January 2018 policy update bulletin - uhcprovider.com · A restorable permanent tooth with irreversible pulpitis or a necrotic pulp The relief of acute pain prior to complete root

UnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is to

support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice

staff with a simple and predictable administrative experience. The Policy Update Bulletin was developed to share important information regarding

UnitedHealthcare Dental Clinical Policy and Coverage Guideline updates.*

*Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law

January 2018

policy update bulletin Dental Clinical Policy & Coverage Guideline Updates

2 Dental Clinical Policy & Coverage Guideline Update Bulletin: January 2018

Dental Clinical Policy & Coverage Guideline Updates

Overview

Tips for using the Policy Update Bulletin:

From the table of contents, click the policy title to be

directed to the corresponding policy update summary.

From the policy updates table, click the policy title to view a

complete copy of a new, updated, or revised policy.

Policy Update Classifications

New

New clinical coverage criteria and/or documentation review

requirements have been adopted for a health service (e.g., test, drug,

device or procedure)

Updated

An existing policy has been reviewed and changes have not been made

to the clinical coverage criteria or documentation review requirements;

however, items such as the clinical evidence, FDA information, and/or

list(s) of applicable codes may have been updated

Revised

An existing policy has been reviewed and revisions have been made to

the clinical coverage criteria and/or documentation review requirements

Replaced

An existing policy has been replaced with a new or different policy

Retired

The health service(s) addressed in the policy are no longer being

managed or are considered to be proven/medically necessary and are

therefore not excluded as unproven/not medically necessary services,

unless coverage guidelines or criteria are otherwise documented in

another policy

Note: The absence of a policy does not automatically indicate or imply

coverage. As always, coverage for a health service must be determined

in accordance with the member’s benefit plan and any applicable

federal or state regulatory requirements. Additionally, UnitedHealthcare

reserves the right to review the clinical evidence supporting the safety

and effectiveness of a medical technology prior to rendering a coverage

determination.

This bulletin provides complete details on UnitedHealthcare Dental

Clinical Policy and Coverage Guideline updates. The inclusion of a

dental service (e.g., procedure or technology) in this bulletin

indicates only that UnitedHealthcare has recently adopted a new

policy and/or updated, revised, replaced or retired an existing

policy; it does not imply that UnitedHealthcare provides coverage

for the dental service. In the event of an inconsistency or conflict

between the information provided in this bulletin and the posted

policy, the provisions of the posted policy will prevail. Note that

most benefit plan documents exclude from benefit coverage health

services identified as investigational or unproven/not medically

necessary. Physicians and other health care professionals may not

seek or collect payment from a member for services not covered by

the applicable benefit plan unless first obtaining the member’s

written consent, acknowledging that the service is not covered by

the benefit plan and that they will be billed directly for the service.

A complete library of Dental Clinical Policies & Coverage

Guidelines is available at UHCprovider.com > Menu >

Policies and Protocols > Dental Clinical Policies and

Coverage Guidelines.

https://www.uhcprovider.com/en/policies-protocols/dental-policies.html





In This Issue

Take Note Page

ANNUAL CDT CODE UPDATES

Application of Medicaments and Desensitizing Resins – Effective Jan. 1, 2018 .......................................................................................................... 5 Full Mouth Debridement – Effective Jan. 1, 2018 .................................................................................................................................................. 5 General Anesthesia Conscious Sedation Services – Effective Jan. 1, 2018 ................................................................................................................ 5 Implants – Effective Jan. 1, 2018 ....................................................................................................................................................................... 5 Medically Necessary Orthodontic Treatment – Effective Jan. 1, 2018 ....................................................................................................................... 5 Miscellaneous Diagnostic Procedures – Effective Jan. 1, 2018 ................................................................................................................................. 5 National Standardized Dental Claim Utilization Review Criteria – Effective Jan. 1, 2018 ............................................................................................. 5 Non-Surgical Endodontics – Effective Jan. 1, 2018 ................................................................................................................................................ 5 Non-Surgical Extractions – Effective Jan. 1, 2018 ................................................................................................................................................. 5 Oral Surgery: Miscellaneous Surgical Procedures – Effective Jan. 1, 2018 ................................................................................................................ 6 Oral Surgery: Orthodontic Related Procedures – Effective Jan. 1, 2018 ................................................................................................................... 6 Removable Prosthodontics – Effective Jan. 1, 2018 ............................................................................................................................................... 6 Single Tooth Indirect Restorations – Effective Jan. 1, 2018 .................................................................................................................................... 6 Surgical Endodontics – Effective Jan. 1, 2018 ....................................................................................................................................................... 6 Surgical Periodontics: Resective Procedures – Effective Jan. 1, 2018 ....................................................................................................................... 6

