Local Coverage Determination (LCD)

Dental Services

L34574

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Contractor Information

LCD Information

Document Information

LCD ID
L34574
LCD Title
Dental Services
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 07/22/2021
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical checkups.

CMS Internet-Only Manual, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §10.3 Certification for Hospital Admissions for Dental Services

CMS Internet-Only Manual, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §70 Physician Defined and §70.2 Dentists

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, §30 Drugs and Biologicals and §70 Inpatient Services in Connection With Dental Services

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §120C Dentures and §150 Dental Services

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 16, §140 Dental Services Exclusion

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §260.6 Dental Examination Prior to Kidey Transplantation

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Dental services are excluded from coverage in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth, except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures. Structures directly supporting the teeth means, the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.

In an outpatient setting when an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. An alveoloplasty and a frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service: e.g. the non-covered extraction or the preparation of the mouth for dentures.

NON-COVERED SERVICES

(The only exception are for inpatient services: "except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures." )

  • The extraction of an impacted tooth
  • An alveoloplasty, (the surgical improvement of the shape and condition of the alveolar process), when performed for the preparation of the mouth for dentures
  • Frenectomy when performed for the preparation of the mouth for dentures
  • Extractions that are due to decay or periodontal disease
  • Extractions done for the purpose of obtaining dentures
  • Services related to chronic dental disease (i.e. gingivectomy)
  • Removal of a benign growth or radicular cyst, in the mouth, or from structures directly supporting the teeth means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process)
  • Insertion of metallic implants used for enhancement of the structure of the jaws in order to support dentures or prosthesis
  • Excision of torus mandibularis or excision of a maxillary torus palatinus is usually performed to accommodate a denture. The removal of the torus palatinus (a bony protuberance of the hard palate) and torus mandibularis could be a covered service. However, with rare exception, this surgery is performed in connection with an excluded service; i.e., the preparation of the mouth for dentures. Under such circumstances, reimbursement is not made for this purpose.

COVERED SERVICES:

  • Surgery related to the jaw or any structure connected to the jaw including structures of the facial area below the eyes, for example (mandible, teeth, gums, tongue, palate, salivary glands, sinuses, etc.)
  • Wiring of the teeth when performed in connection with the reduction of a jaw fracture
  • Reduction of any fracture of the jaw or any facial bone, including dental splints or other appliances, if used for this purpose
  • Reconstruction of a ridge if performed as a result of and at the same time as the surgical removal of a tumor (the total surgical procedure is covered)
  • Removal of a torus palatinus (a bony protuberance of the hard palate) may be covered, if the procedure is not performed to prepare the mouth for dentures
  • Extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease
  • Insertion of metallic implants if the implants are used to assist in or enhance the retention of a dental prosthetic as a result of a covered service

The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is also covered. This is an exception to the requirement that to be covered, a non-covered procedure or service performed by a dentist must be an incident to and integral part of a covered procedure or service performed by the dentist. Whether such services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered. Thus, an x-ray taken in connection with the reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered.

A dentist qualifies as a physician if, he/she is a doctor of dental surgery or dental medicine, and is legally authorized to practice dentistry in the state in which he/she performs such function, and who is acting within the scope of his/her license when he/she performs such functions. Such services include any otherwise covered service that may legally and alternatively be performed by doctors of medicine, osteopathy and dentistry; e.g., dental examinations to detect infections prior to certain surgical procedures, treatment of oral infections and interpretations of diagnostic x-ray examinations in connection with covered services. Payment for the services of dentists in an outpatient setting is limited to those procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting the teeth. The coverage of any given dental service is not affected by the professional designation of the physician rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine or osteopathy.

Dental Examination Prior to Kidney Transplantation

An oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

  1. Documentation supporting the medical necessity, such as ICD-10 codes, including the need for the surgery in an inpatient setting, must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.
  2. Where the dental procedure is not the primary procedure performed, documentation of the primary procedure must be included in the patient’s medical records.
  3. Documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request.

Utilization Guidelines

If a non-covered service is performed as the primary procedure in conjunction with a covered procedure or service, regardless of the complexity, the total service is excluded from coverage.

Anesthesia services, provided by the surgeon performing the surgery, is considered bundled into the payment for the surgical procedure. Since the payment is bundled, the physician is precluded from billing the beneficiary for this service.

Where a patient is hospitalized solely for less than major noncovered dental treatment, both the professional services of the dentist and the inpatient hospital services are not covered. "except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of the individual's underlying medical condition and clinical status or the severity of the dental procedures."

Items and services in connection with an excluded dental service (the care, treatment, filling, removal or replacement of teeth, or structures directly supporting the teeth) are not covered. (i.e. anesthesia services, lab, x-ray services).

Sources of Information
N/A
Bibliography

Amalgamation of national policy

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
07/22/2021 R10

Under CMS National Coverage Policy updated section headings for CMS regulations. Formatting was revised throughout the LCD.

  • Provider Education/Guidance
10/10/2019 R9

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Dental Services A56663 article. Under CMS National Coverage Policy removed statement “Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.”

