| Highmark Medical Policy Bulletin |
| Section: | Dental |
| Number: | D-6 |
| Topic: | Dental Services |
| Effective Date: | August 28, 2000 |
| Issued Date: | August 28, 2000 |
| Date Last Reviewed: |
A dentist 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 his license. 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. Bone grafts to the maxilla (21210) and the mandible (21215) 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. |
| 21210 | 21215 |
Traditional (UCR/Fee Schedule) Guidelines
Payment may be made for any dental work or treatment which is accident related. Also eligible is reconstructive surgery and treatment to restore the mouth to a pre-cancer state. |
Comprehensive/Wraparound/PPO Guidelines
Payment may be made for any dental work or treatment which is accident related. |
Managed Care (HMO/POS) Guidelines
| Term | Description |
|---|---|