Clinical Policy Updates

UPDATED

Genetic Testing for Oral Disease – Effective Jan. 1, 2018 ....................................................................................................................................... 7 Non-Ionizing Diagnostic Procedures – Effective Jan. 1, 2018 .................................................................................................................................. 7

RETIRED

Imaging Services: Cone Beam Computed Tomography – Effective Jan. 1, 2018 ........................................................................................................ 7

Coverage Guideline Updates

UPDATED

Non-Surgical Endodontics – Effective Jan. 1, 2018 ................................................................................................................................................ 8 Provisional Splinting – Effective Jan. 1, 2018 ..................................................................................................................................................... 11 Salivary Testing – Effective Jan. 1, 2018 ........................................................................................................................................................... 12

REVISED

Labial Veneers – Effective Feb. 1, 2018 ............................................................................................................................................................. 12



In This Issue

Single Tooth Indirect Restorations – Effective Feb. 1, 2018 .................................................................................................................................. 13


Take Note


Effective Jan. 1, 2018, the following Dental Clinical Policies, Coverage Guidelines, and Utilization Review Guidelines have been modified to reflect the 2018 Current Dental Terminology (CDT) code additions, revisions, and deletions. Refer to the source below for information on the 2018 code updates:

American Dental Association®. Current Dental Terminology: CDT 2018

Policy Title Policy Type Summary of Changes

Application of

Medicaments and Desensitizing Resins

Clinical Policy Revised description for D1354

Full Mouth Debridement

Coverage Guideline

Revised description for D4355

General Anesthesia Conscious Sedation Services

Coverage Guideline

Added D9222 and D9239 Revised description for D9223 and D9243

Implants Coverage Guideline

Added D6096, D6118, and D6119

Medically Necessary Orthodontic

Treatment

Coverage Guideline

Added D8695

Miscellaneous Diagnostic Procedures

Coverage Guideline

Added D0411

National Standardized Dental Claim

Utilization Review

Criteria

Utilization Review Guideline

Added D0411, D5511, D5512, D5611, D5612, D5621, D5622, D6096, D6118, D6119, D7296, D7297, D7979, D8695, D9222, D9239, D9995, and D9996

Removed D5510, D5610, and D5620

Non-Surgical Endodontics

Coverage Guideline

Revised description for D3320, D3330, and D3347

Non-Surgical Extractions

Coverage Guideline


http://www.ada.org/en/publications/cdt


Take Note


Oral Surgery: Miscellaneous Surgical Procedures

Clinical Policy Added D7979 Revised description for D7980

Oral Surgery: Orthodontic Related Procedures

Clinical Policy Added D7296 and D7297

Removable Prosthodontics

Coverage Guideline

Added D5511, D5512, D5611, D5612, D5621, and D5622 Removed D5510, D5610, and D5620

Single Tooth Indirect Restorations

Coverage Guideline


Surgical Endodontics

Clinical Policy Revised description for D3421

Surgical

Periodontics: Resective

Procedures

Clinical Policy Revised description for D4230 and D4231


Clinical Policy Updates

Policy Title Effective Date Summary of Changes Coverage Rationale

UPDATED

Genetic Testing for Oral Disease

Jan. 1, 2018 Updated supporting information to reflect the most current

clinical evidence, FDA information and references; no change to coverage rationale or list of applicable codes

Collection and Preparation of Genetic Sample Material for Laboratory Analysis and Report

Genetic Test for Susceptibility to Diseases – Specimen Analysis

The collection, preparation and testing of genetic samples are indicated for patients who have known human papilloma virus (HPV) infection, or have

other related risk factors, to identify if the strain of HPV known to be related

to oral and oropharyngeal cancers is present.

The clinical utility of genetic testing for susceptibility to periodontal diseases

has not been established. Additionally, there is a lack of objective, high quality clinical evidence to support these tests.

