Medica Guide To Medical Coverage For Dental-Related Services
Medica Guide to Medical Coverage for Dental-Related ServicesThe following guidelines apply for most Medica products. Coverage for any specific treatment or situation can be verified through the Medica Provider Service Center: 1-800-458-5512 See Mailing Addresses for Claims located on medica.com at Providers Administrative Resources Claim Tools Dental providers using ADA forms should follow ADA completion instructions and ensure diagnosis code is on the formSituationMedical or DentalAdditional InformationServices related to anaccident or injuryCovered as treatment when: Services are completed within 24 months of the original date ofthe accident/injury or the date first covered under the contract.(note: the completion date can vary by group) The injury to the tooth was not caused by biting or chewing Services are to treat an injury to sound, natural teeth or torepair (not replace) sound, natural teethA sound, natural tooth means a tooth (including supportingstructures) that is free from disease that would preventcontinual function of the tooth for at least one year. In the caseof primary (baby) teeth, the tooth must have a life expectancy ofone year.Plans may cover oral surgery for:Oral Surgery Codes:Oral Surgery Partially or completely unerupted impacted teethA tooth root without the extraction of the entire toothThe gums & tissues of the mouth when not in connectionwith the extraction or repair of teethNote: Medica will review appropriate anesthesia codes for payment.Guide to Medical Coverage for Dental-Related ServicesRev 02/19/2019See accident diagnosis chart on last page.Please include the date of injury/accident on the CMS-1500CodeDescriptionD7220Removal of impacted tooth - soft tissueD7230Removal of impacted tooth - partially bonyD7240D7241Removal of impacted tooth - completely bonyRemoval of impacted tooth - completelybony, withunusual surgical complicationsD7250Surgical removal of residual tooth roots (cuttingprocedure)Page 1 of 6
SituationMedical or DentalAdditional InformationTemporoMandibularJoint(TMJ)Medical coverage includes: Diagnostic visits Surgical and non-surgical medical treatment TMJ splints and adjustmentsCoverage for treatment of TMJ disorder includes coverage for thetreatment of craniomandibular disorder.Guide to Medical Coverage for Dental-Related ServicesRev t TMJ disorder, unspecifiedLeft TMJ disorder, unspecifiedBilateral TMJ disorder, unspecifiedM26.609M26.611M26.612Unspecified TMJ disorder, unspecified sideAdhesions and ankylosis of right TMJAdhesions and ankylosis of left TMJM26.613Adhesions and ankylosis of bilateral TMJM26.619Adhesions and ankylosis of TMJ, unspecified sideM26.621Arthralgia of right TMJM26.622M26.623M26.629Arthralgia of left TMJArthralgia of bilateral TMJArthralgia of TMJ, unspecified sideM26.631Articular disc disorder of right TMJM26.632Articular disc disorder of left TMJM26.633Articular disc disorder of bilateral TMJM26.639Articular disc disorder of TMJ, unspecified sideM26.69Other specified disorders of TMJPage 2 of 6
SituationMedical or DentalMedically NecessaryHospitalization forDental ProceduresThe following are considered to be medically necessary hospitalizations for dental procedures:Additional InformationRecommended by a physician; and received during a dental procedure; and provided to amember who:I.Is a child under age five orII.Is severely disabled; orIII.Has a medical condition and requires hospitalization or general anesthesia fordental care treatment.Note: Age, anxiety, and behavioral conditions are not considered medical conditions.Exceptions: Medica Choice CareSM and Medica DUAL Solution members may have expandedbenefit.Autism Note: Autism is a medical diagnosis, not a behavioral condition.If the member’s health condition meets medically necessary criteria, the medical benefit onlycovers the anesthesia and facility charges.Non-Covered ServicesServices not covered include: Dental services to treat an injury from biting and chewing. Osteotomies and other procedures associated with the fitting of dentures or dental implants. Dental implants (tooth replacement), except for treatment of cleft lip and palate as describedin the Cleft lip and palate section. Any other dental procedures or treatment, whether the dental treatment is needed becauseof a primary dental problem or as a manifestation of a medical treatment or condition. Any orthodontia, except for cleft lip and palate as described in the cleft lip and palate section. Tooth extractions, with the exception of covered services described in other sections. Any dental procedures or treatment related to periodontal disease. Endodontic procedures and treatment, including root canal procedures and treatment, unlessprovided as accident-related services as described in that section. Routine diagnostic and preventative dental services except as described in the members plandocument.Guide to Medical Coverage for Dental-Related ServicesRev 02/19/2019This section describes services generallynot covered by Medica. Please rememberto verify coverage by calling the MedicaProvider Service Center at 1-800-458-5512Page 3 of 6
SituationMedical or DentalAdditional InformationOrthodontia related toCleft Palate or Cleft LipDiagnosisMedical diagnosis must be indicated on the claim form for charges to beconsidered as medical.See chart below for Cleft Lip/Cleft Palate ICD-9 codes.Note: Medical orthodontia reimbursement is made asservices are rendered, not on a per-case basis.Straightening of the jaw is considered medical.Surgery must be medically necessary. See Medicapolicies on medica.com at Providers Policies andGuidelines UM Policies and PriorAuthorization Orthognathic Surgery (III-SUR.32)Orthognathic Surgery –(Also known as Lefort I, orII Osteotomy; MaxillaryHyper-plasia; MaxillaryRetrusion; Micrognathia;Prognathia, Retrognathia;Sagittal Split Osteotomy)Prior authorization is required.Coverage for orthognathic procedures varies by group, socall the Medica Provider Service Center to verify coverageat1-800-458-5512Coordination of Benefits (COB) –Medica follows whatever order the dental plan does. If the dental plan states Medica is primary, then Medica will pay primary.Guide to Medical Coverage for Dental-Related ServicesRev 02/19/2019Page 4 of 6
