NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA. Revised: 5/1/2017

Transcription

1 NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA Revised: 5/1/2017 The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines. DIAGNOSTIC Clinical Oral Evaluations D0120 D0191 Pre-Diagnostic Services D0190 screening of a patient D0191 assessment of a patient Diagnostic Imaging Image capture with interpretation D0210 D0371 Image Capture only D0380 D0386 Interpretation and Report only D0391 D0395 CPT codes: 70486, 70487, 70488, and in member record that includes all services performed for the code submitted in member record that includes all services performed for the code submitted. in the member record. Diagnostic, clear, readable images, dated with member name. 1 Criteria for codes D0364 D0368, D0380 D0386, D0391 D0395: Cone beam computed tomography (CBCT) is unproven and not medically necessary for routine dental applications. There is insufficient evidence that CBCT is beneficial for use in routine dental applications. CBCT should not replace traditional dental x-rays as a preliminary diagnostic tool, or for routine dental procedures such as restorations, but be used as an adjunct when the level of detail CBCT is needed to safely render treatment for complex clinical conditions (e.g. oral surgery, implant placement and endodontics). These procedures may have a higher risk of complications without the level of detail CBCT imaging provides. CBCT imaging used for these reasons should be read and interpreted by an appropriately trained professional. In addition, radiation exposure associated with CBCT needs to be weighed against possible benefits, which have not been supported in the published literature. Limited definitive conclusions regarding the clinical role of CBCT can be reached due to the lack of well-designed studies that systematically evaluate diagnostic accuracy and the impact of CBCT on clinical decision making and patient health outcomes. Additional studies are needed to verify that CBCT provides added diagnostic value beyond two-dimensional imaging such as panoramic radiography and conventional computed tomography and to

2 Diagnostic Imaging Bacterial And Viral Testing D0414, D0415, D0416 Salivary Testing D0417, D0418 Provider narrative including clinical reason/diagnosis for test and type of test performed. Provider narrative including clinical reason/diagnosis for test and type of test performed. determine whether CBCT improves treatment decision making and health outcomes. Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP002.02) Criteria for codes D0414, D0415, D0416 Collection of Microorganisms for Culture and Sensitivity Collection of microorganisms for culture and sensitivity is indicated for the following: For odontogenic infections that do not respond to rational antibiotic empiric therapy and/or incision and drainage in a timely manner For odontogenic infections in patients with comorbidities including but not limited to impaired healing response, and compromised immune system Collection of microorganisms for culture and sensitivity is not indicated for the following: As a routine procedure for all infections (unless patient has multiple comorbidities or infection is resistant to conventional therapy) If infection is small and limited to localized area If infection is draining on its own with no evidence of spread of infection For fungal infections For viral culturing (this procedure has its own reporting code) Viral Culture Viral culturing is indicated for the presence of oral and perioral vesicles and ruptured vesicles resulting in lesions that may or may not be crusted over. Viral culturing is not indicated for suspected cytomegalovirus (CMV) oral lesions (an incisional biopsy and testing is indicated). Refer to coverage guideline: Bacterial And Viral Testing (DCG039.01) Criteria for codes D0417, D0418 Collection, Preparation and Analysis of Saliva Sample for Laboratory Diagnostic Testing Collection, preparation and analysis of saliva sample for laboratory diagnostic testing may be indicated as part of oral disease risk assessment and management, including but not limited to caries, periodontal disease and xerostomia. Refer to clinical policy: Salivary Testing (DCG037.01) 2

