Routine dental care and adjunctive dental procedures are generally excluded from coverage under Aetna medical plans. Examples of routine dental services that are excluded include: root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, extensive dental restoration and routine replacement of teeth. Adjunctive procedures to implant placement (for example, sinus lift, soft tissue grafts, barrier membranes) are also generally excluded except where a member's certificate of coverage explicitly provides otherwise. Providers should check the member's plan documents for any plan-specific dental riders or pediatric oral health benefits that may alter coverage.

Services that are integral to a medically necessary medical procedure (for example, extractions required prior to head and neck radiation, reconstruction after medication‑related or radiation‑induced osteonecrosis, or removal of broken teeth necessary to reduce a jaw fracture) may be considered medical benefits when they meet the policy's criteria and any required prior authorization is obtained. Conversely, routine dental treatment that is primarily cosmetic or performed for self‑esteem is not medically necessary and is excluded from medical coverage.

When dental services accompany reconstructive surgery that is medically necessary (for example, nasal/aural/orbital/ocular prostheses, radiation stents, surgical obturators, surgical splints, or appliances related to alveolar bone grafting for cleft palate), those specific services are covered according to the guidelines in the member's plan; however, dental implants and most adjunctive implant procedures remain excluded under most medical plans unless the certificate of coverage states otherwise.

HCPCS/HCPCS D‑codes that are explicitly noted in this Clinical Policy Bulletin as "not covered for indications listed in the CPB" are excluded when billed for those non‑covered indications. The policy enumerates specific D‑codes in this category (for example, D4263–D4276, D5986, D6010–D6199, D7292–D7294, D7953), and use of those codes for the non‑covered indications may result in denial if billed to the medical plan.

Providers should verify plan terms and any precertification requirements before submitting claims for procedures listed in the policy, and submit documentation that supports a covered medical indication when one exists.

Orthodontic treatment that is undertaken primarily for cosmetic reasons or to address self‑esteem concerns is not medically necessary under this policy. Medically necessary pediatric orthodontic services are limited to children and adolescents with a severe handicapping malocclusion related to qualifying medical conditions (for example, cleft palate, trauma requiring surgical treatment, or skeletal anomalies of the maxilla or mandible) and must meet documentation and scoring requirements (Modified Salzmann Index).

Regarding bone graft placement, the policy states that placement of bone grafts into routine extraction sites is generally considered not medically necessary. A limited exception may be made for bone grafting of impacted third molar extraction sites when bony defects are clinically significant and the patient is 26 years of age or older (American Association of Oral and Maxillofacial Surgeons, 2006).

The policy reflects the clinical viewpoint that routine placement of bone grafts into extraction sites is generally unnecessary because most defects refill with native bone over time and the risk of pathologic fracture is low or remote. Consequently, routine bone grafting of extraction sockets is considered not medically necessary.

Bone grafting may be considered when clinically warranted — for example, when a radiolucent lesion associated with an impacted tooth has enlarged sufficiently to risk pathologic fracture, when the lesion's location requires additional surgical access, or when the cystic defect is large and the patient is 26 years of age or older. Outside these specific clinical circumstances, spontaneous bone fill is expected and grafting is not required.

Orthodontic and oral/maxillofacial surgery (OMS) interventions may be medically necessary when they are directed at correcting a functional impairment or are an integral component of reconstructive surgical care. Examples include orthodontic treatment coordinated with reconstructive surgery for congenital craniofacial anomalies (such as cleft palate), orthodontic or surgical interventions to restore function after trauma to the oral cavity, and OMS procedures required to reestablish jaw continuity or oral function after tumor resection or osteonecrosis.

The policy distinguishes routine dental care from medically necessary OMS/dental services by requiring that the service either treat a medical condition (not a dental condition alone) or be incident to and integral to a covered medical procedure. When those conditions are met, and when required by the plan, prior authorization and appropriate clinical documentation (for pediatric orthodontics, a completed Salzmann assessment and physician/dental specialty reports) are necessary to establish medical necessity.