Oral surgery for the treatment of a medical condition does not require prior authorization.
Oral surgery is generally covered subject to the indications listed below and per your plan documents.
Indications that are covered
Coverage is generally limited to the treatment of the following oral medical conditions:
- Infections and abscesses of the mouth which are not of dental origin.
- Perioral diseases or lesions involving the lips.
- Lesions of the hard and/or soft tissue, e.g., suspected neoplasm in the jaw, inflammation of the cheek. This does not include lesions of the teeth or lesions of the supporting bone associated with a dental condition.
- Intraoral cysts with suspicion of neoplasm.
Indications that are not covered
The following list, though not all inclusive, details services not eligible for coverage:
- Tooth extractions for dental, periodontal or occlusal disorders.
- Treatment of the teeth or structures supporting the teeth is not covered.
- Treatment of periodontal disease.
- Treatment of dental cysts, e.g., cysts which contain teeth or by initial exam are dentigerous in nature (e.g., odontoid or toothlike) or benign cysts which interfere with eruption of teeth.
- Treatment necessary for placement of dentures, e.g., jaw reconstruction due to jaw atrophy, dental restorations, dental reconstruction, dental rehabilitation, dental prosthesis, endosseous or osseointegrated implants.
Oral Surgery is the treatment of diseases within the mouth (intraoral) or around the mouth (perioral). These are services related to treatment of medical conditions requiring oral surgery, such as treatment of oral neoplasm, non-dental cysts, fracture of the jaws, trauma of the mouth and jaws, and any other oral surgery procedures provided as medically necessary dental services.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.