3 Genetic Testing for Oral Disease D0422, D0423 Miscellaneous Diagnostic Procedures D0425, D0460, D0470 Provider narrative including clinical reason/diagnosis for test and type of test performed. Criteria for codes D0422, D0423 Collection and Preparation of Genetic Sample Material for Laboratory Analysis and Report Genetic Test for Susceptibility to Diseases Specimen Analysis The collection, preparation and testing of genetic samples are indicated for patients who have known human papilloma virus (HPV) infection, or have other related risk factors, to identify if the strain of HPV known to be related to oral and oropharyngeal cancers is present. The clinical utility of genetic testing for susceptibility to periodontal diseases has not been established. Additionally, there is a lack of objective, high quality clinical evidence to support these tests. Refer to clinical policy: Genetic Testing for Oral Disease (DCP036.01) Criteria for codes D0425, D0460, D0470 Caries Susceptibility Tests There is a lack of objective, high quality clinical evidence to support or refute the efficacy or superiority of this specific testing method as a tool for caries risk assessment and management. Pulp Vitality Tests Pulp vitality tests are indicated for the following: For traumatic injuries to teeth Teeth with deep caries or defective restorations Pulp vitality tests are not indicated for the following: Sensitivity of exposed dentin without evidence of pulp pathosis Teeth with no evidence of caries, resorption, defective restorations, or otherwise asymptomatic As part of routine dental examinations Diagnostic Casts Combined with clinical and radiographic findings, diagnostic casts may be useful for select cases, as they can provide a further understanding of the overall dentition. They may be helpful in developing the treatment plan without the patient present, and can serve as an additional tool for educating the patient. They provide an opportunity for a more thorough evaluation of the following: Tooth interdigitation Functional occlusion, and any occlusal abnormalities Wear facets and defective restorations, coronal contours, proximal contacts and embrasure spaces between teeth Refer to coverage guideline: Miscellaneous Diagnostic Procedures (DCG040.01) 3

4 Non-Ionizing Diagnostic Procedures D0600 Tests and Examinations D0431 caries risk assessment D0601 D0603 Oral Pathology Laboratory D0472 D0502 Unspecified diagnostic procedure by report D0999 PREVENTIVE Dental Prophylaxis D1110 D1120 Topical Fluoride Treatment D1206, D1208 CPT code: Provider narrative including clinical reason/diagnosis for test and type of test performed. Provider narrative including clinical reason/diagnosis for test and type of test performed. Services performed must be documented in the member record. Age and medical necessity. An adult is generally defined as twelve years or older. 4 Criteria for code D0600 There is inadequate evidence demonstrating the efficacy of these devices, limiting their use as a principal diagnostic tool. A non-ionizing diagnostic procedure refers to a device specifically designed to identify, quantify, monitor, and record changes in structure of enamel, dentin and cementum. These devices may be used as an adjunctive tool by the dental provider to identify high caries risk areas, and create non-invasive treatment plans for remineralization before caries begins. Visual and radiographic examinations remain the standard diagnostic methods for diagnosing active caries. Refer to clinical policy: Non-Ionizing Diagnostic Procedures (DCP041.01) Criteria for codes D1206, D1208 Topical Application of Fluoride Excluding Varnish Topical fluoride treatments in the form of gel, foam and rinses applied as a caries preventive agent in the dental office are benefitted twice per consecutive twelve months for children up to age 15. Patients at low risk of developing caries may not need additional topical fluorides other than over-the-counter fluoridated toothpaste and fluoridated water. Topical Application of Fluoride Varnish Fluoride varnish is indicated for the following: As the preferred caries prevention agent for children under age 6 For head and neck radiation therapy patients Sensitivity that does not resolve with an over-the-counter desensitizing dentifrice For moderate to high caries risk patients with a medical or cognitive impairment that limits cooperation with a tray or rinse delivery method Xerostomia due to systemic disease or medication

5 Topical Fluoride Treatment Other Preventive Services D1310 D1330 Sealants D1351, D1352, D1353 /narrative in member record that service was performed and materials supplied to member. Sealant: Tooth numbers. For patients in active orthodontic treatment For the remineralization of incipient or white spot enamel carious lesions Refer to clinical policy: Topical Fluoride Treatment (DCP018.02) Criteria for codes: D1351, D1352, D1353 Sealants Dental caries is the most common pediatric disease. Dental sealants are recognized as an effective preventive approach to preventing pit and fissure caries in children and adolescents. Sealants are indicated for the following: Caries prevention in pit and fissures on permanent molars of children and adolescents Non-cavitated carious lesions on permanent teeth in children and adolescents Caries prevention for primary teeth in children with documented high caries risk with a reasonable prognosis for retention anticipated. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver have active caries o White spot lesions or enamel defects o Visible caries or previous restorations o Poor oral hygiene o Sub-optimal systemic fluoride intake o Frequent exposure to cavity-producing foods and drinks o Patients with special health care needs o Low socioeconomic status o Xerostomia o More than one interproximal lesion o Other factors identified by professional literature o Deep pits and fissures o Patients with special needs Sealants are not generally indicated for the following: Widespread cavitated carious lesions Presence for interproximal or smooth surface lesions Occlusal surfaces that are already carious with involvement of the dentin that requires restoration Extrinsic staining of pits and fissures For placement on premolars, buccal and lingual pits of molars and cingula of anterior teeth 5

