D4275 — Non-auto graft 1st tooth
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Submission of a proposed treatment plan to Aetna for review in plans with precertification provisions (e.g., orthognathic surgery related to cleft palate).
- Meeting the selection criteria specified in CPB 0124 for coverage of general anesthesia and monitored anesthesia care for OMS and dental services when general anesthesia is used.
- Documentation demonstrating that dental/OMS services are incident to and integral to a covered medical service when claiming coverage under the medical plan.
- For pediatric orthodontics: Documentation to support the severe handicapping malocclusion and the presence of a qualifying medical condition, and a score of 42 points or greater on the Modified Salzmann Index is required. Documentation must include a completed Salzmann assessment form and a written report from the attending physician or pediatrician, or qualified medical specialist(s) treating the deformity/anomaly. Progress notes, photographs and other relevant supporting documentation may be included as appropriate.
Key Coverage Criteria
- Comprehensive orthodontic services are considered medically necessary for children and adolescents who have a severe handicapping malocclusion related to a medical condition such as: Cleft palate or other congenital craniofacial or dentofacial malformations requiring reconstructive surgical correction in addition to orthodontic services; or Trauma involving the oral cavity and requiring surgical treatment in addition to orthodontic services; or Skeletal anomaly involving maxillary and/or mandibu [...]
- Reduction of any facial bone fractures is covered under all Aetna medical plans.
- Standard HMO and traditional plans cover the removal of tumors, treatment of dislocations, facial and oral wounds/lacerations, and removal of cysts or tumors of the jaws or facial bones, or other diseased tissues.
- Medically necessary medical services that could be performed by a physician but are performed by a dentist are covered if performance of those services is within the scope of the dentist's license; examples include: Dental examinations to detect infection prior to certain surgical procedures; Diagnostic x-rays in connection with services covered under the medical plan; Treatment of oral infections in connection with services covered under the medical plan.
- Removal (surgical removal) of bone-impacted teeth may be covered under some Aetna medical plans. (Standard traditional plans cover the surgical removal of erupted teeth, soft tissue impacted teeth and bone impacted teeth. Standard HMO-based plans cover only the removal of partly or completely bone impacted teeth.)
- Alveolar ridge closure is covered under Aetna medical plans as part of the cleft palate repair.
1 Active Policy
AETNA-CPB-0082 — Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans
Related Codes
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