Non-Ionizing Diagnostic Procedures

Jan. 1, 2018 Updated supporting information to reflect the most current clinical evidence and references; no change to coverage rationale or list of applicable codes

There is inadequate evidence demonstrating the efficacy of these devices, limiting their use as a principal diagnostic tool. A non-ionizing diagnostic procedure refers to a device specifically designed to identify, quantify, monitor, and record changes in structure of enamel, dentin and cementum. These devices may be used as an adjunctive tool by the dental provider to

identify high caries risk areas, and create non-invasive treatment plans for

remineralization before caries begins. Visual and radiographic examinations remain the standard diagnostic methods for diagnosing active caries.

Policy Title Effective Date Summary of Changes

RETIRED

Imaging Services:

Cone Beam Computed Tomography

Jan. 1, 2018 Policy retired; the use of cone beam computed tomography (CBCT) for routine dental applications no longer

requires clinical coverage review




UPDATED

Non-Surgical Endodontics

Jan. 1, 2018

Updated list of applicable CDT codes to reflect annual code

edits; revised description for D3320, D3330, and D3347

Updated supporting information to reflect the most current

references

Vital Pulp Therapy

Direct Pulp Cap

Direct pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis All caries has been removed Mechanical exposure of a clinically vital and asymptomatic pulp occurs

Bleeding is controlled at the exposure site

Exposure permits the capping material to make direct contact with the vital pulp tissue

Exposure occurs when the tooth is under dental dam isolation Adequate seal of the coronal restoration can be maintained Patient has been fully informed that endodontic treatment may be

indicated in the future

Direct Pulp capping is not indicated for a carious exposure in primary teeth

Indirect Pulp Cap

Indirect pulp capping is indicated for the following:

Tooth has a vital pulp or been diagnosed with reversible pulpitis Tooth has a deep carious lesion that is considered likely to result in pulp

exposure during excavation

No history of subjective pretreatment symptoms Pretreatment radiographs should not show periradicular pathosis

Therapeutic Pulpotomy

Therapeutic pulpotomy is indicated for the following: Exposed vital pulps or irreversible pulpitis of primary teeth Any bleeding was controlled within several minutes As an emergency procedure in permanent teeth until root canal

treatment can be accomplished

As an interim procedure for permanent teeth with immature root formation to allow continued root development

In primary teeth, where there is a reasonable period of retention expected (approximately one year)

Therapeutic pulpotomy is not indicated for the following: Primary teeth with insufficient root structure, internal resorption, furcal

perforation or periradicular pathosis that may jeopardize the permanent successor

As the first stage of complete root canal therapy




UPDATED

Non-Surgical Endodontics (continued)

Jan. 1, 2018

Removal of pulp apical to the dentinocemental junction For primary teeth that are near exfoliation or less than 50% of the tooth

root remains

Partial Pulpectomy for Apexogenesis

A partial pulpotomy for apexogenesis is indicated for the following:

In a young permanent tooth for a carious pulp exposure When the pulpal bleeding is controlled within several minutes

A vital tooth, with a diagnosis of normal pulp or reversible pulpitis

Apexification/Recalcification

Apexification/recalcification is indicated for the following: Incomplete apical closure in a permanent tooth root

External root resorption or when the possibility of external root resorption exists.

Necrotic pulp, irreversible pulpitis or periapical lesion For prevention or arrest of resorption Perforations or root fractures that do not communicate with oral cavity

Apexification/recalcification is not indicated for the following: Tooth with a completely closed apex If patient compliance or long term follow up may be questionable

Pulpal Regeneration

Pulpal regeneration is indicated for the following: Permanent tooth with immature apex Necrotic pulp

Pulp space not needed for post/core or final restoration When tooth is not restorable

Pulpal regeneration is not indicated for the following:

Primary teeth The pulp space would be needed for final restoration

Non-Vital Pulp Therapy

Pulpal Debridement (Pulpectomy)

Pulpal debridement (pulpectomy) is indicated for the following: A restorable permanent tooth with irreversible pulpitis or a necrotic pulp

in which the root is apexified The relief of acute pain prior to complete root canal therapy




UPDATED


Jan. 1, 2018

A primary tooth, where there is a reasonable period of retention expected (approximately one year)

Pulpal debridement (pulpectomy) is not indicated for the following: Complete root canal therapy of an infected or necrotic tooth Primary teeth that are near exfoliation or less than 50% of the tooth root

remains

Pulpal Therapy (Resorbable Filling) – Primary Teeth

Pulpal therapy for primary teeth is indicated for the following:

A restorable primary tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified

The prognosis for keeping the tooth is up to one year and the tooth root lies in at least 25% bone

