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Dental Services Page 1 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.
DENTAL SERVICES Guideline Number: MPG376.02 Approval Date: April 10, 2019 Table of Contents Page POLICY SUMMARY .................................................... 1 APPLICABLE CODES ................................................. 2 DEFINITIONS ......................................................... 11 QUESTIONS AND ANSWERS ..................................... 12 PURPOSE ............................................................... 12 REFERENCES .......................................................... 12 GUIDELINE HISTORY/REVISION INFORMATION .......... 13 TERMS AND CONDITIONS ........................................ 13 POLICY SUMMARY Overview Dental services are excluded from coverage in connection with the care, treatment, removal, filling, or replacement of
teeth, or structures directly supporting the teeth, except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures. Structures directly supporting the teeth means, the periodontium, which includes the gingivae, periodontal membrane, dentogingival junction, cementum, and alveolar process. In an outpatient setting when an excluded service is the primary procedure involved, it is not covered regardless of its difficulty or complexity. A frenectomy and an alveoloplasty are excluded from coverage when either of these
procedures is performed in connection with an excluded service: e.g. the non-covered extraction or the preparation of the mouth for dentures. *Dental coverage is separately available in some plans. Guidelines
Non-Covered Services Extraction of an impacted tooth Alveoloplasty, (the surgical improvement of the shape and condition of the alveolar process), when performed for
the preparation of the mouth for dentures Frenectomy when performed for the preparation of the mouth for dentures Extractions that are due to decay or periodontal disease Extractions done for the purpose of obtaining dentures
Services related to chronic dental disease (i.e. gingivectomy) Removal of a benign growth or radicular cyst, in the mouth, or from structures directly supporting the teeth
means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process)
Insertion of metallic implants used for enhancement of the structure of the jaws in order to support dentures or prosthesis
Excision of torus mandibularis or excision of a maxillary torus palatinus is usually performed to accommodate a
denture. The removal of the torus palatinus (a bony protuberance of the hard palate) and torus mandibularis could be a covered service. However, with rare exception, this surgery is performed in connection with an excluded service; i.e., the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made for this purpose.
(The only exception is for inpatient services: "except for inpatient hospital services in connection with such dental
procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures.")
Related Medicare Advantage Policy Guideline
Dental Examination Prior to Kidney Transplantation (NCD 260.6)
Related Medicare Advantage Coverage Summary
Dental Services, Oral Surgery and Treatment of Temporomandibular Joint (TMJ)
UnitedHealthcare® Medicare Advantage Policy Guideline
Terms and Conditions
See Purpose
Dental Services Page 2 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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Covered Services Wiring of the teeth when performed in connection with the reduction of a jaw fracture Extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease Reduction of any fracture of the jaw or any facial bone, including dental splints or other appliances, if used for this
purpose Reconstruction of a ridge if performed as a result of and at the same time as the surgical removal of a tumor (the
total surgical procedure is covered) Removal of a torus palatinus (a bony protuberance of the hard palate) may be covered, if the procedure is not
performed to prepare the mouth for dentures Surgery related to the jaw or any structure connected to the jaw including structures of the facial area below the
eyes, for example (mandible, teeth, gums, tongue, palate, salivary glands, sinuses, etc.)
Insertion of metallic implants if the implants are used to assist in or enhance the retention of a dental prosthetic as a result of a covered service
The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is also covered. This is an exception to the requirement that to be covered, a non-covered procedure or service performed by a dentist must be an incident to and integral part of a covered procedure or service performed by the dentist. Whether such services as
the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. Thus, an x-ray taken in connection with the
reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered. Associated Information Documentation Requirements
1. Documentation supporting the medical necessity, such as ICD-10 codes, including the need for the surgery in an inpatient setting, must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.
2. Where the dental procedure is not the primary procedure performed, documentation of the primary procedure must be included in the patient’s medical records.
