A mandibular resection prosthesis is indicated when a portion of the mandible is missing or removed due to trauma or ablative surgery. Other prostheses, such as orbital and auricular, may also be needed following this type of surgery and will be covered on the basis of this policy’s limited coverage.

Interim restorative supports such as oral surgical splints and obturator prostheses will be covered within the setting of a comprehensive and documented treatment plan. Maxillary and mandibular prostheses are frequently necessary for the restoration of function, as neither functions in the absence an opposing surface.

Implants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury.

Oral maxillofacial prostheses used in the treatment of Obstructive Sleep Apnea (OSA) will be covered when specifically fashioned to the needs and measurements of individual patients and used to treat essential sleep apnea and obstructive sleep apnea. Use CPT Code 21085 to represent this prosthesis and the work performed for the development of the prosthesis.

Reasons for Noncoverage

Services and diagnoses which do not meet the criteria on this medical policy will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the service being billed and must demonstrate the medical necessity of the services performed in excess of the established frequency guidelines. In addition, the documentation must support that the service was performed.

This information is normally found in the office/progress notes, hospital records and testing results. The role of implant therapy within the total scope of the prosthetic restoration must be clearly documented.

Use CPT codes only when the physician actually designs and prepares the prosthesis and not when the prosthesis is prepared by an outside laboratory.

Documentation representing the actual work performed to develop the sleep apnea prosthesis must be submitted with the claim.

When CPT codes 21089 or 21299 are billed, documentation must be submitted with the claim.

Use CPT code 21299 to bill the implants with an explanation of the intended use. Please note dates of trauma or tumor biopsy/resection, dates of radiation treatment and other pertinent medical history.

Covered Diagnosis Codes

The following is limited coverage for CPT codes 21076, 21077, 21079, 21080, 21081, 21082, 21083, 21084, 21085, 21086, 21087 and 21088:

The following is limited coverage for CPT code 21085 (when used to represent prosthesis for treatment of OSA):