6 Sealants Space Maintenance D1510, D1515, D1520, D1525, D1550, D1555, D1575, D1999 Radiographs of the involved arch. Preventive Resin Restoration (PRR) Preventive resin restoration is done on an active cavitated lesion in a pit or fissure that does not extend into the dentin. This includes placement of a sealant in any radiating non-carious fissures or pits. Preventive resin restorations are indicated for the restoration of pit and fissures carious lesions contained to enamel in moderate to high caries risk patients. Preventive resin restorations are not indicated for the following: When no caries is evident in pits and fissures When a sealant is clinically indicated For carious lesions that extend into dentin Coverage Limitations Sealants and PRRs are limited to one per tooth per 36 months. Refer to coverage guideline: Sealants (DCG026.01) Criteria for codes D1510, D1515, D1520, D1525, D1550, D1555, D1575, D1999 Space maintainers are indicated for the following: Maintaining space due to premature loss of a primary tooth (teeth) To regain space Space maintainers are contraindicated for the following: When tooth/teeth is/are close to eruption Patient is not compliant or has poor oral hygiene Severe crowing already exists Space has already been lost If sufficient amount of space already exists Coverage Limitations and Exclusions Limited to one per tooth per consecutive 60 months Any space maintainer adjustments are inclusive for 6 months Limited to persons under the age of 16 Refer to coverage guideline: Space Maintenance (DCG035.01) 6

7 RESTORATIVE Direct Restorations D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2941, D2990, D2999 Amalgam Restorations D2140 D2161 Resin-Based Composite Restorations Direct D2330 D2394 Gold Foil Restorations D2410 D2430 Tooth number and surface. Caries removal documented in member record. Criteria for codes D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2941, D2990, D2999 Direct Restorations Direct restorations are indicated for the following: To replace a tooth structure lost to caries or trauma To replace restorative material lost in the course of accessing pulp chamber for endodontic therapy To replace existing restorations that exhibit recurrent decay, fracture or marginal defects In addition to the above, glass ionomer restorations are indicated for the following: When teeth cannot be isolated properly to allow placement of resin restorations As an alternative to resin sealants when the teeth cannot be properly isolated (patient cooperation, partially erupted teeth) Class I,II, III and V restorations on primary teeth Class III and V restorations on permanent teeth that cannot be isolated in high risk patients As a caries control plan for high risk patients using atraumatic techniques Direct restorations are not indicated for the following: Teeth with a hopeless prognosis in which extraction is indicated Incipient enamel only lesions extending less than halfway to the dentinoenamel junction (DEJ) When there is sufficient loss of tooth structure that a crown or onlay is indicated When used as part of comprehensive or interceptive orthodontics to maintain an open bite For primary teeth that are near exfoliation or less than 50% of the tooth root remains Composite resin restorations are not indicated for patients with heavy bruxism Composite resin restorations are not indicated for patients with extensive active caries, or high caries risk Amalgam restorations are not indicated for placement on teeth in which they will have contact with gold restorations In addition to the above, glass ionomer restorations are not indicated for the following: As a definitive, long term restoration in permanent teeth 7

8 Direct Restorations When a sealant is indicated Required When a metal allergy is suspected, documentation from an allergist is required to support replacement of amalgam with composite. Protective Restoration Protective restoration is indicated for the following: To relieve pain To promote healing To prevent further deterioration To retain tissue form Protective restoration is not indicated for the following: As a liner or base for a definitive restoration Not for endodontic access closure Not for pulp capping As a definitive restoration Interim Therapeutic Restoration-Primary Dentition Interim therapeutic restorations are indicated for the following: For very young, uncooperative or special needs patients When traditional tooth preparation for an amalgam or composite restoration is not feasible or must be postponed As a caries control plan for high risk patients using atraumatic techniques Resin Infiltration of Incipient Smooth Surface Lesions Resin infiltration of incipient smooth surface lesions is typically used for aesthetic purposes. It is used to describe a proprietary product, and there is a lack of established objective evidence to support its use. Coverage Limitations and Exclusions Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Any dental procedure not directly associated with dental disease Posterior composites may be alternately benefitted to amalgam coverage unless specified in member plan Gold foil restorations are benefitted to amalgam unless specified in member plan, or used to replace material lost on a gold crown due to endodontic therapy Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure Refer to coverage guideline: Single Tooth Direct Restorations (DCG023.01) 8

