Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
Policy #:MA04.002

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Extraction of completely or partially bony impacted teeth or the exposure of impacted or unerupted teeth without extraction, by surgery or by other means, is not covered by the Company, because these services are not covered by Medicare. Therefore, these services, including the following associated services, are not eligible for reimbursement consideration:
  • Evaluation and Management service
  • Provider procedure fee
  • Facility charges
  • Radiographs performed to determine the impacted state

Policy Guidelines

This policy is consistent with Medicare’s coverage determination.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, extraction of completely or partially bony impacted teeth or the exposure of impacted or unerupted teeth without extraction, by surgery or by other means, is not covered under the medical benefits of the Company’s Medicare Advantage plans because they are not covered by Medicare. Therefore, these services are not eligible for reimbursement consideration.

Description

The extraction of bony impacted teeth involves extracting teeth that are either completely or partially covered by bone. Any tooth has the potential to become impacted. However, the most common are the wisdom teeth because they are often the last to emerge, usually between the ages of 17 and 21.

A bony impacted tooth may remain stuck in the bone for various reasons. The area may become overcrowded and prevent the tooth from emerging. The tooth may also become twisted or displaced as it tries to emerge. While impacted teeth may often be painless and cause no apparent trouble, occasionally a partially emerged impacted tooth can trap food, plaque, and other debris causing pericoronitis, a condition associated with inflammation and tenderness around the crown of an impacted tooth.

Impacted teeth may be treated by extraction or exposure. The exposure of impacted teeth involves uncovering unerupted teeth without extraction. Extraction is typically the preferred treatment for an impacted tooth because when the tooth roots of an impacted tooth are allowed to develop, they may wrap around sensitive facial nerves.
References

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. 150 - Dental services. [CMS Web site]. 10/01/03. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.
Accessed March 13, 2014.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 16: General exclusions from coverage. 140 - Dental services exclusion. [CMS Web site]. 10/01/03. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed Accessed March 13, 2014.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

NOT COVERED

70300, 70310, 70320, 70355



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

K01.0 Embedded teeth
K01.1 Impacted teeth



HCPCS Level II Code Number(s)



NOT COVERED
D0220 intraoral - periapical first radiographic image
D0230 intraoral - periapical each additional radiographic image
D0330 panoramic radiographic image
D7230 removal of impacted tooth - partially bony
D7240 removal of impacted tooth - completely bony
D7241 removal of impacted tooth - completely bony, with unusual surgical complications
D7280 surgical access of an unerupted tooth
D7283 placement of device to facilitate eruption of impacted tooth



Revenue Code Number(s)



Coding and Billing Requirements






Policy History

MA04.002
12/31/2019This policy has been reissued in accordance with the Company's annual review process.
01/01/2015This is a new policy.






Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 01/09/2020