CurrentBaylor Scott & White Health PlanPolicy 026

MEDICAL COVERAGE POLICY

Defines medical necessity criteria, prior authorization requirements, covered clinical indications, exclusions, and facility/anesthesia authorization rules for dental and oromaxillary procedures when billed to the medical benefit across lines of business (including Medicare/Medicaid notes).

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMEDICAL COVERAGE POLICY

Policy CodePolicy 026

Change TypeClarified

Effective DateMar 1, 2026

Next Review DateFeb 26, 2027

Key ActionSubmit prior authorization with relevant clinical information; PA required for elective inpatient or ASC dental/oral surgery services and for Level 4 sedation/general anesthesia (CPT 00170) for Medicaid.

SourceLink

POLICY UPDATE CHANGES

Updated Section 1862(a)(12) of the Social Security Act reference and Medicare notes.

Prior authPA Requirement

MultipleConditional Coverage

Routine dentalExclusions

GA <=6Medicaid GA rule

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Policy: Routine dental procedures (e.g., root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, extensive dental restoration) are generally excluded from medical coverage. Certain dental and oromaxillary procedures may be eligible under the medical benefit when they are medically necessary, are incident to and integral to a covered medical service, or are required to manage medical conditions (e.g., osteonecrosis, head/neck cancer, to facilitate cancer therapy).

Hospital or ASC facility use and general anesthesia (including deep sedation) are allowed when medically necessary for safe delivery of care; such services require prior authorization. Note that a medical necessity determination does not itself ensure coverage—benefits are determined by the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD).

Policy identifiers: Payer: Baylor Scott & White Health Plan (BSWHP) and affiliated entities; Policy title: Dental Services and Anesthesia for Dental Services; Policy Number: 026; Effective Date: 03/01/2026.

Key thresholds and quick facts

Periodontal pocket depth> 5mm

Medicaid GA criteria score>= 22 (TMPPM Criteria)

Pulmonary function thresholdFEV1 < 60% predicted

Prior AuthorizationRequired for elective inpatient/ASC and CPT 00170 (Level 4 GA) for Medicaid

Medical-Necessity Criteria

General Authorization / Prior Authorization Requirement

Prior authorization is required for elective (non-emergent) dental and oral surgery services provided in inpatient hospital or ASC settings and for anesthesia services when applicable.

Prior authorization requirements: Prior authorization required for elective inpatient or ASC dental/oral surgery services.
PA limitations: Prior authorization does NOT authorize restorative dental/oral surgery services excluded by the member's benefit plan (EOC or SPD).

Dental Services Covered When Incident to Medical Care or Medically Necessary

Dental services that would otherwise be excluded may be covered if medically necessary and incident to a covered medical service; coverage requires prior authorization and submission of relevant clinical information.

Examples (ANY of the following may make dental services medical-benefit eligible)

Periodontal surgery for drug-induced gingival hyperplasia
- Required documentation: Required Documentation: Periodontal charting, photographs, and relevant medication history including dosages.
- Authorization thresholds
  - Pocket depth criterion: Pocket depths > 5mm> 5mm
  - Orthodontic bracket criterion: Difficulty with hygiene due to orthodontic brackets impinging on the gingiva
Medical/surgical care for osteonecrosis of the jaw

Use of Hospital or ASC Settings and Anesthesia

Hospital or ASC facility use and general anesthesia allowed when medically necessary for safe delivery of dental/oral surgery services; prior authorization required.

Authorized indications for facility/anesthesia setting (ANY of the following)

Facility covered when medically necessary: Hospital facility or ASC covered when medically necessary for safe delivery of dental/oral surgery services or serious medical issues; prior authorization required.
Medicaid-specific documentation/PA requirements: For Medicaid plans: General anesthesia available for members age six years or younger; ALL Level 4 sedation/general anesthesia services (CPT 00170) require prior authorization. Required documentation: Completed Criteria for Dental Therapy under general anesthesia with a score >= 22; Proof of DMO approval for dental services (for age 6 and below); Procedure location; Narrative/clinical records unique to the member.Tmpmm score >= 22
Dental rehabilitation for young children:

Exclusions / Not Covered

Exclusions / Not Covered Indications

Dental/restorative procedures and procedures for preparation for dentures are generally excluded unless specific medical criteria are met.

