Cone Beam Computed Tomography (CBCT)
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Medical policy governing when dental/oral CBCT imaging is considered medically necessary or not for Blue Cross Blue Shield of Kansas members; affects providers ordering or performing CBCT for dental/oral maxillofacial indications.
Medical Policy reviewed; with no revisions.
Added ICD-10 diagnosis codes M26.641, N26.642, M26.643, M26.649, M26.651, M26.652, M26.653, M26.659 to the Coding Section.
In Coding section: Removed CDT code D0363 and added CDT codes D0393, D0394, D0395 (new codes effective January 1, 2014).
In Coding section: Removed ICD-9 codes (02-15-2018).
Added Item A.5.c. to the Policy section.
Updated Coding Section: Removed ICD-10 Codes (08-08-2023).
Coverage Criteria for CBCT
inv-01: Medically necessary indications
Covered when ANY of the following conditions are met and when clinical justification/history and exam indicate CBCT will add information to patient management:
CBCT must be justified for the specific indication and individual patient; selection should follow history and clinical examination and demonstrate that potential benefits outweigh risks.
A history and clinical examination must indicate conventional radiographs are inadequate before selecting CBCT.
inv-02: Not medically necessary / Screening
Not covered when:
Refer to the member's contract for coverage specifics; routine use risks denial.
CBCT is considered not medically necessary for general dental screenings unless the clinical documentation (narrative) explicitly provides supporting medical necessity. Refer to the member's contract and benefits at the time of service to determine coverage for individual members.
No explicit exclusions beyond those stated in the policy text are listed in the provided document chunks. The policy history and coding updates are recorded, but no additional exclusion items appear in these excerpts.
The policy states that routine or screening use of CBCT—that is, imaging obtained regardless of the presence or absence of clinical signs or symptoms—is unacceptable and is considered not medically necessary. CBCT should only be selected after an appropriate history and clinical examination indicate that conventional radiographs are inadequate and when the examination will add information to patient management.
Within the supplied chunks, no additional explicit statements labeled expressly as 'not medically necessary' beyond the routine/screening language and the general dental screening statement are present.
Coding and Billing
| D0363 | CDT code removed (Deleted code, effective December 31, 2013) |
| D0393 | CDT code added (New code, effective January 1, 2014) |
| D0394 | CDT code added (New code, effective January 1, 2014) |
| D0395 | CDT code added (New code, effective January 1, 2014) |
| M26.641 | ICD-10 diagnosis code added to Coding Section |
| N26.642 | ICD-10 diagnosis code added to Coding Section |
| M26.643 | ICD-10 diagnosis code added to Coding Section |
| M26.649 | ICD-10 diagnosis code added to Coding Section |
| M26.651 | ICD-10 diagnosis code added to Coding Section |
| M26.652 | ICD-10 diagnosis code added to Coding Section |
Provider Actions and Documentation Requirements
Check member benefits
Coverage depends on the member's contract and benefits. Verify member benefits with Blue Cross and Blue Shield of Kansas Customer Service prior to providing services.
- Contact BCBSKS Customer Service to confirm eligibility and benefit limitations prior to service.
Denial risk for routine/screening CBCT
CBCT exams that are routine or performed for general dental screening without documentation of signs/symptoms or individual clinical justification are at risk for denial.
- 'Routine' or 'screening' CBCT (radiograph taken regardless of clinical signs/symptoms) is unacceptable practice and may be denied.
- Document history, clinical exam findings, and why conventional radiographs are inadequate to justify CBCT.
Imaging selection sequence
Select CBCT only after an appropriate history and clinical examination demonstrate it will add new information to patient management and when conventional radiographs are inadequate. CBCT should be chosen based on individual patient history, clinical signs/symptoms, disease prevalence, progression rates, and diagnostic accuracy for the indication.
- CBCT is medically necessary for specific indications (e.g., TMJ diagnosis, impacted tooth surgery planning, implant planning, tumor/cyst evaluation, endodontic cases, resorption lesions, orthodontic workup).
- Do not use CBCT routinely or as a first-line screening tool.
Step therapy / prior steps
No step therapy or prior step requirements are described in this policy section.
- There are no step therapy constraints or required prior imaging steps detailed here.
Prior authorization
Prior authorization requirements are not specified in this document section. Verify any payer-specific prior authorization rules with BCBSKS prior to scheduling.
- If prior authorization is required by the member's benefit plan, obtain it before performing CBCT.
Provider actions (unspecified)
Some provider actions are not specified in this document section. When unspecified, follow standard clinical documentation practices and payer guidance.
- Maintain complete records of history, clinical exam, indication, and any prior imaging to support medical necessity.
- If policy history or coding changes affect billing, consult the coding section or BCBSKS resources.
Background
Cone beam computed tomography (CBCT) is a three-dimensional dental CT modality that uses a cone-shaped x‑ray beam to image a defined, localized volume (for example, the lower face and mouth) at a relatively low radiation dose. It is used to assist diagnosis, treatment planning, and evaluation in dental and maxillofacial specialties when conventional imaging is insufficient, and each CBCT examination must be justified individually to ensure potential benefits outweigh risks.
Definitions
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