Utilization Guidelines
If a non-covered service is performed as the primary procedure in conjunction with a covered procedure or service, regardless of the complexity, the total service is excluded from coverage. Anesthesia services, provided by the surgeon performing the surgery, are considered bundled into the payment for
the surgical procedure. Since the payment is bundled, the physician is precluded from billing the beneficiary for this service.
Where a patient is hospitalized solely for less than major noncovered dental treatment, both the professional services of the dentist and the inpatient hospital services are not covered. "Except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures." Items and services in connection with an excluded dental service (the care, treatment, filling, removal or replacement
of teeth, or structures directly supporting the teeth) are not covered. (i.e. anesthesia services, lab, x-ray services). A dentist qualifies as a physician if, he/she is a doctor of dental surgery or dental medicine, and is legally authorized to practice dentistry in the state in which he/she performs such function, and who is acting within the scope of his/her license when he/she performs such functions. Such services include any otherwise covered service that may legally and alternatively be performed by doctors of medicine, osteopathy and dentistry; e.g., dental examinations to detect infections prior to certain surgical procedures, treatment of oral infections and interpretations of diagnostic x-ray
examinations in connection with covered services. Payment for the services of dentists in an outpatient setting is
limited to those procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting the teeth. The coverage of any given dental service is not affected by the professional designation of the physician rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine or osteopathy. APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.
Dental Services Page 3 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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CPT Code Description
The following codes are not covered if performed primarily for dental related conditions. These codes are not covered if done with endodontic surgery or third molar removal.
21030 Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage
21032 Excision of maxillary torus palatinus
21040 Excision of benign tumor or cyst of mandible, by enucleation and/or curettage
21046 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])
21047 Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s])
21048 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])
21060 Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with allograft
21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial
21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete
21299 Unlisted craniofacial and maxillofacial procedure
21480 Closed treatment of temporomandibular dislocation; initial or subsequent
29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
29804 Arthroscopy, temporomandibular joint, surgical
40814 Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair
40816 Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle
40840 Vestibuloplasty; anterior
40842 Vestibuloplasty; posterior, unilateral
40843 Vestibuloplasty; posterior, bilateral
40844 Vestibuloplasty; entire arch
40845 Vestibuloplasty; complex (including ridge extension, muscle repositioning)
40899 Unlisted procedure, vestibule of mouth
41820 Gingivectomy, excision gingiva, each quadrant
41821 Operculectomy, excision pericoronal tissues
41822 Excision of fibrous tuberosities, dentoalveolar structures
41823 Excision of osseous tuberosities, dentoalveolar structures
41825 Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair
41828 Excision of hyperplastic alveolar mucosa, each quadrant (specify)
41830 Alveolectomy, including curettage of osteitis or sequestrectomy
41850 Destruction of lesion (except excision), dentoalveolar structures
41870 Periodontal mucosal grafting
41872 Gingivoplasty, each quadrant (specify)
41874 Alveoloplasty, each quadrant (specify)
41899 Unlisted procedure, dentoalveolar structures
Dental Services Page 4 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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CPT Code Description
The following radiological codes are not covered if performed primarily for dental related conditions.
70250 Radiologic examination, skull; less than 4 views
70300 Radiologic examination, teeth; single view
70310 Radiologic examination, teeth; partial examination, less than full mouth
70320 Radiologic examination, teeth; complete, full mouth
70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral
70330 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral
70332 Temporomandibular joint arthrography, radiological supervision and interpretation
70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)
70350 Cephalogram, orthodontic
70355 Orthopantogram (eg, panoramic x-ray)
70390 Sialography, radiological supervision and interpretation
70486 Computed tomography, maxillofacial area; without contrast material
70487 Computed tomography, maxillofacial area; with contrast material(s)
70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections
70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)
70542 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)
70543 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences
70544 Magnetic resonance angiography, head; without contrast material(s)
70546 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences
76140 Consultation on X-ray examination made elsewhere, written report
76376
3D rendering with interpretation and reporting of computed tomography, magnetic
resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation
76377
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation
76536 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation
80500 Clinical pathology consultation; limited, without review of patient's history and medical records
80502 Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records
81599 Unlisted multianalyte assay with algorithmic analysis
82397 Chemiluminescent assay
83036 Hemoglobin; glycosylated (A1C)
83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use
87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
87071 Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
87181 Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip)
Dental Services Page 5 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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CPT Code Description
The following laboratory codes are not covered if performed primarily for dental related conditions.
