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 (e.g., Treacher-Collins
syndrome, hemifacial microsomia) 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.