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Coverage criteria policies

Dental Services - cone beam computed tomography (CBCT) scan for medically-related dental services

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.

Administrative Process

Prior authorization is required for cone beam computed tomography (CBCT) scan for medically-related dental services.

Coverage

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

CBCT is covered for the following indications:

  1. Evaluation of dental implants when coverage criteria under the accidental dental medical coverage policy are met.
  2. Evaluation prior to one of the following oral surgery indications:
    1. Removal of maxillo-facial tumor, non-odontogenic cyst (cyst not originating from a tooth or the closely surrounding tissues), neoplasm or other pathologic entities that, due to their size and/or anatomic location, appear to encroach, impinge or are invested in/on critical anatomic structures (e.g. inferior alveolar nerve, maxillary sinus);
    2. Arthroplasty of Temporomandibular (TM) fossae or condyle, TM joint replacement;
    3. Developmental mid-face syndromes such as cleft palate, Treacher-Collins syndrome, etc;
    4. 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:

    1. The panoramic radiograph indicates that a deviation from a routine surgical approach is probable and further data necessary to plan such an approach; or
    2. 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.
  1. Evaluation prior to orthognathic surgery (to correct conditions of the jaw) 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 may not be limited to

  1. 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.
  2. CBCT for other medically-related dental indications not listed above as covered.

Definition

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. CBCT provides an image of hard tissue that has no distortion and is anatomically correct. Views may include cross-sectional, axial, coronal, sagittal, cephalometric, or panoramic.

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

Codes

Description

D0364

Cone beam CT capture and interpretation with limited field of view - less than one whole jaw

D0365

Cone beam CT capture and interpretation with field of view of one full dental arch - mandible

D0366

Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium

D0367

Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium

D0368

Cone beam CT capture and interpretation for TMJ series including two or more exposures

D0380

Cone beam CT image capture with limited field of view - less than one whole jaw

D0381

Cone beam CT image capture with field of view of one full dental arch - mandible

D0382

Cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium

D0383

Cone beam CT image capture with field of view of both jaws, with or without cranium

D0384

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.

Products

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.

References

  1. 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
  2. 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.
  3. 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.
  4. ECRI Institute. (2013). Custom Rapid Responses- Guidance. Cone-beam Computed Tomography Imaging of Craniofacial Anomalies. Plymouth Meeting, PA: ECRI Institute.
  5. ECRI Institute. (2013).Custom Rapid Responses-Guidance. Cone-beam Computed Tomography for Imaging Temporomandibular Joint Disorders. Plymouth Meeting, PA: ECRI Institute.
  6. ECRI Institute. (2008, updated 2011). Cone-beam Computed Tomography for Dental and Maxillofacial Imaging. ECRI Institute. Plymouth Meeting, PA.
  7. Harrison, L. (2011). New Guidelines Issued for Cone-Beam CT in Endodontics. Retrieved from http://www.medscape.com
  8. Hatcher, D. (2010) Operational Principles for Cone-Beam Computed Tomography. Journal of the American Dental Association (JADA). 141:3S-6S.
  9. 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.
  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.
  11. 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
  12. 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.
  13. 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
  14. Scrivani, S., Keith, D. and Kaban, L. (2008). Temporomandibular Disorders. New England Journal of Medicine. 359; 3693-2705.
  15. Scrivani, S. and Mehta, N. Temporomandibular disorders in adults. Aronson, M. and Deschler, D. (Ed), UpToDate, Waltham, MA. (Accessed on April 26, 2018).
  16. 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.
  17. 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