Date of Service Prior to 10/1/2015Cleft Lip/Cleft PalateDiagnosis GuideFor orthodontic services related tocleft lip/palate treatment, thediagnosis must be indicated on theCMS-1500 claim form for services tobe considered under the medicalplan. Please include the diagnosiscode on the CMS-1500 claim form.Code749.00749.01DescriptionCleft Palate, unspecifiedUnilateral, al, incomplete (cleft uvula)Bilateral, completeBilateral, incompleteCleft Lip, unspecifiedUnilateral, completeUnilateral, incomplete(Cleft Lip) Bilateral, completeBilateral, incompleteCleft Palate w/Cleft Lip, unspecifiedUnilateral, completeUnilateral, incompleteBilateral, completeBilateral, incompleteOther CombinationsDate of Service on or After left hard palateCleft soft palateCleft hard palate with cleft soft palateCleft uvulaCleft lip, bilateralCleft lip, medianCleft lip, unilateralCleft hard palate with bilateral cleft lipCleft hard palate with unilateral cleft lipCleft soft palate with bilateral cleft lipCleft soft palate with unilateral cleft lipCleft hard and soft palate with bilateral cleftlipCleft hard and soft palate with unilateralcleft lipUnspecified cleft palate with bilateral cleftlipUnspecified cleft palate with unilateral cleftlipIf services are related to an injury/accident, Box 10 on the CMS-1500 claim form should indicate so.Accident Coding – Date of Service Prior to 10/1/2015CodeDescription525.11Loss of teeth due to trauma873.63Tooth (broken) (fractured) (due to trauma)873.73Tooth (broken) (fractured) (due to trauma)-complicated873.44Face without complication (jaw)873.54Face, complicated (jaw)959.09Injury of face & neck (jaw)Guide to Medical Coverage for Dental-Related ServicesRev 02/19/2019Page 5 of 6
Accident Coding – Date of Service on or After 10/1/2015CodeDescriptionK08.111Complete loss of teeth due to trauma, class IK08.112Complete loss of teeth due to trauma, class IIK08.113Complete loss of teeth due to trauma, class IIIK08.114Complete loss of teeth due to trauma, class IVK08.119Complete loss of teeth due to trauma, unspecified classK08.411Partial loss of teeth due to trauma, class IK08.412Partial loss of teeth due to trauma, class IIK08.413Partial loss of teeth due to trauma, class IIIK08.414Partial loss of teeth due to trauma, class IVK08.419Partial loss of teeth due to trauma, unspecified classS01.401AUnspecified open wound of right cheek and temporomandibular area, initial encounterS01.402AUnspecified open wound of left cheek and temporomandibular area, initial encounterS01.409AUnspecified open wound of unspecified cheek and temporomandibular area, initial encounterS01.411ALaceration without foreign body of right cheek and temporomandibular area, initial encounterS01.412ALaceration without foreign body of left cheek and temporomandibular area, initial encounterS01.419ALaceration without foreign body of unspecified cheek and temporomandibular area, initial encounterS01.421ALaceration with foreign body of right cheek and temporomandibular area, initial encounterS01.422ALaceration with foreign body of left cheek and temporomandibular area, initial encounterS01.429ALaceration with foreign body of unspecified cheek and temporomandibular area, initial encounterS01.431APuncture wound without foreign body of right cheek and temporomandibular area, initial encounterS01.432APuncture wound without foreign body of left cheek and temporomandibular area, initial encounterS01.439APuncture wound without foreign body of unspecified cheek and temporomandibular area, initial encounterS01.441APuncture wound with foreign body of right cheek and temporomandibular area, initial encounterS01.442APuncture wound with foreign body of left cheek and temporomandibular area, initial encounterS01.449APuncture wound with foreign body of unspecified cheek and temporomandibular area, initial encounterS01.451AOpen bite of right cheek and temporomandibular area, initial encounterS01.452AOpen bite of left cheek and temporomandibular area, initial encounterS01.459A Open bite of unspecified cheek and temporomandibular area, initial encounter 2019 Medica. Medica and Medica Prime Solution are registered service marks of Medica Health Plans. “Medica” refers to the family of health services companies that includes Medica Health Plans, Medica HealthPlans of Wisconsin,S02.5XXAMedica InsuranceCompany,MedicaSelf-Insured,MMSI,Inc. d/b/aPlan Solutions, Medica Health Management, LLC and the Medica Foundation.Fractureof althfractureS02.5XXBFracture of tooth (traumatic), initial encounter for open fractureGuide to MedicalCoverageDislocationfor Dental-RelatedServicesS03.2XXAof tooth, initialencounterRev 02/19/2019Page 6 of 6
Coverage for orthognathic procedures varies by group, so call the Medica Provider Service Center to verify coverage at 1-800-458-5512 Coordination of Benefits (COB) - Medica follows whatever order the dental plan does. If the dental plan states Medica is primary, then Medica will pay primary.
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Summary of Benefits and Coverage: Coverage Period: What this Plan Covers & What You Pay For Covered Services 01/01/20 21- /3 /20 Coverage for:Horizon BCBSNJ: St. Joseph's Health All Coverage Types Plan Type: EPO 1(0076322:0003:0004:0005; pkg 001) M/CP (Prescription/Advantage EPO Inner Circle of 8 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan.
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