Medical Policy

Effective Date:08/23/2012

Title:Dental Treatment in Accidental Injury

Revision Date:06/01/2018

Document:BI373:00

CPT Code(s):00170, 21248, 41899, D0411, D5511-D5622, D6010, D6012, D6040, D6050, D6053-D6080, D6090-D6096, D6100, D6118, D6119, D6190, D6194, D6199, D6205, D7296, D7297, D7610-D7680, D7710-D7771, D7780, D7979, D8695, D922, D9223, D9239, D9240, D9995, D9996

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1) Benefits for the treatment of dental injuries may have limitations; consult your plan documents.

2) All dental treatment of injuries requires medical review.

3) Coverage for dental injuries is limited to the immediate injury to natural teeth without evidence of cavity, gum disease or other compromise.

4) The services must be provided by a Doctor of Dental Surgery (DDS) or a Doctor of Medical Dentistry (DMD).

5) The services must begin within 72 hours of the accident and be completed within 12 months.

6) Dental implants are not covered.

7) Repair of dentures, dental implants or orthodontic appliances are not covered.

8) Anesthesia required to make the repairs of dental injuries is covered under the benefit limitations.

9) Teledentistry is not covered.

Medical Statement

1) All dental treatment of injuries requires medical review.

2) Coverage for dental injuries is limited to the immediate injury to natural teeth without evidence of cavity, gum disease or other compromise.

3) The services must be provided by a Doctor of Dental Surgery (DDS) or a Doctor of Medical Dentistry (DMD).

4) The services must begin within 72 hours of the accident and be completed within 12 months.

5) Only the sound and natural tooth or teeth avulsed or extracted as a direct result of the Accidental Injury will be considered for replacement with a bridge or removable partial denture.

6) Orthodontic services are limited to the stabilization and re-alignment of the accident-involved teeth to their pre-accident position; reimbursement for this service will be based upon a Maximum Allowable Charge per tooth.

7) Double abutments are not covered.

8) Any health intervention related to dental caries or tooth decay is not covered.

9) Removal of teeth alone is not covered.

10) Dental implants of any kind are not covered

11) Anesthesia required to make the repairs is covered under the benefit limitations.

Codes Used In This BI:

00170 Anesth procedure on mouth

21248 Reconstruction of jaw

41899 Dental surgery procedure

D0411	HbA1C in office point of service testing (1/1/2018)
D5511	Repair broken complete dental base, mandibular (1/1/2018)
D5512	Repair broken complete dental base, maxillary (1/1/2018)
D5611	Repair resin partial dental base, mandibular (1/1/2018)
D5612	Repair broken complete dental base, maxillary (1/1/2018)
D5621	Repair cast partial framework, mandibular (1/1/2018)
D5622	Repair cast partial framework, maxillary (1/1/2018)
D6010	Surgical placement impl body: Endosteal
D6012	Surgical placement interm impl pros: Endos
D6040	Surgical placement: Eposteal implant
D6050	Surgical placement: Transosteal implant
D6053	Implant abutment denture compl edntuls arch
D6054	Implant abutment denture part edntuls arch
D6055	Connecting bar implant abutment support
D6056	Prefabricated abutment incl placement
D6057	Custom abutment includes placement
D6058	Abutment support porcelain/ceramic crown
D6059	Abutment porcelain to metal crown/high noble metal
D6060	Abutment porcelain to metal crown/base metal
D6061	Abutment porcelain to metal crown noble metal
D6062	Abutment support/cast metal crown/high noble metal
D6063	Abutment support/cast metal crown/base metal
D6064	Abutment support/cast metal crown/noble metal
D6065	Implant support porcelain/ceramic crown
D6066	Implant support porcelain fused metal crown
D6067	Implant supported metal crown
D6068	Abutment support retain porcelain/ceramic full partial denture
D6069	Abutment retain porcelain metal full part denture/high noble metal
D6070	Abutment retain porcelain metal/full part denture/base metal
D6071	Abutment support retainer/porcelain fused metal/full part denture
D6072	Abutment support retainer/cast metal full partial denture
D6073	Abutment retainer/cast metal/full partial denture base metal
D6074	Abutment retainer/cast metal/full partial denture/noble metal
D6075	Implant support retainer/ceramic/full partial denture
D6076	Implant support retainer/porcelain fused metal/full partial denture
D6077	Implant support retainer/cast metal/full partial denture
D6078	Implant abutment denture/complete arch
D6079	Implant abutment denture/partial edntuls arch
D6080	Implant maintenance porcelain removable/clean reinsert
D6090	Repair implant support prosthetic by report
D6091	Replace implant abutment prosthesis per attachment
D6092	Re-cement implant supported crown
D6093	Re-cement implant abutment fixed partial denture
D6094	Abutment supported crown/titanium
D6095	Repair implant abutment, by report
D6096	Remove broken implant retaining screw (1/1/2018)
D6100	Implant removal, by report
D6118	Implant/abutment support interim denture mandibular (1/1/2018)
D6119	Implant/abutment support interim denture maxillary (1/1/2018)
D6190	Radiographic/surgical implant index report
D6194	Abutment support retainer/crown for full partial denture
D6199	Unspecified implant procedure, by report
D6205	Pontic indirect resin based composite
D7296	Osteotomy, mandible, segmental
D7297	Osteotomy, maxilla, segmental
D7610	Maxilla-open reduction
D7620	Maxilla-closed reduction
D7630	Mandible-open reduction
D7640	Mandible-closed reduction
D7650	Malar & Zygo arch-open reduction
D7660	Malar & Zygo arch-closed reduction
D7670	Alvelo-closed reduction may w/stable teeth
D7671	Alvelo-open reduction may w/stable teeth
D7680	Face bones-complex reduction fix & mx apprch
D7710	Maxilla open reduction
D7720	Maxilla closed reduction
D7730	Mandible open reduction
D7740	Mandible closed reduction
D7750	Malar & Zygomatic arch-open reduction
D7760	Malar & Zygo arch-closed reduction
D7770	Alveol-open reduction stabilize teeth
D7771	Alveol-closed reduction stabilize teeth
D7780	Face bones-complex reduction fix & mx apprches
D7979	Non-surgical sialolithotomy (1/1/2018)
D8695	Remove fixed orthodontic appliance not for completion of Tx (1/1/18)
D9222	Deep sedation/general anesthesia, 1st 15 mins (1/1/2018)
D9223	Deep sedation/general anesthesia, subsequent 15 mins (1/1/2018)
D9239	Intravenous moderate sedation/anesthesia, 1st 15 mins (1/1/2018)
D9240	Intravenous moderate sedation/anesthesia, subsequent 15 mins (1/1/2018)
D9995	Teledentistry, synchronous (1/1/2018)
D9996	Teledentistry, asynchronous (1/1/2018)

Limits

Intentially left empty

Reference

Intentially left empty

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.