9 Indirect Restorations: Inlay/Onlay Restorations D2510 D2664 (Inlay/onlays) Crowns Single Restorations Only D2710 D2799 Pre-operative x-rays. If endodontic therapy has been performed, a periapical radiographic image clearly showing the apex of the completed treatment is required; otherwise, bitewing x-rays may be sufficient at the discretion of the reviewer. A narrative or photograph may provide additional information, especially for replacement of existing crowns. Cracked tooth syndrome requires adequate documentation of extent of fracture, location and how it was diagnosed. Tooth must be symptomatic. Restorations for members under age 15 require statement of medical necessity. Inclusive Local anesthesia; tooth preparation; temporary crown; fitting; cementation; post-op adjustments, impressions; bases. 9 Criteria for codes D2510, D2520 D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2799 Indications for Coverage For indirect restorations, the following clinical parameters apply: Five-year longevity should be evident, periodontium must be healthy or have documentation the member has periodontal disease under control for a period of at least 6 months, and no evidence of endodontic pathology or potential endodontic issues on the radiographic image. Crowns Crowns are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Large, >50% of the tooth, defective restoration that can be seen on the radiographic image Fracture of cusps Endodontically treated teeth, unless minimal access opening on anterior tooth that a direct restoration is not possible Crown/root ratio must be favorable /narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image 50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and one or more cusps involved Symptomatic cracked tooth syndrome (not enamel craze lines ) Full coverage restoration of a primary tooth without a permanent successor Crowns are not indicated for the following: If a lesser means of restoration is acceptable If root resorption is present Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration) For alteration of vertical dimension For purposes of preventing future fracture, or to eliminate enamel craze lines (cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative; tooth must be symptomatic) To treat non-pathologic wear/abrasion, or abfraction lesions in the absence of decay For molars exhibiting bone loss with a class III furcation involvement

10 Indirect Restorations Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable Fracture of porcelain not involving the margin or a functional ridge is not sufficient for replacement Onlays Onlays are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Large, >50% of the tooth, defective restoration that can be seen on the radiographic image Fracture of cusps Endodontically treated teeth, unless minimal access opening on anterior tooth that a direct restoration is not possible Crown/root ratio must be favorable /narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image 50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and one or more cusps involved Benefitted for primary teeth without permanent successor Bicuspids and molars: 3 or more surfaces and one or more cusps involved Symptomatic cracked tooth syndrome Onlays are not indicated for the following: If a lesser means of restoration is acceptable If root resorption is present Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration) For alteration of vertical dimension For purposes of preventing future fracture, or to eliminate enamel craze lines (cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative; tooth must be symptomatic) To treat non-pathologic wear/abrasion, or abfraction lesions in the absence of decay For molars exhibiting bone loss with a class III furcation involvement Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable Fracture of porcelain not involving the margin or a functional ridge is not sufficient for replacement 10

11 Indirect Restorations Other Restorative Services D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2982, D2999 Repairs necessitated by restorative material failure D2980 D2999 Inlays Inlays are unproven Inlays have not been proven superior over direct restorations and are alternative benefitted to amalgam restorations. Coverage Limitations and Exclusions Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). Any Dental Procedure performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance). Refer to coverage guideline: Single Tooth Indirect Restorations (DCG008.02) Criteria for codes: D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2982, D2999 Recement and Rebond of Single Tooth Indirect Restorations Recement and rebond of single tooth indirect restorations are subject to frequency limitations. Please refer to member specific benefit plan document for guidance. Repair of Single Tooth Indirect Restorations Repair of single tooth indirect restorations is indicated to repair a fractured inlay, onlay, crown or veneer in which the functional area is involved due to restorative material failure. Repair of single tooth indirect restorations is not indicated solely for cosmetic/aesthetic purposes. Reattachment of Tooth Fragment Reattachment of tooth fragment is indicated for a tooth fracture confined to enamel and dentin with loss of structure, but not exposing the pulp. Reattachment of tooth fragment is not indicated for the following: Tooth fractures involving pulpal exposure Fractures involving roots Coping Coping is considered inclusive to the preparation of crowns and bridge 11

