Oral Surgery: Miscellaneous Surgical Procedures

1 Or a l Sur ger y: Miscella neous Sur gica l Pr ocedur es Page 1 of 7 UnitedHealthcare Denta l Clinica l Policy Effective 07/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Dental Clinical Policy Oral Surgery: Miscellaneous Surgical Procedures Policy Number: Effective Date: July 1, 2021 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Definitions .. 2 Applicable Codes .. 3 Description of Services .. 4 Clinical Evidence .. 4 Food and Drug Administration .. 6 References .. 6 Policy History/Revision 7 Instructions for Use .. 7 Coverage Rationale Oroantral Fistula Closure An Oroantral Fistula will not heal spontaneously and must be surgically repaired.

2 Primary Closure of a Sinus Perforation Primary closure of a sinus perforation is indicated for large ( 2mm) defects resulting from routine tooth extraction, retrieval of root tips, or implant placement. Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth are indicated for the following: Subluxation injuries to permanent teeth Lateral Luxation injuries of primary and permanent teeth Extrusion injuries of <3mm in an immature developing primary tooth Avulsion of permanent teeth Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth are not indicated for the following, and extraction is recommended.

3 Primary teeth if injury is severe or tooth is near exfoliation Intrusion injuries to primary teeth when the apex is displaced toward the permanent tooth germ Extrusion injuries of a primary tooth that is fully formed, mobile, and near exfoliation, or the child is unable to cope with an emergency situation When a tooth has been out of the oral cavity for 60 minutes or more Lack of alveolar integrity Risk of ankylosis Related Dental Policies Dental Barrier Membrane Guided Tissue Regeneration Fixed Prosthodontics Implants Oral Surgery: Alveoloplasty and Vestibuloplasty Oral Surgery: Non-Pathologic Excisional Procedures Removable Prosthodontics Related Medical Policy Cosmetic and Reconstructive Procedures Or a l Sur ger y: Miscella neous Sur gica l Pr ocedur es Page 2 of 7 UnitedHealthcare Denta l Clinica l Policy Effective 07/01/2021 Proprietary Information of UnitedHealthcare.

4 Copyright 2021 United HealthCare Services, Inc. Surgical Repositioning of Teeth Surgical repositioning of teeth is indicated for the following: The treatment of displacement injuries to permanent teeth Extrusion of teeth with crown/root fractures to prepare for restoration of permanent teeth Bone Replacement Graft for Ridge Preservation Bone replacement graft for ridge preservation is indicated to preserve the alveolar ridge needed to support a dental prosthesis. Osseous, osteoperiosteal or cartilage grafting is indicated to augment deficient alveolar bone needed to support a dental prosthesis. Collection and Application of Autologous Blood Concentrate Product Collection and application of autologous blood concentrate product is not indicated due to insufficient evidence of efficacy.

5 Sinus Augmentation Procedures Sinus Augmentation is indicated when there is poor bone quality/quantity that prevents adequate initial stability during implant placement. Sinus Augmentation is not indicated when conditions blocking the ventilation and clearance of the maxillary sinus are present. Salivary Gland and Duct Procedures Procedures include the removal of sialoliths, Surgical excision of portions of, or the entire gland, repair of salivary fistulas a nd defects of salivary ducts, and may be completed intraorally or extraorally. As with any surgery, these oral surgery Procedures may not be indicated for individuals with unmanaged medical conditions that may result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response.

6 Coverage Limitations Bone replacement graft for ridge preservation is limited to 1 per site per lifetime, and not covered if done in conjunction with other bone graft replacement Procedures Primary closure of a sinus perforation is limited to 1 per tooth per lifetime Tooth reimplantation and transplantation is limited to 1 per site per lifetime Exclusions Any Dental Procedure performed solely for cosmetic/aesthetic reasons Procedures that are considered to be Experimental, Investigational or Unproven Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision Dental Services that are not Necessary Definitions Avulsion: Complete displacement of the tooth out of socket; the periodontal ligament is severed and fracture of the alveolus may occur.

7 (AAPD) Experimental, Investigational or Unproven Services: Medical, dental, Surgical , diagnostic, or other health care services, technologies, supplies, treatments, Procedures , drug therapies or devices that, are determined to be: Not approved by the Food and Drug Administration (FDA) to be lawfully marketed for the propose use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Informati on a s appropriate for the proposed use; or Or a l Sur ger y: Miscella neous Sur gica l Pr ocedur es Page 3 of 7 UnitedHealthcare Denta l Clinica l Policy Effective 07/01/2021 Proprietary Information of UnitedHealthcare.

8 Copyright 2021 United HealthCare Services, Inc. Subject to review and approval by any institutional review board for the proposed use; or The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or Not demonstrated through prevailing peer reviewed professional literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed; or Pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics Extrusion: Partial displacement of the tooth axially from the socket; partial Avulsion.

9 The periodontal ligament is usually torn. (AAPD) Intrusion: Apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament and commonly causes a crushing fracture of the alveolar socket. (AAPD) Lateral Luxation: Displacement of the tooth in a direction other than axially. The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs. (AAPD) Necessary: Dental Services and supplies which are determined through case-by -case assessments of care based on accepted dental practices to be appropriate; and Needed to meet your basic dental needs; and Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the dental service; and Consistent in type, frequency and duration of treatment with scientifically based guidelines of national clinical, research, or health care coverage organizations or governmental agencies that are accepted; and Consistent with the diagnosis of the condition.

10 And Required for reasons other than the convenience of you or your dental provider; and Demonstrated through prevailing peer-reviewed dental literature to be either: o Safe and effective for treating or diagnosing the condition or sickness for which its use is proposed; or o Safe with promising efficacy: For treating a life threatening dental disease or condition; and In a clinically controlled research setting; and Using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health Oroantral Fistula: An open connection between the maxillary sinus usually caused by extraction of maxillary posterior teeth.