1.0 AMERICAN
DENTAL ASSOCIATION (ADA) DENTAL NOMENCLATURE CODES
07285 - 07286, 07410 - 07420, 07430 - 07431,
07440 - 07441, 07450 - 07451, 07460 - 07461, 07465, 07480, 07490,
07520, 07530, 07540, 07550, 07560, 07610, 07620, 07630, 07640, 07650,
07660, 07670, 07680, 07710, 07720, 07730, 07740, 07750, 07760, 07770,
07780, 07810, 07820, 07830, 07840, 07860, 07870, 07910 - 07912,
07920, 07955, 07980 - 07983, 20605, 21010, 21050, 21060, 21141 -
21142, 21193 - 21198, 21215, 21240 - 21243, 21480, 21485, 21490,
21499, 29804.
3.0 POLICY
3.1 The following
are examples of procedures are considered to be in this category
and are covered:
3.1.1 Excision of tumors and cysts of the jaws, cheeks,
lips, tongue, roof and floor of the mouth, when such conditions
require a pathological (histological) examination.
3.1.2 Surgical
procedures required to correct accidental injuries of the jaws,
cheeks, lips, tongue, roof and floor of the mouth.
3.1.3 Treatment
of oral and/or facial cancer.
3.1.4 Treatment of fractures of
facial bones.
3.1.5 External (extraoral) incision
and drainage of cellulitis.
3.1.6 Surgery of accessory sinuses,
salivary glands or ducts.
3.1.7 Surgical treatment of the
temporal bone and the lower bone of the jaw.
3.1.7.1 The following
are examples of conditions under which surgical treatment of the temporomandibular
joint will be allowed:
• Osteoarthritis
• Trauma
• Congenital causes,
e.g., agenesis or hypoplastic condyle
• Ankylosis
• Tumors
• Dislocations.
3.1.7.2 The contractor
may use the current recommendations for Management of Patients with Temporomandibular
Joint Implants published by the American Academy of Oral Maxillofacial
Surgeons in their adjudication of claims involving temporomandibular
joint surgery.
3.2 Any oral surgical procedure
which falls within the cosmetic, reconstructive and/or plastic surgery
definition is subject to the limitations and requirements set forth
in
32 CFR 199.4(e)(8). Surgical correction of
prognathism and micrognathism and congenital craniofacial anomalies
(i.e., Treacher-Collins syndrome, hemifacial microsomia, etc.) is
covered.
3.3 Oral surgical procedures for treatment of the
following medical conditions are also covered:
3.3.1 Osteomyelitis.
3.3.2 Removal
of a foreign body which is hazardous to the patient’s health, which
is reaction-producing or complicates a primary medical condition.
3.3.3 Intrinsic
and traumatic diseases of the temporomandibular joint which require
surgery such as rheumatoid arthritis and osteoarthritis.
3.3.4 Mandibular
bone grafts performed for other than orthodontia or dental support.
3.3.5 Surgical
treatment of the temporomandibular joint.
3.3.6 The Therabite Jaw Motion System
may be considered for cost-sharing as Durable Medical Equipment
(DME).
4.0 EXCLUSIONS
4.1 Treatment
of Temporomandibular Joint Syndrome,
also known as
Myofacial Pain Dysfunction Syndrome, occlusal equilibration
and restorative occlusal rehabilitation are excluded from this category.
See Chapter 8, Section 13.1.
4.2 Extraction
of unerupted or partially erupted, malposed or impacted teeth, with
or without the attached follicular or development tissues, are not
covered oral surgery procedures except when the care is indicated
in preparation for, or as a result of, dental trauma caused by the
medically necessary treatment of an injury or illness.
4.3 Surgical
preparation of the mouth for dentures except for adjunctive dental
care (Current Procedural Terminology (CPT) codes
40840 - 40845).
4.4 Mandibular staple implants
are not covered because their primary purpose is to prepare the mouth
for dentures.