Routine dental exclusions: Routine dental services (root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, extensive dental restoration) are generally excluded from medical coverage.
Office-based anesthesia not covered: Dental office-based anesthesia is NOT covered.
Excision codes not covered when for denture preparation or routine dental indications: Excision codes (40810, 40812, 40814, 40816, 41825) are NOT covered when indication is preparation for dentures, removal of tori exostoses, fibrous tuberosity (preparation for dentures), periodontal abscess, or endodontic cyst (generally dental).
Tori excision exception: Torus mandibularis or maxillary torus excision is generally not medically necessary and not covered except when diagnosis is head/neck cancer.
Dental reconstruction not covered: Dental reconstruction for replacement of extracted teeth is NOT covered by the medical plan.

Denial Risk

Denied if Routine Dental or Denture Preparation

Claims for routine dental services, dental office-based anesthesia, or excisions performed for preparation for dentures will be denied unless a covered medical indication is present (e.g., head/neck cancer).

Affected codes: 40810, 40812, 40814, 40816, 41825, 21031, 21032

Coding

Generally covered CPT codes for medical indicationsCPTCovered

21030	Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage
21040	Excision of benign tumor or cyst of mandible by enucleation and/or curettage
21046	Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy
21047	Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy
21048	Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy
21049	Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy
40810	Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair
40812	Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair
40814	Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair
40816	Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle

1–10 of 12

1/2

CPT codes not covered except with specific cancer diagnosisCPTNot Covered

21031	Excision of torus mandibularis: COVERED only with diagnosis of head/neck cancer
21032	Excision of maxillary torus palatinus: COVERED only with diagnosis of head/neck cancer

ICD-10 codes (examples that may justify coverage)ICD-10

C03.X	Malignant neoplasm of gum
C04.X	Malignant neoplasm of floor of mouth
C05.X	Malignant neoplasm of palate
C41.X	Malignant neoplasm of skull, face, jaw
C76.X	Malignant neoplasm of head, face, neck
D00.XX	Carcinoma in situ of oral cavity, gingiva, palate, mouth, tongue, etc.
Q37.X	Cleft palate
S02.4XXX	Fracture - zygomatic, maxilla, Le Forte
S02.6XXX	Fracture of mandible
S02.8XXX	Fractures of skull and facial bones

1–10 of 14

1/2

Provider Actions

Prior Authorization

Prior Authorization Required for Inpatient/ASC Dental and Anesthesia Services

Submit prior authorization with relevant clinical information; PA required for elective inpatient or ASC dental/oral surgery services and for Level 4 sedation/general anesthesia (CPT 00170) for Medicaid.

Affected code: 00170

Documentation Required

Documentation Requirements for Medical Indications

For procedures like periodontal surgery, osteonecrosis care, and tooth extraction, submit narrative clinical history, periodontal charting (if applicable), photographs, and X-rays/CT demonstrating bone involvement; include medication history when relevant.

Prior Authorization

Medicaid-specific PA and DMO Approval

For Medicaid members age <= 6, provide completed Criteria for Dental Therapy under general anesthesia with score >= 22 and proof of DMO approval when requesting general anesthesia.

TMPPM Criteria score >= 22
DMO approval required for age <= 6

Denial Risk

Denied if Service is Routine Dental or for Denture Preparation

Claims for routine dental services, dental office-based anesthesia, or excisions performed for preparation for dentures will be denied unless a covered medical indication is present.

Affected CPTs: 40810, 40812, 40814, 40816, 41825, 21031, 21032

Medicare and Medicaid Notes

Prior authorization is required for elective (non-emergent) inpatient or ASC dental and oral surgery services; PA does not authorize restorative dental/oral surgery services excluded by the member's benefit plan (EOC/SPD). For Medicaid, all Level 4 sedation/general anesthesia (CPT 00170) services require PA and, for members age six and under, a completed TMPPM "Criteria for Dental Therapy under general anesthesia" with a score ≥ 22 and proof of DMO approval when applicable.

