Notification



Notification Issue Date:



Claim Payment Policy


Title:Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery

Policy #:04.00.03a

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

Dental extractions performed prior to cardiac surgery, radiation therapy, or transplant surgery are covered and eligible for reimbursement consideration by the Company.
  • Individual benefits must be verified because some group contracts exclude coverage for dental extractions prior to cardiac surgery, radiation therapy, or transplant surgery.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Dental extractions prior to cardiac surgery, radiation therapy, or transplant surgery may be performed in the office, ambulatory surgery center, short procedure unit, hospital outpatient, or inpatient setting depending on the individual's medical needs.

This policy applies only to dental extractions performed prior to cardiac surgery, radiation therapy, or transplant surgery. It does not imply coverage of other dental services that may be performed at the same time.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, dental extractions performed prior to cardiac surgery, radiation therapy, or transplant surgery are covered under the medical benefits of the Company's Commercial products unless the group contract specifically excludes coverage for dental extractions.

Description

Based on an individual's medical condition, it may be medically necessary to perform dental extractions prior to the initiation of cardiac surgery (when there is risk for bacterial endocarditis from procedures such as valve replacement or surgical correction of tetralogy of Fallot), radiation therapy, or transplant surgery to prevent medical complications or infections.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 16: General exclusions from coverage. 140 - Dental Services Exclusion. [CMS Web site]. Original: 10/01/03. (Revised: 04/09/10). Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed February 15, 2016.


Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual.Chapter 15: Covered medical and other health services. 150 - Dental Services. [CMS Web site]. Original: 10/01/03. (Revised 08/20/10). Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed February 15, 2016.

Company benefit contracts.




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)

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 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)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 03/02/2016
Version Issued Date: 01/20/2006
Version Reissued Date: 03/16/2016

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.