12 Other Restorative Services abutments unless and indicated a separate procedure for the following: If insufficient natural tooth structure remains to retain the crown To allow a common path of insertion when retainer teeth are tipped or misaligned Coverage Limitations and Exclusions Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Repairs are limited to those performed more than 12 months after the initial insertion. Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure Refer to coverage guideline: Other Restorative Services (DCG024.01) Prefabricated Crowns Porcelain/Ceramic Crown D2929 Stainless Steel Crown D2930, D2931, D2932, D2933, D2934 Tooth number Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934 Prefabricated Crowns are indicated for the following: For the restoration of teeth with more than two surfaces affected with carious lesions, or where extensive one or two surface lesions are present. For one and two surface carious lesions in documented high caries risk children. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver has active caries; o White spot lesions or enamel defects; o Visible caries or previous restorations; o Poor oral hygiene; o Sub-optimal systemic fluoride intake; o Frequent exposure to cavity-producing foods and drinks; o Patients with special health care needs; o Low socioeconomic status; o Xerostomia; o More than one interproximal lesion; o Other factors identified by professional literature; Cervical decalcification, and/or developmental defects (hypoplasia, hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.). Interproximal caries extending beyond line angles. Following pulpotomy or pulpectomy. For restoring a primary tooth that is to be used as an abutment for a space maintainer. For the intermediate restoration of fractured teeth. Restoration and protection of teeth exhibiting extensive tooth surface loss 12

13 Prefabricated Crowns Protective restoration D2940 Core Buildup, Post and Core and Pin Retention D2949 Core buildup: D2950 Pin retention per tooth: D2951 Post and Core: D2952, D2953, D2954, D2955, D2957 D2999 Recorded in member chart. Bitewing unless tooth has had root canal therapy, then a periapical should be submitted. 13 due to attrition, abrasion or erosion. In patients with impaired oral hygiene in which the breakdown of intracoronal restorations is likely. When the tooth cannot be effectively isolated for amalgam or composite restorations. Prefabricated Crowns are not indicated for the following: A primary molar that is close to exfoliation, with more than half the roots resorbed. Excessive tooth crown loss resulting in the inability for mechanical retention. Loss of space due to tipping of neighboring teeth into carious defect interfering with the ability to attain proper fit. As a definitive restoration on a permanent tooth. For low and moderate caries risk patients, when a more conservative restoration is indicated. Solely for cosmetic purposes. As a prophylactic measure for teeth with no evidence of pathology. Refer to clinical policy: Prefabricated Crowns (DCP012.02) Criteria Direct placement of a restorative material to protect tooth and/or tissue form. Used to relieve pain, promote healing, or prevent further deterioration. Covered as a separate procedure only if no other service other than radiographic images and exam were performed on the same tooth on the same day. Not to be used for endodontic access closure, or as a base or liner under a restoration Criteria for codes D2949, D2950, D2951, D2952, D2953, D2954, D2957, D2955, D2999 Restorative Foundation for an Indirect Restoration Restorative foundation for an indirect restoration is indicated as a filler to eliminate undercuts, voids and other irregularities that have occurred during tooth preparation to create a more favorable tooth form for the retention of an indirect restoration. Core Buildup (Including Any Pins When Required) Core buildup is indicated for teeth with significant loss of coronal tooth structure (> 50%) due to caries or trauma to aid in retention of an indirect restoration. Core buildup is not indicated for the following:

14 Core Buildup, Post and Core and Pin Retention When adequate tooth structure remains to retain a crown As a filler to correct irregularities in preparation As a definitive composite or amalgam restoration For retention of intracoronal restorations Post and Core Post and core are indicated for the following: For teeth with significant loss of coronal tooth structure due to caries or trauma in endodontically treated teeth (> 50%) to aid in retention of an indirect restoration Post and Core is not indicated for the following: For vital teeth For a post, when anatomic features are available to retain the core (e.g., for molars, as canals and pulp chamber can usually retain a core) For teeth with short roots Pin Retention Pin retention is indicated for teeth with significant loss of coronal tooth structure due to caries or trauma, to allow retention of a direct restoration when preparation design alone is insufficient. Pin retention is not indicated for the following: For restoration of teeth with significant malocclusion If the tooth cannot be properly restored with a direct restoration due to anatomic or functional considerations Post Removal Post removal is indicated for the following: When there has been loss of adequate retention In the case of fracture of tooth and/or post and core When there is recurrent caries associated with post and core When access is needed to root canal system for non-surgical endodontics When the tooth has a reasonable long term prognosis for a new restoration Coverage Limitations and Exclusions Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Pin retention is limited to 2 pins per tooth; not covered in addition to cast restoration. Post and core is covered only for teeth that have had root canal therapy. Post removal is considered inclusive to retreatment procedure, and not 14