87184 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents)
87207 Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses)
87209 Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites
87250 Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection
87252 Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect
87253 Virus isolation; tissue culture, additional studies or definitive identification (eg, hemabsorption, neutralization, immunofluorescence stain), each isolate
87254 Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus
87255 Virus isolation; including identification by non-immunologic method, other than by
cytopathic effect (eg, virus specific enzymatic activity)
87999 Unlisted microbiology procedure
88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation
88112 Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
88160 Cytopathology, smears, any other source; screening and interpretation
88161 Cytopathology, smears, any other source; preparation, screening and interpretation
88162 Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains
88239 Tissue culture for neoplastic disorders; solid tumor
88264 Chromosome analysis; analyze 20-25 cells
88271 Molecular cytogenetics; DNA probe, each (eg, FISH)
88272 Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells (eg, for derivatives and markers)
88273 Molecular cytogenetics; chromosomal in situ hybridization, analyze 10-30 cells (eg, for microdeletions)
88274 Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells
88275 Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells
88291 Cytogenetics and molecular cytogenetics, interpretation and report
88300 Level I - Surgical pathology, gross examination only
88302
Level II - Surgical pathology, gross and microscopic examination Appendix, incidental
Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglion Testis, castration Vaginal mucosa, incidental Vas deferens, sterilization
88304
Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm - arterial/ventricular Anus, tag Appendix, other than incidental
Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologic fracture Bursa/synovial cyst Carpal tunnel tissue Cartilage, shavings Cholesteatoma Colon, colostomy stoma Conjunctiva - biopsy/pterygium Cornea Diverticulum - esophagus/small intestine Dupuytren's contracture tissue Femoral head, other than fracture Fissure/fistula Foreskin, other than newborn Gallbladder Ganglion cyst Hematoma Hemorrhoids Hydatid of Morgagni Intervertebral disc Joint, loose body Meniscus Mucocele, salivary Neuroma - Morton's/traumatic Pilonidal
cyst/sinus Polyps, inflammatory - nasal/sinusoidal Skin - cyst/tag/debridement Soft tissue, debridement Soft tissue, lipoma Spermatocele Tendon/tendon sheath Testicular appendage Thrombus or embolus Tonsil and/or adenoids Varicocele Vas deferens, other than sterilization Vein, varicosity
Dental Services Page 6 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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CPT Code Description
The following laboratory codes are not covered if performed primarily for dental related conditions.
88305
Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis
Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx,
biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp,
cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than
cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy
88307
Level V - Surgical pathology, gross and microscopic examination Adrenal, resection
Bone - biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple Cervix, conization
Colon, segmental resection, other than for tumor Extremity, amputation, non-traumatic Eye, enucleation Kidney, partial/total nephrectomy Larynx, partial/total resection Liver, biopsy - needle/wedge Liver, partial resection Lung, wedge biopsy Lymph nodes, regional resection Mediastinum, mass Myocardium, biopsy Odontogenic tumor Ovary with or without tube, neoplastic Pancreas, biopsy Placenta,
third trimester Prostate, except radical resection Salivary gland Sentinel lymph node Small intestine, resection, other than for tumor Soft tissue mass (except lipoma) -
biopsy/simple excision Stomach - subtotal/total resection, other than for tumor Testis, biopsy Thymus, tumor Thyroid, total/lobe Ureter, resection Urinary bladder, TUR Uterus, with or without tubes and ovaries, other than neoplastic/prolapse
88309
Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity,
disarticulation Fetus, with dissection Larynx, partial/total resection - with regional lymph nodes Lung - total/lobe/segment resection Pancreas, total/subtotal resection Prostate, radical resection Small intestine, resection for tumor Soft tissue tumor, extensive resection Stomach - subtotal/total resection for tumor Testis, tumor Tongue/tonsil -resection for tumor Urinary bladder, partial/total resection Uterus, with or without tubes and ovaries, neoplastic Vulva, total/subtotal resection
88311 Decalcification procedure (List separately in addition to code for surgical pathology
examination)
88312 Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver)
88313 Special stain including interpretation and report; Group II, all other (eg, iron,
trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry
88314 Special stain including interpretation and report; histochemical stain on frozen tissue block (List separately in addition to code for primary procedure)
88321 Consultation and report on referred slides prepared elsewhere
88323 Consultation and report on referred material requiring preparation of slides
88346 Immunofluorescence, per specimen; initial single antibody stain procedure
Dental Services Page 7 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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CPT Code Description
The following laboratory codes are not covered if performed primarily for dental related conditions.