Pulpal therapy is not indicated for the following: Primary teeth that are near exfoliation or less than 50% of the tooth root

remains Permanent teeth

Endodontic Therapy

Endodontic therapy is indicated for the following: A restorable mature, completely developed permanent or primary tooth

with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure

Teeth with radiographic periapical pathology Primary teeth without a permanent successor Trauma When needed for prosthetic rehabilitation

Endodontic therapy is not indicated for the following: Teeth with a poor long term prognosis Teeth that are considered non-restorable

Teeth with inadequate bone support or advanced or untreated periodontal disease

Teeth with incompletely formed root apices

Treatment of Root Canal Obstruction; Non-Surgical Access

Treatment of a root canal obstruction is indicated for the following:

When there is an obstruction of the root canal system, (biological, iatrogenic ledges or post removal) and endodontic retreatment is needed

Removal of obstruction is complex and/or requires significant time




UPDATED


Jan. 1, 2018 Treatment of a root canal obstruction is not indicated when there is no obstruction evident.

Incomplete Endodontic Therapy: Inoperable, Unrestorable or Fractured Tooth

Incomplete endodontic therapy is indicated for the following:

During endodontic treatment of a tooth, it becomes apparent that the procedure cannot be successfully completed

The tooth will not be able to be restored, or the tooth fractures, necessitating discontinuation of treatment

Internal Root Repair of Perforation Defects

Internal root repair of perforation defects is indicated for the following:

There is a root perforation caused by pathology such as resorption or decay

A communication between the pulp space and external root surface as a result of internal root resorption.

Internal root repair of perforation defects is not indicated for the following:

Teeth that are considered non-restorable Teeth with inadequate bone support or advanced untreated periodontal

disease

Retreatment of Previous Root Canal Therapy

Retreatment of previous root canal therapy is indicated for the following: Canal fill appears to extend to a point shorter than 2millimeters from the

apex, or extends significantly beyond the apex

Fill appears to be incomplete Tooth is sensitive to pressure and percussion or other subjective

symptoms The existing endodontics is poor

Placement of a post has the potential to compromise the existing obturation or apical seal of the canal system

The canal is accessible and allows for retreatment with a non-surgical procedure

Provisional Splinting

Jan. 1, 2018

Updated supporting information to reflect the most current references; no change to coverage rationale or list of

Provisional Splinting using these codes is indicated for the following: Multiple teeth that have become mobile due to loss of alveolar bone loss

and periodontium During surgical and healing phases of regenerative periodontal therapy




UPDATED

Provisional Splinting (continued)

Jan. 1, 2018 applicable codes

Provisional Splinting using these codes is not indicated for the following: Tooth transplantation Trauma resulting in the reimplantation of completely avulsed tooth/teeth

Trauma resulting in displacement or fracture of tooth/teeth

Coverage Limitations and Exclusions

Limited to once per 36 months per same tooth/teeth Not to be billed on same day as any restoration, prostheses or implant

for same tooth/teeth

Salivary Testing Jan. 1, 2018 Updated coverage rationale; added language to indicate salivary testing may be indicated as part of oral disease risk assessment and management for oral cancers

Updated supporting information to reflect the most current references

Collection, Preparation and Analysis of Saliva Sample for Laboratory Diagnostic Testing

Collection, preparation and analysis of saliva sample for laboratory diagnostic testing may be indicated as part of oral disease risk assessment and management, including but not limited to caries, periodontal disease, oral cancers and xerostomia.


REVISED

Labial Veneers

Feb. 1, 2018

Updated list of related policies; added reference link to Dental

Coverage Guideline titled Single Tooth Direct Restorations

Revised coverage rationale: o Removed language

indicating labial veneers are not covered for most plans

o Updated list of indications to

clarify labial veneers are indicated for coverage of enamel only fractures that cannot be adequately repaired with a direct restoration (i.e., CDT codes D2330 – D2335)

o Updated coverage limitations

A labial veneer is a thin layer of material placed over a tooth to protect it from further damage or for aesthetic reasons. The following identify

guidelines for placement.

Labial Veneers

Labial veneers are indicated for the following: For coverage of enamel only fractures that cannot be adequately

repaired with a direct restoration (i.e., CDT codes D2330 – D2335)

Teeth with enamel defects including but not limited to enamel hypoplasia, severe decalcification, enamel hypocalcification and fluorosis

Labial veneers are not indicated for the coverage of fractures that extend into dentin.


