Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services

Description of Procedure or Service

Dental treatment and/or oral surgery can usually be provided in an office setting. However, hospital inpatient, hospital outpatient or ambulatory surgery facilities may be indicated in some situations. When it is medically necessary that the services be provided in a setting other than an office, the facilities may be hospital based or free-standing.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility services used to provide dental services when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application

Note: This policy addresses the Hospital Inpatient or Outpatient Facility services and Ambulatory Surgery Center Facility services, not the provision of dental care or oral surgery. Professional dental services are covered only to the extent that the member has dental benefits.

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

See Dental Treatment Covered Under Your Medical Benefit.

When Use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services for Dental is covered

1. The use of an Ambulatory Surgery Center or Hospital Outpatient facility services may be medically necessary when providing dental care or oral surgery in the following situations: 
   1. Complex oral surgical procedures with a high probability of complications due to the nature of the surgery; 
   2. Concomitant systemic disease for which the patient is under current medical management and which increases the probability of complications; or ) 
   3. When anesthesia is required for the safe and effective administration of dental procedures for young children (below the age of 9 years), persons with serious mental or physical conditions or persons with significant behavioral problems.
2. The use of Hospital Inpatient facility services may be medically necessary when providing dental care or oral surgery in the following situations: 
   1. Complex oral surgical procedures with a greater than average incidence of life threatening complications, such as excessive bleeding or airway obstruction; 
   2. Concomitant, non-dental systemic conditions for which the patient is under current medical management and which currently are not in optimal control and, therefore, may increase the risk of serious complications. 
   3. Postoperative complications following outpatient dental/oral surgery. 
   4. When anesthesia is required for the safe and effective administration of dental procedures for young children (below the age of 9 years), persons with serious mental or physical conditions or persons with significant behavioral problems.

When Use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services for Dental is not covered

In the absence of the medical criteria shown above.

For the dentist’s or patient’s convenience.

Policy Guidelines

Claims should be reviewed for documentation of medical necessity.

Prior review and certification are required for inpatient admission for dental/oral surgery.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: There is no specific code for these services.

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual

Medical Policy Advisory Group Review - 3/99

General Assembly of North Carolina, House Bill 1119, General Statues '58-3-122. 

MEDLINE and MD Consult literature search from 1995 to present.

Specialty Matched Consultant Advisory Panel - 5/2001

Specialty Matched Consultant Advisory Panel - 5/2003

Specialty Matched Consultant Advisory Panel - 5/2005

Specialty Matched Consultant Advisory Panel - 5/2007

Specialty Matched Consultant Advisory Panel- 11/2009

Senior Medical Director Review- 8/2010

Specialty Matched Consultant Advisory Panel- 10/2011

Specialty Matched Consultant Advisory Panel- 9/2012

Specialty Matched Consultant Advisory Panel- 10/2013

Specialty Matched Consultant Advisory Panel- 10/2014

Medical Director Review- 10/2014

Specialty Matched Consultant Advisory Panel 10/2015

Medical Director Review 10/2015

Specialty Matched Consultant Advisory Panel 10/2020

Medical Director Review 10/2021

Specialty Matched Consultant Advisory Panel 10/2021

Medical Director Review 10/2022

Specialty Matched Consultant Advisory Panel 10/2022

Medical Director Review 10/2023

Specialty Matched Consultant Advisory Panel 10/2023

Policy Implementation/Update Information

99/99 Revised: Coding revisions – ImplementInfo

5/87 Original Policy

1/97 Reaffirmed

3/99 Reviewed by MPAG. Reaffirmed

9/99 Reformatted, Medical Term Definitions added, Combined Inpatient and Outpatient Policies

10/00 System coding changes.

2/01 Reaffirm. No change in criteria.

5/01 Specialty Matched Consultant Advisory Panel review (5/2001). No change to policy. Coding format change.

5/02 Policy clarified to indicate that the services addressed are the inpatient, outpatient, or ambulatory services, not the dental care or oral surgery services. 

6/03 Specialty Matched Consultant Advisory Panel review (5/30/2003). No changes to criteria. Revised Benefits Application section. Typos corrected.

3/04 Billing/Coding section updated for consistency.

5/05 Specialty Matched Consultant Advisory Panel review. No changes to criteria.

8/28/06 Medical Policy changed to Evidence Based Guideline. (pmo)

10/2/06 Evidence Based Guideline changed to Medical Policy. (pmo)

6/18/07 Under "When Covered" section 1.c. and 2.d. changed "and" to "or persons with significant behavioral problems." Reference source added. (pmo)

9/28/10: Under “When Covered” section 1.c. and 2.d. changed from 9 years and under to below the age of 9 years. Under Policy Guidelines added “Prior review and certification are required for inpatient admission for dental/oral surgery.” Under Policy Guidelines, changed statement “Claims should be reviewed by individual consideration for documentation of medical necessity to “Claims should be reviewed for documentation of medical necessity.” Specialty Matched Consultant Advisory Panel review 1/2010. Reviewed by Senior Medical Director. (lpr)

11/8/11 Specialty Matched Consultant Advisory Panel review 10/26/2011. No changes to policy statement. (lpr)

10/30/12 Specialty Matched Consultant Advisory Panel review 10/17/2012. No changes to policy statement. (lpr)

11/12/13 Specialty Matched Consultant Advisory Panel review 10/21/2013. No changes to policy statement. (lpr)

11/11/14 Specialty Matched Consultant Advisory Panel review 10/2014. Medical Director Review 10/2014. No changes to policy statement. (td)

12/30/15 Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director Review 10/2015. (td)

11/22/16 Specialty Matched Consultant Advisory Panel review 10/26/2016. No change to policy statement. (an)

11/10/17 Specialty Matched Consultant Advisory Panel review 10/25/2017. No change to policy statement. (an)

11/9/18 Specialty Matched Consultant Advisory Panel review 10/24/2018. No change to policy statement. (an)

10/29/19 Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement. (eel)

11/10/20 Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement. (eel)

11/2/21 Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement. (tt) 

11/1/22 Specialty Matched Consultant Advisory Panel review 10/2022. Medical Director Review 10/2022. No change to policy statement. (tt)

11/7/23 Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement. (tt)