Currentblue cross blue shield - kansasPolicy N/A

Cone Beam Computed Tomography (CBCT)

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.

Policy Summary

Payerblue cross blue shield - kansas

PolicyCone Beam Computed Tomography (CBCT)

Policy CodePolicy N/A

Change TypeCoding updates and periodic review

Effective DateMay 21, 2021

Next Review DateN/A

Key ActionVerify member benefits with BCBSKS Customer Service prior to service.

SourceLink

POLICY UPDATE CHANGES

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).

A.1-7Medically necessary indications

~62Number literature refs

2021-05-21Current effective date

2026-01-13Most recent review

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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:

Medically necessary indications: 1. Diagnosing temporomandibular joint disorder (TMJ); 2. Surgical planning for extraction or exposure of impacted teeth; 3. Treatment planning for dental implants; 4. Evaluation and/or treatment of tumors or cysts; 5. Endodontics (including: a. multi-rooted teeth; b. endodontic retreatment; c. any apical surgery); 6. Evaluation of resorption lesions; 7. Orthodontic work up

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.

Clinical justification: CBCT examinations must be justified on an individual basis and should add new information to aid patient management; not appropriate as routine or screening imaging performed regardless of signs or symptoms.

A history and clinical examination must indicate conventional radiographs are inadequate before selecting CBCT.

inv-02: Not medically necessary / Screening

Not covered when:

Not medically necessary: General dental screenings or routine/screening CBCT without narrative documentation of medical necessity (i.e., imaging obtained regardless of presence or absence of clinical signs or symptoms)

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

Coding updates and entries mentioned in this document portionmixed

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

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Provider Actions and Documentation Requirements

Note

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

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.

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

inv-18: CBCT — Cone beam CT

TermCBCT (Cone beam CT)

DefinitionCT using a cone-shaped x-ray projection to image a small, well-defined volume (e.g., lower face and mouth) at a relatively low radiation dose.

Primary use3‑dimensional dental/oral imaging for diagnosis, treatment planning, monitoring disease progression, and assessing treatment efficacy.

Selection requirementShould be used when individual patient history and clinical examination indicate CBCT will add information to patient management.

inv-19: Routine/screening imaging

TermRoutine / screening imaging

Policy Summary

Payerblue cross blue shield - kansas

PolicyCone Beam Computed Tomography (CBCT)

Policy CodePolicy N/A

Change TypeCoding updates and periodic review

Effective DateMay 21, 2021

Next Review DateN/A

Key ActionVerify member benefits with BCBSKS Customer Service prior to service.

SourceLink

On This Page

Documentation Required

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

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

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.

Note

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.

DefinitionA radiographic examination taken regardless of the presence or absence of clinical signs and symptoms.

Policy stanceRoutine or screening use of dental CBCT is unacceptable and considered not medically necessary without documented clinical justification.

Provider actionCBCT should not be selected unless a history and clinical examination have been performed demonstrating likely benefit.

inv-20: Cone beam computed tomography (CBCT)

TermCone beam computed tomography (CBCT)

DescriptionAn imaging modality commonly referenced in dental and maxillofacial literature for diagnostic and preoperative planning purposes, providing small‑volume 3D imaging relevant to implant planning, impacted tooth localization, endodontic assessment, and evaluation of lesions.

Literature supportMultiple clinical studies and reviews cite CBCT applications in implant planning, impacted canine localization, endodontic applications, and assessment of periapical defects (see cited references).

Clinical considerationSelection should consider disease prevalence, progression rates, and diagnostic accuracy versus traditional techniques.