15 Core Buildup, Post and Core and Pin Retention covered Restorative foundation for an Indirect Restoration is not covered Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure Labial Veneer D2960, D2961, D2962 ENDODONTICS Non-Surgical Endodontics Endodontic codes: D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357 Radiographic image and narrative of medical necessity. Intraoral photo helpful. General documentation requirements Pre and post endodontic periapical radiographic images showing apex of tooth. For retreatment, surgical endodontics, cracked tooth syndrome and other procedures: pre and post-op images, taken within one year and narrative if the reason for treatment is not evident on films. Diagnosis Diagnostic tests used to determine a diagnosis of irreversible pulpitis or periapical pathology must be documented in the record. 15 Refer to coverage guideline: Core Buildup, Post and Core and Pin Retention (DCG021.01) Criteria for codes D2960, D2961, D2962 A labial veneer is a thin layer of material placed over a tooth to protect it from further damage or for aesthetic reasons. For most plans, veneers are not covered, but for those plans that do have coverage, the following identify guidelines for placement. Labial Veneers Labial veneers are indicated for the following: For coverage of enamel only fractures Teeth with enamel defects including but not limited to enamel hypoplasia, severe decalcification, enamel hypocalcification and fluorosis Labial veneers are not indicated for the coverage of fractures that extend into dentin. Coverage Limitations and Exclusions The following are excluded from coverage: Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) Refer to coverage guideline: Labial Veneers (DCG025.01) Criteria for codes D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357 Vital Pulp Therapy Direct Pulp Cap Direct pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis All caries has been removed Mechanical exposure of a clinically vital and asymptomatic pulp occurs Bleeding is controlled at the exposure site Exposure permits the capping material to make direct contact with the vital pulp tissue

16 Non-Surgical Endodontics Exposure occurs when the tooth is under dental dam isolation Adequate seal of the coronal restoration can be maintained Patient has been fully informed that endodontic treatment may be indicated in the future Direct Pulp capping is not indicated for a carious exposure in primary teeth Indirect Pulp Cap Indirect pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation No history of subjective pretreatment symptoms Pretreatment radiographs should not show periradicular pathosis Therapeutic Pulpotomy Therapeutic pulpotomy is indicated for the following: Exposed vital pulps or irreversible pulpitis of primary teeth Any bleeding was controlled within several minutes As an emergency procedure in permanent teeth until root canal treatment can be accomplished As an interim procedure for permanent teeth with immature root formation to allow continued root development In primary teeth, where there is a reasonable period of retention expected (approximately one year) Therapeutic pulpotomy is not indicated for the following: Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor As the first stage of complete root canal therapy Removal of pulp apical to the dentinocemental junction For primary teeth that are near exfoliation or less than 50% of the tooth root remains Partial Pulpectomy for Apexogenesis A partial pulpotomy for apexogenesis is indicated for the following: In a young permanent tooth for a carious pulp exposure When the pulpal bleeding is controlled within several minutes A vital tooth, with a diagnosis of normal pulp or reversible pulpitis 16 Apexification/Recalcification Apexification/recalcification is indicated for the following: Incomplete apical closure in a permanent tooth root External root resorption or when the possibility of external root resorption

17 Non-Surgical Endodontics exists. Necrotic pulp, irreversible pulpitis or periapical lesion For prevention or arrest of resorption Perforations or root fractures that do not communicate with oral cavity Apexification/recalcification is not indicated for the following: Tooth with a completely closed apex If patient compliance or long term follow up may be questionable Pulpal Regeneration Pulpal regeneration is indicated for the following: Permanent tooth with immature apex Necrotic pulp Pulp space not needed for post/core or final restoration When tooth is not restorable Pulpal regeneration is not indicated for the following: Primary teeth The pulp space would be needed for final restoration Non-Vital Pulp Therapy Pulpal Debridement (Pulpectomy) Pulpal debridement (pulpectomy) is indicated for the following: A restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified The relief of acute pain prior to complete root canal therapy A primary tooth, where there is a reasonable period of retention expected (approximately one year) Pulpal debridement (pulpectomy) is not indicated for the following: Complete root canal therapy of an infected or necrotic tooth Primary teeth that are near exfoliation or less than 50% of the tooth root remains Pulpal Therapy (Resorbable Filling) Primary Teeth Pulpal therapy for primary teeth is indicated for the following: A restorable primary tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified The prognosis for keeping the tooth is up to one year and the tooth root lies in at least 25% bone Pulpal therapy is not indicated for the following: Primary teeth that are near exfoliation or less than 50% of the tooth root remains Permanent teeth 17