88348 Electron microscopy, diagnostic
88364 In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure)
88365 In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure
88366 In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure
88367 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; initial single probe stain procedure
88368 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure
88369 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative),
manual, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure)
88373 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure)
88374 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure
88377 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure
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CDT Codes
Dental Services: CDT Code List
CDT® is a registered trademark of the American Dental Association
Coding Clarification: The following ICD-10-CM codes are considered to be routine dental diagnoses and are not covered.
ICD-10 Diagnosis Code Description
K00.0 Anodontia
K00.1 Supernumerary teeth
K00.2 Abnormalities of size and form of teeth
K00.3 Mottled teeth
K00.4 Disturbances in tooth formation
K00.5 Hereditary disturbances in tooth structure, not elsewhere classified
K00.6 Disturbances in tooth eruption
K00.7 Teething syndrome
K00.8 Other disorders of tooth development
K00.9 Disorder of tooth development, unspecified
K02.3 Arrested dental caries
K02.52 Dental caries on pit and fissure surface penetrating into dentin
K02.53 Dental caries on pit and fissure surface penetrating into pulp
K02.61 Dental caries on smooth surface limited to enamel
K02.62 Dental caries on smooth surface penetrating into dentin
K02.63 Dental caries on smooth surface penetrating into pulp
K02.7 Dental root caries
K02.9 Dental caries, unspecified
K03.0 Excessive attrition of teeth
K03.1 Abrasion of teeth
K03.2 Erosion of teeth
Dental Services Page 8 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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ICD-10 Diagnosis Code Description
K03.3 Pathological resorption of teeth
K03.4 Hypercementosis
K03.5 Ankylosis of teeth
K03.6 Deposits [accretions] on teeth
K03.7 Posteruptive color changes of dental hard tissues
K03.81 Cracked tooth
K03.89 Other specified diseases of hard tissues of teeth
K03.9 Disease of hard tissues of teeth, unspecified
K04.01 Reversible pulpitis
K04.02 Irreversible pulpitis
K04.1 Necrosis of pulp
K04.2 Pulp degeneration
K04.3 Abnormal hard tissue formation in pulp
K04.4 Acute apical periodontitis of pulpal origin
K04.5 Chronic apical periodontitis
K04.6 Periapical abscess with sinus
K04.7 Periapical abscess without sinus
K04.90 Unspecified diseases of pulp and periapical tissues
K04.99 Other diseases of pulp and periapical tissues
K05.00 Acute gingivitis, plaque induced
K05.01 Acute gingivitis, non-plaque induced
K05.10 Chronic gingivitis, plaque induced
K05.11 Chronic gingivitis, non-plaque induced
K05.20 Aggressive periodontitis, unspecified
K05.211 Aggressive periodontitis, localized, slight
K05.212 Aggressive periodontitis, localized, moderate
K05.213 Aggressive periodontitis, localized, severe
K05.219 Aggressive periodontitis, localized, unspecified severity
K05.221 Aggressive periodontitis, generalized, slight
K05.222 Aggressive periodontitis, generalized, moderate
K05.223 Aggressive periodontitis, generalized, severe
K05.229 Aggressive periodontitis, generalized, unspecified severity
K05.30 Chronic periodontitis, unspecified
K05.311 Chronic periodontitis, localized, slight
K05.312 Chronic periodontitis, localized, moderate
K05.313 Chronic periodontitis, localized, severe
K05.319 Chronic periodontitis, localized, unspecified severity
K05.321 Chronic periodontitis, generalized, slight