Veneers are limited to one time per tooth per consecutive 60 months. Any dental procedure performed solely for cosmetic/aesthetic reasons

(cosmetic procedures are those procedures that improve physical




REVISED

Labial Veneers (continued)

Feb. 1, 2018 and exclusions; added language to indicate: Veneers are limited to

one time per tooth per consecutive 60 months

Any dental procedure

performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those

procedures that improve physical appearance) is excluded from coverage

appearance) is excluded from coverage.


Feb. 1, 2018

Revised coverage rationale for: Crowns o Updated language to clarify

crowns are indicated for:

Large, >50% of the tooth, defective restoration that can be seen on the radiographic image or intraoral photograph

Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image or intraoral photograph

Bicuspids and molars: 3 or more surfaces and/or one or more cusps involved

Onlays o Updated language to clarify

onlays are indicated for:

Large, >50% of the tooth, defective

Indications for Coverage

For indirect restorations, the following clinical parameters apply: Five-year longevity should be evident, periodontium must be healthy or

have documentation the member has periodontal disease under control

for a period of at least 6 months, and no evidence of endodontic pathology or potential endodontic issues on the radiographic image.

Crowns

Crowns are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Large, >50% of the tooth, defective restoration that can be seen on the

radiographic image or intraoral photograph Fracture of cusps Endodontically treated teeth, unless minimal access opening on anterior

tooth Documentation that a direct restoration is not possible Crown/root ratio must be favorable

Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image or intraoral photograph

50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery

Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and/or one or more cusps

involved




REVISED


(continued)

Feb. 1, 2018

restoration that can be seen on the radiographic image or intraoral

photograph Documentation/narrative

that the failing existing

onlay can only be resolved with a new onlay if not visible on radiographic image or

intraoral photograph Bicuspids and molars: 3

or more surfaces and/or one or more cusps involved

Symptomatic “cracked tooth syndrome” (not enamel craze lines) Full coverage restoration of a primary tooth without a permanent

successor

Crowns are not indicated for the following: If a lesser means of restoration is acceptable

If root resorption is present Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure,

discoloration) For alteration of vertical dimension For purposes of preventing future fracture, or to eliminate enamel craze

lines (cracked tooth syndrome must be diagnosed with documented

diagnostic tests and supported by a narrative; tooth must be symptomatic)

To treat non-pathologic wear/abrasion, or abfraction lesions in the absence of decay

For molars exhibiting bone loss with a class III furcation involvement Periodontally compromised teeth, even with successful endodontics,

unless the patient has undergone previous periodontal therapy/surgery

and progress notes/periodontal notes indicate the tooth is stable Fracture of porcelain not involving the margin or a functional ridge is not

sufficient for replacement

Onlays

Onlays are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Large, >50% of the tooth, defective restoration that can be seen on the

radiographic image or intraoral photograph Fracture of cusps Endodontically treated teeth, unless minimal access opening on anterior

tooth

Documentation that a direct restoration is not possible Crown/root ratio must be favorable Documentation/narrative that the failing existing onlay can only be

resolved with a new onlay if not visible on radiographic image or intraoral photograph

50% bone support with no ligament or root pathology unless patient has

undergone periodontal therapy/surgery Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and/or one or more cusps




REVISED


(continued)

Feb. 1, 2018

involved Benefitted for primary teeth without permanent successor Bicuspids and molars: 3 or more surfaces and one or more cusps

involved Symptomatic “cracked tooth syndrome”

Onlays are not indicated for the following: If a lesser means of restoration is acceptable If root resorption is present Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure,

discoloration) For alteration of vertical dimension

For purposes of preventing future fracture, or to eliminate enamel craze lines (cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative; tooth must be symptomatic)

To treat non-pathologic wear/abrasion, or abfraction lesions in the absence of decay

For molars exhibiting bone loss with a class III furcation involvement

Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable

Fracture of porcelain not involving the margin or a functional ridge is not sufficient for replacement

Inlays

Inlays are unproven Inlays have not been proven superior over direct restorations and are alternative benefitted to amalgam restorations.


Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance,

the patient is liable for the cost of replacement. Fixed or removable prosthodontic restoration procedures for complete

oral rehabilitation or reconstruction. Procedures related to the reconstruction of a patient's correct vertical

dimension of occlusion (VDO).




REVISED


(continued)

Feb. 1, 2018 Any Dental Procedure performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance).

Documents

January 2018 policy update bulletin - uhcprovider.com · A restorable permanent tooth with irreversible pulpitis or a necrotic pulp The relief of acute pain prior to complete root