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July 2014

Reminder: Dental medical-surgical coverage guidelines

Facility charges

Facility charges are part of the medical-surgical benefit when associated with the dental procedures if circumstances prevent the dental procedures from being performed in an office setting. These circumstances include the following:

  • A member is admitted to the hospital as an inpatient with a medical condition that is negatively impacted by a dental condition and treatment of the dental condition is medically necessary to optimize the treatment of the primary medical problem.
  • A member requires dental services and meets the anesthesia criteria for outpatient general anesthesia.

General anesthesia accompanying dental services is covered under the medical-surgical benefit if the memeber meets the selection criteria set forth in the Dental Anesthesia medical policy and as specified in the plan documents.

For procedures performed in a facility-based setting where facility charges and anesthesia charges are covered under the medical-surgical benefit, the specific dental procedures performed are still covered under the dental benefit.

Blue Cross Blue Shield of Michigan dental programs are intended to cover services for the treatment of the teeth and supporting structures. These include routine care, treatment and replacement of structures that directly involve the teeth or support the teeth.

These services are generally excluded from coverage under BCBSM medical-surgical benefit plans. However, dental services and surgeries that are “dental in nature” (for example, restoration and extraction of teeth) may qualify for payment as a medical-surgical benefit if the following criteria are met.

Inclusions

  • Services are part of the member’s benefit design and required criteria are met. (Some groups have specifically opted to have certain specific primary dental procedures covered under their medical-surgical benefit).
  • A member is admitted to the hospital as an inpatient with a medical condition that is negatively impacted by a dental condition.
    • The treatment of that dental condition is medically necessary to optimize the treatment of the primary medical problem.
    • A member requires prophylactic extractions performed as an in-patient before an organ transplant, cardiac valve surgery or ionizing radiation (5,000 cGy or more) that involves the jaw.
  • Services are part of the accidental dental injury benefit. This benefit applies when a patient experiences an external force to the lower half of the face or jaw that damages or breaks the teeth, periodontal structures or bone (other than by self-inflicted external force or chewing).

Exclusions

  • Extraction of teeth except when extraction occurs:
    • Prior to therapeutic radiation therapy (5000 cGy or more) for a patient with cancer of the head and neck
    • Immediately prior to transplant surgery
    • In the case of impending cardiac surgery, such as artificial cardiac valve replacement
    • When a hospitalized member has a dental condition that is adversely affecting a medical condition and the dental extraction is intended to optimize the treatment of the primary medical problem
  • Dentoalveolar surgery
  • Endodontic treatment
  • Periodontal treatment
  • Orthodontic treatment
  • Prosthodontic treatment
  • Routine dental care
  • Restorative dental treatment
  • Dental implant surgery and related services including surrounding tissue preparation procedures, repair and maintenance of implants and surrounding tissue (e.g., extraction site preservation, bone replacement grafts, sinus lift surgery, soft tissue grafts and guided tissue regeneration procedures)
  • Reversible or irreversible dental services performed for diagnosis or treatment of temporomandibular joint (jaw joint) dysfunction, except for:
    • Surgery to the temporomandibular joint (jaw joint) and related anesthesia services
    • Diagnostic X-rays
    • Arthrocentesis
    • Physical therapy
    • Reversible appliance therapy
  • Devices for the diagnosis or treatment of temporomandibular joint (jaw joint) dysfunction
  • Cosmetic surgery for congenital deformities of the teeth

Note: Contract and group coverage may vary. Please check the contract, certificate and rider for specific coverage information. For additional details and guidelines, reference the BCBSM Guide for Dental Care Providers.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
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