18 Non-Surgical Endodontics Endodontic Therapy Endodontic therapy is indicated for the following: A restorable mature, completely developed permanent or primary tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure Teeth with radiographic periapical pathology Primary teeth without a permanent successor Trauma When needed for prosthetic rehabilitation Endodontic therapy is not indicated for the following: Teeth with a poor long term prognosis Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease Teeth with incompletely formed root apices Treatment of Root Canal Obstruction; Non-Surgical Access Treatment of a root canal obstruction is indicated for the following: When there is an obstruction of the root canal system, (biological, iatrogenic ledges or post removal) and endodontic retreatment is needed Removal of obstruction is complex and/or requires significant time Treatment of a root canal obstruction is not indicated when there is no obstruction evident. Incomplete Endodontic Therapy: Inoperable, Unrestorable or Fractured Tooth Incomplete endodontic therapy is indicated for the following: During endodontic treatment of a tooth, it becomes apparent that the procedure cannot be successfully completed The tooth will not be able to be restored, or the tooth fractures, necessitating discontinuation of treatment Internal Root Repair of Perforation Defects Internal root repair of perforation defects is indicated for the following: There is a root perforation caused by pathology such as resorption or decay A communication between the pulp space and external root surface as a result of internal root resorption. Internal root repair of perforation defects is not indicated for the following: Teeth that are considered non-restorable Teeth with inadequate bone support or advanced untreated periodontal disease Retreatment of Previous Root Canal Therapy 18

19 Non-Surgical Endodontics Surgical Endodontics D3410, D3421, D3425, D3426, D3427, D3430, D3450, D3470, D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, D3999 Pre and post-operative radiograph image. Provider narrative may be requested if pathology is not visible. Date of last root canal treatment if needed. 19 Retreatment of previous root canal therapy is indicated for the following: Canal fill appears to extend to a point shorter than 2millimeters from the apex, or extends significantly beyond the apex Fill appears to be incomplete Tooth is sensitive to pressure and percussion or other subjective symptoms The existing endodontics is poor Placement of a post has the potential to compromise the existing obturation or apical seal of the canal system The canal is accessible and allows for retreatment with a non-surgical procedure Refer to coverage guideline: Non-Surgical Endodontics (DCG009.02) Criteria for codes D3410, D3421, D3425, D3426, D3427, D3430, D3450, D3470, D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, D3999 Apicoectomy Apicoectomy is indicated for the following: Failed retreatment of endodontic therapy When the apex of tooth cannot be accessed due to calcification or other anomaly Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked over extension of obturating materials interfering with healing Apicoectomy is not indicated for the following: Unusual bony or root configurations resulting in lack of surgical access The possible involvement of neurovascular structures Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease When non-surgical endodontic treatment has not been attempted or was not indicated Periradicular Surgery Without Apicoectomy (Includes Surgery and Periradicular Curettage) Periradicular surgery without apicoectomy is indicated for the following: Failed retreatment of endodontic therapy When the apex of tooth cannot be accessed due to calcification or other anomaly When a biopsy of periradicular tissue is necessary

20 Surgical Endodontics Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked overextension of obturating materials interfering with healing Periradicular surgery without apicoectomy is not indicated for the following: Unusual bony or root configurations resulting in lack of surgical access The possible involvement of neurovascular structures Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease When non-surgical endodontic treatment has not been attempted or was not indicated Retrograde Filling Retrograde filling is indicated for the following: Periradicular pathosis and a blockage of the root canal system that could not be obturated by nonsurgical root canal treatment Persistent periradicular pathosis resulting from an inadequate apical seal that cannot be corrected nonsurgically. Root perforations Resorptive defects Retrograde filling is not indicated for the following: When canals are successfully obturated and no evidence of radiographic pathology or clinical symptoms persist When a tooth has an overall poor prognosis with or without retrograde filling placement Root Amputation Root amputation is indicated for the following: Class III furcation involvement Untreatable bony defect (of one root) Root fracture Root caries Root resorption Persistent sinus tract or recurrent apical pathology When there is greater than 75% bone supporting remaining root(s) The tooth has had successful endodontic treatment on remaining root(s) Root amputation is not indicated for the following: Teeth with an overall poor prognosis with or without root amputation 20

