Coverage Policies

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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: 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)


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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.