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.

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.

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.

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