5101:3-5-09 Dental program: covered oral surgery services and limitations.

The following oral surgery services are covered under the dental care program subject to the specified limitations.

(A) The decision to remove a tooth or teeth must be based on the tooth or teeth being too broken down to save, too poorly supported by alveolar bone to save, and/or the presence of some pathological condition which contraindicates saving. Extractions that render a consumer edentulous must be deferred until authorization to construct a denture has been given, except in absolute emergency situations.

(B) The extraction of an impacted tooth is authorized only when conditions arising from such an impaction warrant its removal. The prophylactic removal of an asymptomatic tooth or teeth exhibiting no overt clinical pathology is covered only when at least one tooth is symptomatic.

(C) Local anesthesia and routine postoperative care are included in the fee for extractions.

(D) Extractions (includes local anesthesia, suturing, if needed and routine postoperative care).

(1) Extraction, erupted tooth or exposed root (elevation and/or forceps removal).

(2) Extraction, erupted tooth or exposed root (elevation and/or forceps removal) may be billed only once per tooth.

(E) Surgical extraction.

(1) Removal of impacted tooth - soft tissue. A "soft tissue impaction" is any tooth which requires an incision of overlying soft tissue and removal of the tooth without necessity of removing the bone. Partial eruption of a tooth with portions of the crown located at or above the occlusal plane does not disqualify the tooth as a soft tissue impaction if the position is such that soft tissue does in fact cover portions of the occlusal surface, for example, distoangular position. This procedure shall be permitted for third molars only without prior authorization. All other procedures shall require prior authorization.

(2) Removal of impacted tooth - partially bony. A "partially bony impaction" is one where the crown of the tooth is partially covered by bone. This tooth may or may not be partially erupted. This type of impaction requires an incision of overlying soft tissue, elevation of a flap, removal of bone and removal of the tooth. Partial eruption of a tooth with portions of the crown located at or above the occlusal plane does not disqualify this tooth from being classified a partially bony impaction if bone does in fact cover the greatest convexity of the distal portion of the crown, for example, distoangular position within the ramus of the mandible. If not visible on radiograph, bony impaction must be evidenced from clinical documentation. A radiograph of the impaction must be maintained in the patient's clinical record.

(3) Removal of impacted tooth - completely bony. A "completely bony impaction" is one where the crown of the tooth is completely covered by bone or a substantial part of the tooth above the greatest convexity of the crown is covered by bone on both the mesial and distal sides as demonstrated radiographically. In the case of horizontally impacted lower third molars, to be classified as a completely bony impaction the central groove of the crown must not be located superior to the occlusal plane. This type impaction requires an incision of overlying soft tissue, elevation of a flap, removal of bone, and sectioning of the tooth, if necessary for removal. Prior authorization is required for all completely bony impactions including a radiograph of the impaction.

(4) Removal of impacted tooth - completely bony with unusual surgical complications. Prior authorization is required for all completely bony impactions including a radiograph of the impaction.

(5) Surgical removal of a residual tooth roots (cutting procedure). Prior authorization is required for this procedure.

(6) Surgical removal of a supernumerary tooth. Prior authorization is required for the surgical removal of a supernumerary tooth. Surgical removal of supernumerary teeth must be billed on a paper claim form using local level program code Y7255 until a CDT code is assigned for this procedure.

(F) Tooth reimplantation and/or stabilization of accidentally avulsed or displaced tooth and/or alveolus. This procedure shall be authorized by report. Submission of radiographs of the area and a detailed explanation of the findings and treatment are required for authorization.

(G) Alveoplasty - surgical perparation of ridges for dentures.

(1) Alveoplasty is a covered service only when provided in conjunction with the construction of a prosthodontic appliance.

(2) Alveoplasty in conjunction with extractions - per quadrant.

(3) Alveoplasty, not in conjunction with extractions - per quadrant.

(H) Surgical excision.

(1) Coverage of removal of cysts or tumors is on a by-report basis. Submission of radiographs of the area and detailed explanation of findings and treatment are required for authorization.

(2) Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm.

(3) Removal of benign odontogenic cyst or tumor- lesion diameter greater than 1.25 cm.

(4) Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm.

(5) Removal of benign nonodontogenic cyst or tumor- lesion diameter greater than 1.25 cm.

(6) Removal of lateral exostosis (maxilla or mandible).

(a) Prior authorization is required for all removal of lateral exostosis procedures.

(b) A study cast of the mouth with the area of surgery outlined must be submitted for prior authorization.

(I) Surgical incision.

(1) Incision and drainage of abscess - intraoral soft tissue.

(2) Incision and drainage of abscess - extraoral soft tissue.

(3) Coverage of incision and drainage of abscesses is on a by-report basis requiring submission of radiographs of the area and detailed explanation of findings and treatment.

(J) Treatment of fractures.

(1) The treatment of fractures should be billed to the department using codes from the "American Medical Association's Current Procedural Terminology (CPT)".

(2) Alveolus - open reduction, may include stabilization of teeth, may be billed as a CPT code or dental code.

(K) Other repair procedures.

(1) Frenulectomy - also known asfrenectomy or frenotomy - separate procedure not incidental to another procedure. Prior authorization is required and must include submission of complete radiographs of the mouth and study casts of the arch with outline of indicated surgery .

(2) Excision of hyperplastic tissue - per arch. Prior authorization is required and must include submission of complete radiographs of the mouth and study casts of the arch with the outline of the indicated surgery.

(L) Oral surgery services shall be billed to the department using procedure codes from either the surgery section, CPT codes or dental codes . Regardless of the code used, all claims must be submitted to the department on the appropriate claim type.

Effective: 03/30/2011
R.C. 119.032 review dates: 01/07/2011 and 03/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 1/4/88, 11/15/93, 1/1/00, 10/1/03, 1/1/06, 7/1/08, 12/30/10 (Emer)