Mountain State Medical Policy Bulletin
Section: Dental
Number: D-5
Topic: Oral Surgical Procedures
Effective Date: June 5, 2006
Issued Date: September 10, 2007
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Generally, vestibuloplasty, buccal or labial frenectomy, frenotomy, or frenuloplasty (40819, 40806, D7960, D7963) are considered to be dental procedures and are noncovered services under the Medical-Surgical programs.

Coverage for oral surgical procedures is determined according to individual or group customer benefits.

Payment may be made under the Medical-Surgical programs for lingual frenectomy, frenotomy, or frenoplasty (41010, 41115, 41520) performed to correct tongue-tie.

Procedure Codes

408064081940840408424084340844
40845410104111541520D7960D7963

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 003 of D-5]
[Version 002 of D-5]
[Version 001 of D-5]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.