K05.322 Chronic periodontitis, generalized, moderate
K05.323 Chronic periodontitis, generalized, severe
K05.329 Chronic periodontitis, generalized, unspecified severity
K05.4 Periodontosis
K05.5 Other periodontal diseases
K05.6 Periodontal disease, unspecified
K06.010 Localized gingival recession, unspecified
K06.011 Localized gingival recession, minimal
K06.012 Localized gingival recession, moderate
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ICD-10 Diagnosis Code Description
K06.013 Localized gingival recession, severe
K06.020 Generalized gingival recession, unspecified
K06.021 Generalized gingival recession, minimal
K06.022 Generalized gingival recession, moderate
K06.023 Generalized gingival recession, severe
K06.1 Gingival enlargement
K06.2 Gingival and edentulous alveolar ridge lesions associated with trauma
K06.3 Horizontal alveolar bone loss
K06.8 Other specified disorders of gingiva and edentulous alveolar ridge
K06.9 Disorder of gingiva and edentulous alveolar ridge, unspecified
K08.0 Exfoliation of teeth due to systemic causes
K08.101 Complete loss of teeth, unspecified cause, class I
K08.102 Complete loss of teeth, unspecified cause, class II
K08.103 Complete loss of teeth, unspecified cause, class III
K08.104 Complete loss of teeth, unspecified cause, class IV
K08.109 Complete loss of teeth, unspecified cause, unspecified class
K08.111 Complete loss of teeth due to trauma, class I
K08.112 Complete loss of teeth due to trauma, class II
K08.113 Complete loss of teeth due to trauma, class III
K08.114 Complete loss of teeth due to trauma, class IV
K08.119 Complete loss of teeth due to trauma, unspecified class
K08.121 Complete loss of teeth due to periodontal diseases, class I
K08.122 Complete loss of teeth due to periodontal diseases, class II
K08.123 Complete loss of teeth due to periodontal diseases, class III
K08.124 Complete loss of teeth due to periodontal diseases, class IV
K08.129 Complete loss of teeth due to periodontal diseases, unspecified class
K08.131 Complete loss of teeth due to caries, class I
K08.132 Complete loss of teeth due to caries, class II
K08.133 Complete loss of teeth due to caries, class III
K08.134 Complete loss of teeth due to caries, class IV
K08.139 Complete loss of teeth due to caries, unspecified class
K08.191 Complete loss of teeth due to other specified cause, class I
K08.192 Complete loss of teeth due to other specified cause, class II
K08.193 Complete loss of teeth due to other specified cause, class III
K08.194 Complete loss of teeth due to other specified cause, class IV
K08.199 Complete loss of teeth due to other specified cause, unspecified class
K08.20 Unspecified atrophy of edentulous alveolar ridge
K08.21 Minimal atrophy of the mandible
K08.22 Moderate atrophy of the mandible
K08.23 Severe atrophy of the mandible
K08.24 Minimal atrophy of maxilla
K08.25 Moderate atrophy of the maxilla
K08.26 Severe atrophy of the maxilla
K08.3 Retained dental root
K08.401 Partial loss of teeth, unspecified cause, class I
K08.402 Partial loss of teeth, unspecified cause, class II
K08.403 Partial loss of teeth, unspecified cause, class III
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ICD-10 Diagnosis Code Description
K08.404 Partial loss of teeth, unspecified cause, class IV
K08.409 Partial loss of teeth, unspecified cause, unspecified class
K08.411 Partial loss of teeth due to trauma, class I
K08.412 Partial loss of teeth due to trauma, class II
K08.413 Partial loss of teeth due to trauma, class III
K08.414 Partial loss of teeth due to trauma, class IV
K08.419 Partial loss of teeth due to trauma, unspecified class
K08.421 Partial loss of teeth due to periodontal diseases, class I
