These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Prior authorization is required for cone beam computed tomography (CBCT), a specialized 3D x-ray scan, for medically-related dental services.
Cone beam computed tomography (CBCT) for medically-related dental services is generally covered subject to the indications listed below and per your plan documents.
Indications that are covered
Cone beam computed tomography (CBCT) is covered for the following indications:
- Evaluation of dental implants when coverage criteria under the accidental dental medical coverage policy are met.
- Evaluation prior to one of the following oral surgery indications:
- Removal of maxillo-facial tumors (tumors within the jaw or jaw joint structures), non-odontogenic cysts (cysts not originating from a tooth or the closely surrounding tissues), or neoplasms (abnormal growths) that, due to their size and/or location, appear to negatively impact critical anatomic structures (such as inferior alveolar nerves which supply sensation to the teeth or maxillary sinuses located above the teeth on either side of the nose);
- Surgical reconstruction or replacement of the temporomandibular joint (TMJ)
- Developmental mid-face syndromes (such as cleft palate or Treacher-Collins syndrome)
- Surgical reconstruction after severe oral-facial trauma (such as injuries resulting from motor vehicle accidents, gunshot wounds, boating accidents or other disfiguring trauma).
In addition, when CBCT is requested prior to an oral surgery listed as A-D above, one of the following must also be satisfied:
- The panoramic x-ray indicates that a deviation from a routine surgical approach is probable and further data are necessary to plan such an approach; or
- Information obtained by CBCT is considered critical in determining a surgical plan for the avoidance of disruption, invasion, or fracture of a surrounding, critical oral-facial structure.
- Evaluation prior to orthognathic (jaw) surgery when coverage criteria under the orthognathic surgery coverage policy are met and information obtained by CBCT is considered critical in determining a surgical plan for the avoidance of disruption, invasion or fracture of a surrounding, critical oral-facial structure.
Indications that are not covered include but are not limited to
- Cone beam computed tomography (CBCT) when used in conjunction with non-covered dental procedures including but not limited to dental implants or bone grafting in preparation for dental implants.
- CBCT for other medically-related dental indications not listed above as covered.
Cone Beam Computed Tomography (CBCT) refers to a cone-shaped tomographic imaging beam that is rotated around a patient’s head to obtain concentrated images of a narrow field of the body, as in the case of dental views. These images are then processed by software programs that generate a 3-D image of the following regions of patient’s anatomy: dental (teeth); oral and maxillofacial (mouth, jaw, and neck); and ears, nose and throat (ENT) which are used in diagnosis and treatment planning for the patient.
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.
CDT Codes: (Dental Codes
Cone beam CT capture and interpretation with limited field of view - less than one whole jaw
Cone beam CT capture and interpretation with field of view of one full dental arch - mandible
Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium
Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium
Cone beam CT capture and interpretation for TMJ series including two or more exposures
Cone beam CT image capture with limited field of view - less than one whole jaw
Cone beam CT image capture with field of view of one full dental arch - mandible
Cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium
Cone beam CT image capture with field of view of both jaws, with or without cranium
Cone beam CT image capture for TMJ series including two or more exposures
CDT copyright American Dental Association. All rights reserved. CDT is a registered trademark of the American Dental Association.
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.
- American Academy of Endodontics and American Academy of Oral and Maxillofacial Radiology (2016) Joint Position Statement- Use of Cone beam Computed Tomography in Endodontics- 2015/2016 Update. Retrieved from www.aae.org/clinical-resources/cone-beam-computed-tomography.aspx
- American Academy of Oral and Maxillofacial Radiology (2008) Executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral and Maxillofacial Radiology. 106(4); 561-562.
- American Dental Association Council on Scientific Affairs. (2012). The use of cone-beam computed tomography in dentistry. An advisory statement from the ADA Council on Scientific Affairs. Journal of the American Dental Association (JADA), 143(8); 899-902.
- ECRI Institute. (2013). Custom Rapid Responses- Guidance. Cone-beam Computed Tomography Imaging of Craniofacial Anomalies. Plymouth Meeting, PA: ECRI Institute.
- ECRI Institute. (2013).Custom Rapid Responses-Guidance. Cone-beam Computed Tomography for Imaging Temporomandibular Joint Disorders. Plymouth Meeting, PA: ECRI Institute.
- ECRI Institute. (2008, updated 2011). Cone-beam Computed Tomography for Dental and Maxillofacial Imaging. ECRI Institute. Plymouth Meeting, PA.
- Harrison, L. (2011). New Guidelines Issued for Cone-Beam CT in Endodontics. Retrieved from http://www.medscape.com
- Hatcher, D. (2010) Operational Principles for Cone-Beam Computed Tomography. Journal of the American Dental Association (JADA). 141:3S-6S.
- Horner, K., O’Malley, L. Taylor, K. and Glenny, A-M (2015) Guidelines for clinical use of CBCT: a review. Dentomaxillofacial Radiology, 44(1); 1-10.
- Mah, J., Huang, J. and Choo, H. (2010). Practical Applications of Cone-Beam Computed Tomography in Orthodontics. Journal of the American Dental Association (JADA). 141; 7S-13S.
- Mallya, Sanjay M. (2015) Evidence and Professional Guidelines for Appropriate Use of Cone Beam Computed Tomography, California Dental Association Journal, 43(9); 512-519. Retrieved from http://www.cda.org/member-resources/journal
- Miracle, A.C. and Mukherji, S.K. (2009) Cone beam CT of the Head and Neck, Part 2: Clinical Applications. American Journal of Neuroradiology 30:1285-1292.
- Pliska, B., DeRocher, M. and Larson, B. (2011). Incidence of Significant Findings on CBCT Scans of an Orthodontic Patient Population. Northwest Dentistry- Journal of the Minnesota Dental Association. Retrieved from http://www.mndental.org/features
- Scrivani, S., Keith, D. and Kaban, L. (2008). Temporomandibular Disorders. New England Journal of Medicine. 359; 3693-2705.
- Scrivani, S. and Mehta, N. Temporomandibular disorders in adults. Aronson, M. and Deschler, D. (Ed), UpToDate, Waltham, MA. (Accessed on April 26, 2018).
- Tyndall, D., Price, J., Tetradis, S. Ganz, S. Hildebolt, C. and Scarfe, W. (2012). Statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral and Maxillofacial Radiology, 113(6); 817-826.
- Worthington, P., Rubenstein, J. and Hatcher, D. (2010). The Role of Cone-Beam Computed Tomography in the Planning and Placement of Implants. Journal of the American Dental Association (JADA).141(10suppl); 19S-24S. Retrieved from http://jada.ada.org
- 08/12/2011 - Date of origin
- 06/01/2017 - Effective date