Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: D-6-011
Topic: Dental Services
Section: Dental
Effective Date: October 11, 2010
Issue Date: May 28, 2018
Last Reviewed: May 2018

Dentists and oral surgeons may be paid for surgery for the treatment of fractures and dislocations of the jaw or any other facial bone, the extraction of impacted teeth when partially or totally covered by bone, and any other covered services within the scope of their license.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Bone grafts to the maxilla and the mandible are eligible for payment only when performed due to unusual and extenuating circumstances, e.g., cancer or trauma. Charges for obtaining the graft, regardless of the provider, may be paid only when the graft itself is eligible for payment.

In most circumstances dental extractions (i.e., wisdom teeth) can be safely performed in an office setting.  However, there may be rare circumstances where the procedure needs to be performed in an ambulatory surgery center or a hospital outpatient setting.  In those instances when there are oral surgery benefits under the member's benefit plan, dental extractions may be medically necessary when they are performed in those settings.

In order for dental extractions to be considered medically necessary in a hospital outpatient or an ambulatory surgery center, the requesting physician or the patient's primary care physician must have documentation in the patient's medical record that supports the necessity of performing such extractions in these settings. The physician must provide substantiating documentation of such necessity as follows:

  • Individuals with significant cognitive impairment or significant emotional conditions who have difficulty understanding what is expected in a dental treatment situation and have difficulty cooperating or following instructions.  These individuals may require sedation and a higher level of monitoring.
  • Individuals with complex medical problems under current medical management which increases the probability of complications (such as, but not limited to, severe hypertension and cardiac or respiratory disease) who require intra- and peri-operative monitoring.
Procedure Codes
21210, 21215, D7220, D7230, D7240, D7241

Place of Service: Inpatient/Outpatient

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services primarily provided for the care, treatment, removal or replacement of teeth or structures (e.g., root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, extensive dental restoration) directly supporting the teeth are non-covered services under the Medical-Surgical programs.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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