K08.422 Partial loss of teeth due to periodontal diseases, class II
K08.423 Partial loss of teeth due to periodontal diseases, class III
K08.424 Partial loss of teeth due to periodontal diseases, class IV
K08.429 Partial loss of teeth due to periodontal diseases, unspecified class
K08.431 Partial loss of teeth due to caries, class I
K08.432 Partial loss of teeth due to caries, class II
K08.433 Partial loss of teeth due to caries, class III
K08.434 Partial loss of teeth due to caries, class IV
K08.439 Partial loss of teeth due to caries, unspecified class
K08.491 Partial loss of teeth due to other specified cause, class I
K08.492 Partial loss of teeth due to other specified cause, class II
K08.493 Partial loss of teeth due to other specified cause, class III
K08.494 Partial loss of teeth due to other specified cause, class IV
K08.499 Partial loss of teeth due to other specified cause, unspecified class
K08.50 Unsatisfactory restoration of tooth, unspecified
K08.51 Open restoration margins of tooth
K08.52 Unrepairable overhanging of dental restorative materials
K08.530 Fractured dental restorative material without loss of material
K08.531 Fractured dental restorative material with loss of material
K08.539 Fractured dental restorative material, unspecified
K08.54 Contour of existing restoration of tooth biologically incompatible with oral health
K08.55 Allergy to existing dental restorative material
K08.56 Poor aesthetic of existing restoration of tooth
K08.59 Other unsatisfactory restoration of tooth
K08.81 Primary occlusal trauma
K08.82 Secondary occlusal trauma
K08.89 Other specified disorders of teeth and supporting structures
K08.9 Disorder of teeth and supporting structures, unspecified
K09.1 Developmental (nonodontogenic) cysts of oral region
M26.20 Unspecified anomaly of dental arch relationship
M26.211 Malocclusion, Angle's class I
M26.212 Malocclusion, Angle's class II
M26.213 Malocclusion, Angle's class III
M26.219 Malocclusion, Angle's class, unspecified
M26.220 Open anterior occlusal relationship
M26.221 Open posterior occlusal relationship
M26.23 Excessive horizontal overlap
M26.24 Reverse articulation
M26.25 Anomalies of interarch distance
Dental Services Page 11 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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ICD-10 Diagnosis Code Description
M26.29 Other anomalies of dental arch relationship
M26.30 Unspecified anomaly of tooth position of fully erupted tooth or teeth
M26.31 Crowding of fully erupted teeth
M26.32 Excessive spacing of fully erupted teeth
M26.33 Horizontal displacement of fully erupted tooth or teeth
M26.34 Vertical displacement of fully erupted tooth or teeth
M26.35 Rotation of fully erupted tooth or teeth
M26.36 Insufficient interocclusal distance of fully erupted teeth (ridge)
M26.37 Excessive interocclusal distance of fully erupted teeth
M26.39 Other anomalies of tooth position of fully erupted tooth or teeth
M26.4 Malocclusion, unspecified
M26.70 Unspecified alveolar anomaly
M26.71 Alveolar maxillary hyperplasia
M26.72 Alveolar mandibular hyperplasia
M26.73 Alveolar maxillary hypoplasia
M26.74 Alveolar mandibular hypoplasia
M26.79 Other specified alveolar anomalies
M26.81 Anterior soft tissue impingement
M26.82 Posterior soft tissue impingement
M26.89 Other dentofacial anomalies
M26.9 Dentofacial anomaly, unspecified
M27.3 Alveolitis of jaws
M27.61 Osseointegration failure of dental implant
M27.62 Post-osseointegration biological failure of dental implant
M27.63 Post-osseointegration mechanical failure of dental implant
M27.69 Other endosseous dental implant failure
DEFINITIONS D.D.S.: Doctor of Dental Surgery. D.M.D.: Doctor of Medicine in Dentistry or Doctor of Dental Medicine (same degree as a D.D.S.).
