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.