21 Surgical Endodontics 21 Vital teeth Intentional Reimplantation Intentional replantation is indicated when all of the following clinical conditions exist: Persistent periradicular pathosis following endodontic treatment Nonsurgical retreatment is not possible or has an unfavorable prognosis Periradicular surgery is not possible or involves a high degree of risk to adjacent anatomical structures The tooth presents a reasonable opportunity for removal without fracture The tooth has an acceptable periodontal status prior to the replantation procedure Intentional replantation is not indicated when any of the above criteria are not met. Hemisection Hemisection of multirooted teeth is indicated for the following: Class III or Class IV periodontal furcation defect Infrabony defect of one root of a multi-rooted tooth that cannot be successfully treated periodontally Coronal fracture extending into the furcation Vertical root fracture confined to the root to be separated and removed Carious, resorptive root or perforation defects that are inoperable or cannot be corrected without root removal Persistent periradicular pathosis where nonsurgical treatment or periradicular surgery is not possible and the problem is confined to one root The tooth has had successful endodontic treatment on remaining portion of tooth Hemisection of multirooted teeth is not indicated for the following: Teeth with overall poor prognosis with or without hemisection Vital teeth Bone Graft in Conjunction with Periradicular Surgery Bone graft in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate possible benefits of bone grafting in endodontic surgery. Biologic Materials to Aid in Soft and Osseous Tissue Regeneration in Conjunction with Periradicular Surgery Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery are unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate

22 Surgical Endodontics PERIODONTICS Surgical Periodontics: Resective Procedures D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261, D4274 /Other for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261 Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. for code D4274 Pre-surgical radiograph images. Grafts: One soft tissue graft per two contiguous teeth. Bone graft and guided tissue regeneration: only one or the other allowed. Evidence of mobility, bruxism and/or hyperocclusion may contraindicate grafting 22 possible benefits of biologic material to aid in tissue and osseous regeneration in endodontic surgery. Guided Tissue Regeneration Resorbable Barrier in Conjunction with Periradicular Surgery Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery is unproven for the treatment of lesions that are endodontic in origin. Additional clinical studies are needed to further evaluate possible benefits of guided tissue regeneration techniques in endodontic surgery. Refer to coverage guideline: Surgical Endodontics (DCG010.02) Criteria for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261, D4274 Gingivectomy/Gingivoplasty Gingivectomy/Gingivoplasty is indicated for the following: Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is fibrous and firm and there is an adequate zone of keratinized tissue; Elimination of gingival enlargements/overgrowth due to medications, medical conditions or tooth position; Elimination of suprabony periodontal abscesses; For exposure of soft tissue impacted teeth to aid in eruption; To reestablish gingival contour following an episode of acute necrotizing ulcerative gingivitis; To allow restorative access, including root surface caries. Gingivectomy/Gingivoplasty is not indicated for the following: When bone surgery is required for infrabony defects, or for the purpose of examining bone shape and morphology; Situations in which the bottom of the pocket is apical to the mucogingival junction; Areas where aesthetics are a concern (particularly in the anterior maxilla); In areas with a shallow palatal vault or prominent external oblique ridge; Severely edematous or inflamed tissue; Patients with poor plaque control or non-compliance with non-surgical procedures; Patients with an uncontrolled underlying medical condition; Solely for cosmetic/aesthetic purposes. Anatomical Crown Exposure Anatomical Crown exposure is indicated for the following: In an otherwise periodontally healthy area to facilitate the restoration of

23 Surgical Periodontics: Resective Procedures subgingival caries; In an otherwise periodontally healthy area to allow proper contour of restoration; In an otherwise periodontally healthy area to allow management of a fractured tooth in which the fracture extends subgingivally. Anatomical Crown exposure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition. Gingival Flap Procedure Gingival flap procedure is indicated for the following (includes root planing): The presence of moderate to deep probing depths; Loss of attachment; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful; The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods. Gingival flap procedure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies. Apically Positioned Flap Procedure Apically Positioned Flap Procedure is indicated for the following: The presence of moderate to deep probing depths; Loss of attachment; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful; The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods; To preserve keratinized tissue in conjunction with osseous surgery. Apically Positioned Flap Procedure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies. Clinical Crown Lengthening-Hard Tissue Clinical Crown Lengthening-Hard Tissue is indicated for the following: In an otherwise periodontally healthy area to allow a restorative procedure on a tooth with little to no crown exposure. 23