Endodontist: Endodontists are dentists who specialize in maintaining teeth through endodontic therapy - procedures, involving the soft inner tissue of the teeth, called the pulp. The word "endodontic" comes from "endo" meaning inside and "odont" meaning tooth. Orthodontist: Orthodontia is an area of dentistry that prevents, diagnoses and treats dental and facial irregularities.
Pedodontist: A pedodontist is a dentist who specializes in caring for children’s teeth.
Peridontist: A dentist who specializes in the prevention, diagnosis, and treatment of periodontal disease, and in the placement of dental implants. Periodontists are also experts in the treatment of oral inflammation. Prosthodontist: A dentist specialized in the field of Prosthodontics. Prosthodontics is “that branch and specialty of
dentistry concerned with the diagnosis, restoration and maintenance of oral function, comfort, appearance and health of the patient by the restoration of the natural teeth and/or the replacement of missing teeth and contiguous oral and maxillofacial tissues with artificial substitutes”. T.M.D.: Temporomandibular disorders (TMD). TMD refers to problems associated with the jaw joint, also known as the temporomandibular joint (TMJ), and the surrounding tissues—with symptoms ranging from slight discomfort to severe pain.
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QUESTIONS AND ANSWERS
1
Q: Does my medical plan have dental coverage?
A:
No, not for routine dental services ie: dental caries.
Under the general exclusion of coverage, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered by Medicare. Structures directly supporting the teeth can be defined as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.
PURPOSE
The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable: Medicare coding or billing requirements, and/or Medical necessity coverage guidelines; including documentation requirements.
UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of
determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.
REFERENCES
CMS National Coverage Determinations (NCDs)
Dental Examination Prior to Kidney Transplantation (NCD 260.6) Manipulation (NCD 150.1)
CMS Local Coverage Determinations (LCDs)
LCD Medicare Part A Medicare Part B
L34574 (Dental Services) Palmetto AL, GA, NC, SC, TN, VA, WV
L33428 (Cosmetic and Reconstructive Surgery) Palmetto
AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV
CMS Articles
Article Medicare Part A Medicare Part B
A52977 (Routine Dental Services) Noridian
AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY
AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY
A52978 (Routine Dental Services) Noridian
AS, CA, GU, HI, MP, NV AS, CA, GU, HI, MP, NV
A53497 (Oral Maxillofacial Prosthesis) Palmetto
AL, GA, NC, SC, TN, VA, WV AL, GA, NC, SC, TN, VA, WV
CMS Benefit Policy Manual
Chapter 1; § 70 Inpatient Services in Connection With Dental Services Chapter 15; § 150 Dental Services
Chapter 15; § 150.1 Treatment of Temporomandibular Joint (TMJ) Syndrome
Chapter 16; § 140 Dental Services Exclusion
CMS Claims Processing Manual
Chapter 23; § 20.7 Use of the American Medical Association’s (AMA’s) Physicians’ Current Procedural Terminology (CPT) Fourth Edition Codes, and Use of the American Dental Association’s (ADA’s) Current Dental Terminology-Fourth Edition (CDT) Codes, on A/B MACs (A)’s, (B)’s, (HHH)’s, and DME MACs’ Web Sites and Other Electronic Media
CMS Transmittals
Transmittal 323, Change Request 3499, Dated 10/22/2004 (Update Regarding the Use of American Dental Association’s (ADA) Current Dental Terminology (CDT) Codes on Medicare Contractors’ Web Sites and Other Electronic Media)
MLN Matters
Article ICN 906765, Items and Services Not Covered Under Medicare
Dental Services Page 13 of 13 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/10/2019
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Article ICN 900943, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets
Others
Medicare Dental Coverage, CMS Website
GUIDELINE HISTORY/REVISION INFORMATION
Revisions to this summary document do not in any way modify the requirement that services be provided and documented in accordance with the Medicare guidelines in effect on the date of service in question.
