complex

21049

Excis upper jaw cyst w/repair

21050

Removal of jaw joint

21060

Remove jaw joint cartilage

21070

Remove coronoid process

21073

Mnpj of tmj w/anesth

21076

Prepare face/oral prosthesis

21077

Prepare face/oral prosthesis

21079

Prepare face/oral prosthesis

21080

Prepare face/oral prosthesis

21081

Prepare face/oral prosthesis

21082

Prepare face/oral prosthesis

21083

Prepare face/oral prosthesis

21084

Prepare face/oral prosthesis

21085

Prepare face/oral prosthesis

21086

Prepare face/oral prosthesis

21087

Prepare face/oral prosthesis

21088

Prepare face/oral prosthesis

21089

Prepare face/oral prosthesis

21100

Maxillofacial fixation

21110

Interdental fixation

21116

Injection jaw joint x-ray

21141

Reconstruct midface lefort

21142

Reconstruct midface lefort

21143

Reconstruct midface lefort

21145

Reconstruct midface lefort

21146

Reconstruct midface lefort

21147

Reconstruct midface lefort

21150

Reconstruct midface lefort

21151

Reconstruct midface lefort

21154

Reconstruct midface lefort

21155

Reconstruct midface lefort

21159

Reconstruct midface lefort

21160

Reconstruct midface lefort

21193

Reconst lwr jaw w/o graft

21194

Reconst lwr jaw w/graft

21195

Reconst lwr jaw w/o fixation

21196

Reconst lwr jaw w/fixation

21198

Reconstr lwr jaw segment

21199

Reconstr lwr jaw w/advance

21206

Reconstruct upper jaw bone

21208

Augmentation of facial bones

21209

Reduction of facial bones

21210

Face bone graft

21215

Lower jaw bone graft

21230

Rib cartilage graft

21235

Ear cartilage graft

21240

Reconstruction of jaw joint

21242

Reconstruction of jaw joint

21243

Reconstruction of jaw joint

21244

Reconstruction of lower jaw

21245

Reconstruction of jaw

21246

Reconstruction of jaw

21247

Reconstruct lower jaw bone

21248

Reconstruction of jaw

21249

Reconstruction of jaw

21255

Reconstruct lower jaw bone

21256

Reconstruction of orbit

21260

Revise eye sockets

21261

Revise eye sockets

21263

Revise eye sockets

21267

Revise eye sockets

21268

Revise eye sockets

21270

Augmentation cheek bone

21275

Revision orbitofacial bones

21280

Revision of eyelid

21282

Revision of eyelid

21295

Revision of jaw muscle/bone

21296

Revision of jaw muscle/bone

21421

Treat mouth roof fracture

21422

Treat mouth roof fracture

21423

Treat mouth roof fracture

21431

Treat craniofacial fracture

21432

Treat craniofacial fracture

21433

Treat craniofacial fracture

21435

Treat craniofacial fracture

21436

Treat craniofacial fracture

21440

Treat dental ridge fracture

21445

Treat dental ridge fracture

21450

Treat lower jaw fracture

21451

Treat lower jaw fracture

21452

Treat lower jaw fracture

21453

Treat lower jaw fracture

21454

Treat lower jaw fracture

21461

Treat lower jaw fracture

21462

Treat lower jaw fracture

21465

Treat lower jaw fracture

21470

Treat lower jaw fracture

21480

Reset dislocated jaw

21485

Reset dislocated jaw

21490

Repair dislocated jaw

D0120

Periodic oral evaluation

D0140

Limit oral eval problem focus

D0145

Oral evaluation, pt < 3yrs

D0150

Comprehensive oral evaluation

D0160

Extensive oral eval prob focus

D0170

Re-eval, est pt, problem focus

D0180

Comp periodontal evaluation

D0210

Intraoral complete film series

D0220

Intraoral periapical first f

D0230

Intraoral periapical ea add

D0240

Intraoral occlusal film

D0250

Extraoral first film

D0260

Extraoral ea additional film

D0270

Dental bitewing single film

D0272

Dental bitewings two films

D0273

Bitewings - three films

D0274

Dental bitewings four films

D0277

Vert bitewings-sev to eight

D0290

Dental film skull/facial bon

D0310

Dental saliography

D0320

Dental tmj arthrogram incl i

D0321

Dental other tmj films

D0322

Dental tomographic survey

D0330

Dental panoramic film

D0340

Dental cephalometric film

D0350

Oral/facial photo images

D0360

Cone beam ct

D0362

Cone beam, two dimensional

D0363

Cone beam, three dimensional

D0415

Collection of microorganisms

D0416

Viral culture

D0417

Collect & prep saliva sample

D0418

Analysis of saliva sample

D0421

Gen tst suscept oral disease

D0425

Caries susceptibility test

D0431

Diag tst detect mucus abnormal

D0460

Pulp vitality test

D0470

Diagnostic casts

D0472

Gross exam, prep & report

D0473

Micro exam, prep & report

D0474

Micro w exam of surg margins

D0475

Decalcification procedure

D0476

Spec stains for microorganism

D0477

Spec stains not for microorg

D0478

Immunohistochemical stains

D0479

Tissue in-situ hybridization

D0480

Cytopath smear prep & report

D0481

Electron microscopy diagnostic

D0482

Direct immunofluorescence

D0483

Indirect immunofluorescence

D0484

Consult slides prep elsewhere

D0485

Consult inc prep of slides

D0486

Access of transep cytol samp

D0502

Other oral pathology procedure

D0999

Unspecified diagnostic proce


Limits

The following dental services are considered not covered under the medical plan regardless of whether they accompany medically necessary reconstructive surgery:

    1. Dental implants (except as specified in the certificate of coverage). Most medical plans do not cover the routine replacement of teeth via surgical placement of a dental implant body. In addition, any procedures (e.g., bone replacement graft, sinus lift surgery, soft tissue graft, and barrier membrane placement) considered as adjunctive procedures to the surgical placement of the dental implant body are also not covered. For those medical plans that do cover routine replacement of teeth by dental implants, the only procedure covered by the medical plan related to the dental implant is the surgical placement of the dental implant body (replacement of the missing root). The restorative procedure (replacement of the missing crown) is considered a dental expense;

B.   Fluoride carrier.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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