 At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
07/04/2019 R8

All coding located in the Coding Information section has been moved into the related Billing and Coding: Dental Services A56663 article and removed from the LCD. Under CMS National Coverage Policy the verbiage “NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860 (b) and 42 CFR 426 (Subpart D)). In addition, an administrative law judge may not review a NCD. See section 1869 (f)(1)(A)(l) of the Social Security Act” has been deleted.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
02/08/2018 R7

Under Coverage Indications, Limitations and/or Medical Necessity Non-Covered Services removed the italics from the verbiage in the first sentence. Under Covered Services revised the second sentence to read This is an exception to the requirement that to be covered, a non-covered procedure or service performed by a dentist must be an incident to and integral part of a covered procedure or service performed by the dentist”. Under Dental Examination Prior to Kidney Transplantation revised the verbiage to read “An oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery”. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
01/29/2018 R6 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/26/2017 R5 Under CMS National Coverage Policy Title XVIII of the Social Security Act, §1862(a)(12) revised the verbiage to read “ states no payment may be made for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made for inpatient hospital services because of underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services”, for Title XVIII of the Social Security Act, §1862(a)(7) revised the verbiage to read “states Medicare will not cover any services or procedures associated with routine physical checkups” and for 42 CFR §411.15(i) revised the verbiage to read “states no payment may be made for dental services in connection with care, treatment filling, removal, or replacement of teeth, or structures directly supporting teeth, except for inpatient services in connection with dental procedures when hospitalization is required because of an underlying medical condition and clinical status or the severity of the dental procedures”.
  • Provider Education/Guidance
  • Other (Annual Validation)
10/01/2016 R4 Under ICD-10 Codes That Support Medical Necessity: Group 1 added S0240AA, S0240AB, S0240AD, S0240AG, S0240AK, S0240AS, S0240BA, S0240BB, S0240BD, S0240BG, S0240BK, S0240BS, S0240CA, S0240CB, S0240CD, S0240CG, S0240CK, S0240CS, S0240DA, S0240DB, S0240DD, S0240DG, S0240DK, S0240DS, S0240EA, S0240EB, S0240ED, S0240EG, S0240EK, S0240ES, S0240FA, S0240FB, S0240FD, S0240FG, S0240FK, S0240FS, S02601A, S02601B, S02601D, S02601G, S02601K, S02601S, S02602A, S02602B, S02602D, S02602G, S02602K, S02602S, S02611A, S02611B, S02611D, S02611G, S02611K, S02611S, S02612A, S02612B, S02612D, S02612G, S02612K, S02612S, S02621A, S02621B, S02621D, S02621G, S02621K, S02621S, S02622A, S02622B, S02622D, S02622G, S02622K, S02622S, S02631A, S02631B, S02631D, S02631G, S02631K, S02631S, S02632A, S02632B, S02632D, S02632G, S02632K, S02632S, S02641A, S02641B, S02641D, S02641G, S02641K, S02641S, S02642A, S02642B, S02642D, S02642G, S02642K, S02642S, S02651A, S02651B, S02651D, S02651G, S02651K, S02651S, S02652A, S02652B, S02652D, S02652G, S02652K, S02652S, S02671A, S02671B, S02671D, S02671G, S02671K, S02671S, S02672A, S02672B, S02672D, S02672G, S02672K and S02672S. Under ICD-10 Codes That Support Medical Necessity: Group 1 deleted S02.61XA, S02.61XB, S02.61XD, S02.61XG, S02.61XK, S02.61XS, S02.62XA, S02.62XB, S02.62XD, S02.62XG, S02.62XK, S02.62XS, S02.63XA, S02.63XB, S02.63XD, S02.63XG, S02.63XK, S02.63X,S S02.64XA, S02.64XB, S02.64XD, S02.64XG, S02.64XK, S02.64X, S02.65XA, S02.65XB, S02.65XD, S02.65XG, S02.65XK, S02.65XS, S02.67XA, S02.67XB, S02.67XD, S02.67XG, S02.67XK, S02.67XS, S02.8XX,A S02.8XXB, S02.8XXD, S02.8XXG, S02.8XXK and S02.8XXS. Under ICD-10 Codes That Support Medical Necessity: Group1 updated code description for S02.400A, S02.400B, S02.400D, S02.400G, S02.400K, S02.400S, S02.401A, S02.401B, S02.401D, S02.401G, S02.401K, S02.401S, S02.402A, S02.402B, S02.402D, S02.402G, S02.402K, S02.402S, S02.600A, S02.600B, S02.600D, S02.600G, S02.600K and S02.600S. Under ICD-10 Codes that DO NOT Support Medical Necessity: Group 1 deleted all ICD-10 codes. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2016.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
01/28/2016 R3 Under CMS National Coverage Policy added the first paragraph related to italicized text. Under Coverage Indications, Limitations and/or Medical Necessity language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized. Under Coverage Indications, Limitations and/or Medical Necessity-Non-Covered Services in the seventh bullet added “or from”.
  • Provider Education/Guidance
10/01/2015 R2 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R1 Under Coverage Indications, Limitations, and/or Medical Necessity in the first sentence of the first paragraph added “are excluded from coverage…” and added “….or the severity of the dental procedures.” Under Coverage Indications, Limitations, and/or Medical Necessity-Non-Covered Services in the first sentence of the first paragraph added “...or the severity of the dental procedures.” Under Coverage Indications, Limitations, and/or Medical Necessity-Covered Services-Dental Examination Prior to Kidney Transplant revised “This” to read “The” in the second sentence and italicized the paragraph. Under Bill Type Codes deleted 013X, 023X, 071X and 077X. During a quality review of this LCD it was identified that bill types 013X (Hospital outpatient), 023X Skilled Nursing- Outpatient), 071X (Clinic-Rural Health) and 077X (Clinic-Federally Qualified Health Center (FQHC) were inadvertently included among the Bill Type Codes . These bill type codes were deleted without substantive change (non-substantive revision) to the coverage of inpatient dental services “when hospitalization is required because of the individual’s underlying medical condition and clinical status or the severity of the dental procedures” or for a dental examination performed prior to a kidney transplant. Under Associated Information-Utilization Guidelines added “…or the severity of the dental procedures” to the last sentence of the third paragraph.
  • Provider Education/Guidance
  • Other

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56663 - Billing and Coding: Dental Services
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
07/16/2021 07/22/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Dental

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