Date Action/Description
04/10/2019
Administrative updates
Reorganized policy template; relocated Terms and Conditions and Purpose section
Reformatted lists of applicable CDT and ICD-10 diagnosis codes
TERMS AND CONDITIONS
The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.
These Policy Guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and healthcare providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Benefit coverage for health services is determined by the member specific benefit plan document* and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes the Medicare Advantage Policy Guidelines.
Medicare Advantage Policy Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this website. Medicare source materials used to develop these guidelines include, but are not limited to, CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Benefit Policy Manual, Medicare
Claims Processing Manual, Medicare Program Integrity Manual, Medicare Managed Care Manual, etc. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of
publication, and is provided on an "AS IS" basis. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply. You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT® or other sources
are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment. Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. *For more information on a specific member's benefit coverage, please call the customer service number on the back
of the member ID card or refer to the Administrative Guide.
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D4212 D5913 D5914 D5915 D5916 D5919 D5922 D5923 D5924 D5925 D5926 D5927 D5928 D5929 D5931
D5932 D5933 D5934 D5935 D5936 D5937 D5952 D5953 D5954 D5955 D5958 D5959 D5960 D5982 D5988
D5992 D5993 D5994 D5999 D6010 D6011 D6040 D6050 D6055 D6080 D6090 D6095 D6100 D6101 D6102
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D7970 D7971 D7972 D7980 D7981 D7982 D7983 D7990 D7991 D7995 D7996 D7999 D9210 D9211 D9212
D9215 D9219 D9310 D9410 D9420 D9430 D9440 D9450 D9610 D9985 D9986 D9987 D9999 D0120 D0140
D0145 D0160 D0170 D0171 D0180 D0190 D0191 D0273 D0364 D0365 D0366 D0367 D0368 D0369 D0370
D0371 D0380 D0381 D0382 D0383 D0384 D0385 D0386 D0391 D0393 D0394 D0395 D0411 D0412 D0414
D0415 D0417 D0418 D0422 D0423 D0425 D0470 D0486 D1110 D1120 D1206 D1208 D1310 D1320 D1330
D1351 D1353 D1354 D1516 D1517 D1526 D1527 D1555 D2140 D2150 D2160 D2161 D2330 D2331 D2332
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D3431 D3432 D3450 D3470 D3910 D3920 D3950 D4230 D4231 D4240 D4241 D4245 D4249 D4261 D4265
D4266 D4267 D4274 D4275 D4276 D4283 D4285 D4320 D4321 D4341 D4342 D4346 D4910 D4920 D4921
D4999 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5221 D5222 D5223 D5224 D5225 D5226
D5281 D5282 D5283 D5410 D5411 D5421 D5422 D5510 D5511 D5512 D5520 D5610 D5611 D5612 D5620
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D6116 D6117 D6118 D6119 D6190 D6194 D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245
D6250 D6251 D6252 D6253 D6545 D6548 D6549 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607
D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740
D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6793 D6794 D6930 D6940 D6950
D6980 D6985 D6999 D7270 D7272 D7280 D7282 D7290 D7292 D7293 D7294 D7296 D7297 D7311 D7871
D7881 D7951 D7952 D7953 D7963 D7979 D7997 D7998 D8010 D8020 D8030 D8040 D8050 D8060 D8070
D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8681 D8690 D8691 D8692 D8693 D8694 D8695 D8999
D9120 D9130 D9222 D9223 D9239 D9243 D9311 D9612 D9613 D9910 D9911 D9920 D9932 D9933 D9934
D9935 D9941 D9942 D9943 D9944 D9945 D9946 D9961 D9970 D9971 D9972 D9973 D9974 D9975 D9990
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D0431 D0460 D0472 D0473 D0474 D0475 D0476 D0477 D0478 D0479 D0480 D0481 D0482 D0483 D0484
D0485 D0502 D0600 D0601 D0602 D0603 D0999 D1510 D1515 D1520 D1525 D1550 D1575 D1999 D2999
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