Medicare guidance takes precedence where applicable. Refer to Medicare Benefit Policy Manual Chapter 15 and NCD 260.6 (Dental Examination Prior to Kidney Transplantation) and applicable LCDs. Note Section 1862(a)(12) of the Social Security Act generally precludes Medicare payment for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except for inpatient hospital services when required by the underlying medical condition or severity of the procedure.

Medicaid: confirm coverage per the Texas Medicaid Provider Procedures Manual (TMPPM) and related TMPPM children’s dental chapters. Children's mandated Medicaid dental services are administered by Dental Maintenance Organizations (DMOs) that process dental authorization requests and claims regardless of the member's medical benefit plan.

Background

Context: Most routine dental procedures can be safely provided in a dental office and are excluded from the medical benefit. However, select dental and oromaxillary procedures may be considered medical-benefit eligible when they are medically necessary or are incident to a covered medical service (for example, extractions or excisions required for cancer therapy, osteonecrosis care, or to manage severe infection or trauma).

Use of hospital or ASC settings and general anesthesia is covered when necessary for safe delivery of the dental/oral surgery service or when the member has serious medical issues that preclude office-based care. Prior authorization is required for elective inpatient/ASC services; routine dental services and dental office-based anesthesia remain not covered by the medical plan.

Documentation: Requests for medically indicated dental/oromaxillary procedures should include relevant narrative clinical history, imaging (X-ray/CT), photographs, periodontal charting when applicable, and medication history to support the medical necessity determination.

Definitions

Medical necessity: As defined by this policy, a determination that a service is medically necessary supports the clinical decision to request coverage, but such a determination does not guarantee that the service will be a covered benefit. Coverage and payment are ultimately determined by the member's plan documents (EOC or SPD) and any applicable federal or state rules.

Operational note: Prior authorization is required for elective inpatient or ASC dental/oral surgery services and for anesthesia when applicable; PA authorization decisions are based on submitted clinical information and applicable policy criteria but do not override benefit exclusions in the member's plan document.

Tooth extraction when medically necessary

Required documentation: Required Documentation: Narrative description of the clinical history and findings; X-rays and/or CT scan and photographs demonstrating bone involvement.
Authorization conditions - any of the following
- Pre/post radiation or transplant: Is pre-or post-head and neck/mantle field radiation therapy, pre-chemotherapy, or pre bone marrow or solid organ transplant
- Severe immunodeficiency: Has severe immunodeficiency (e.g., post organ transplant, peri-chemotherapy)
- Osteonecrosis related to therapy or disease: Has osteonecrosis of the jaw related to chemotherapy, bone marrow or solid organ transplant, HIV immunodeficiency, or IV bisphosphonate therapy
- Osteoradionecrosis due to radiation: Has osteoradionecrosis due to head and neck, or mantle field radiation
- Removal to reduce jaw fracture: Removal of broken teeth necessary to reduce a jaw fracture

Dental rehabilitation for functional/behavioral impairment

Criteria branch: Either: member has rampant decay or high complexity needs OR documentation of EITHER two unsuccessful attempts to treat in office OR PCP/attending documents why impairment inhibits safe delivery of care in office.
Extreme apprehension/anxiety branch: Members with extreme apprehension and anxiety: member has rampant decay or high complexity needs AND two unsuccessful attempts to treat in office AND PCP/attending documents why impairment inhibits safe delivery of care in office.

Member medical-comorbidity criteria for facility/anesthesia

FEV1 threshold: Abnormal pulmonary function measurements (FEV1 < 60% of predicted)FEV1 < 60%
Other listed conditions: History of serious blood dyscrasia or bleeding disorder requiring preoperative care not available in office; Evidence of acute cardiac disease/current angina/CHF class III/IV or MI within 90 days; History of immunodeficiency; Difficulty regulating endocrine diseases (e.g., diabetes, Addison's), hypertension, bronchospastic lung disease, or seizures; History of adverse reaction to anesthesia or sedation; Previous unsuccessful attempts to provide care in office and/or significant functional/behavioral impairment.

OpenPayer