CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Reconstructive Dental Services

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Defines medical necessity coverage criteria, exclusions, billing codes, and documentation guidance for reconstructive dental procedures under BCBSNC medical benefits; applies to providers treating members whose benefits include medical coverage for these services.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyReconstructive Dental Services

Policy CodePolicy N/A

Change TypeClarifications and coding updates

Effective Date

Last ReviewOct 29, 2025

Next Review DateOct 1, 2025

Key ActionSubmit operative reports to confirm dentigerous cyst size and follow billing guidance for codes that may require prior authorization.

SourceLink

POLICY UPDATE CHANGES

When the procedures are the direct or indirect result of cancer treatments, including chemotherapy, biotherapy, or radiation therapy, they were added to the When Covered section to align with HB 646.

Charges related to an accidental injury must be submitted within 2 years of the accident when stated in the member benefit booklet was added to the Billing/Coding section.

Dental codes D6011 and D6013 (and previously D6052 which was later deleted) were added to the Billing/Coding section for a 2014 code update.

Policy Guidelines items were clarified and item 7 was added; item 3 was clarified to explicitly include labial or buccal frenectomy, frenotomy, frenuloplasty.

Statement added that for dentigerous cysts, the operative report is needed for review to confirm size.

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CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Reconstructive Dental Services

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Sign up for all Blue Cross Blue Shield - North Carolina policy alerts

Know when Blue Cross Blue Shield - North Carolina releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyReconstructive Dental Services

Policy CodePolicy N/A

Change TypeClarifications and coding updates

Effective Date

Last ReviewOct 29, 2025

Next Review DateOct 1, 2025

Key ActionSubmit operative reports to confirm dentigerous cyst size and follow billing guidance for codes that may require prior authorization.

SourceLink

POLICY UPDATE CHANGES

When the procedures are the direct or indirect result of cancer treatments, including chemotherapy, biotherapy, or radiation therapy, they were added to the When Covered section to align with HB 646.

Charges related to an accidental injury must be submitted within 2 years of the accident when stated in the member benefit booklet was added to the Billing/Coding section.

Dental codes D6011 and D6013 (and previously D6052 which was later deleted) were added to the Billing/Coding section for a 2014 code update.

Policy Guidelines items were clarified and item 7 was added; item 3 was clarified to explicitly include labial or buccal frenectomy, frenotomy, frenuloplasty.

Statement added that for dentigerous cysts, the operative report is needed for review to confirm size.

multipleApplicable codes referenced

2 yearsAccidental injury claim window

yesIncludes cancer-related care

listedExclusions enumerated

multipleHistorical updates

Coverage Criteria

Medically Necessary Indications

Covered when ALL of the following general conditions are met:

General medical necessity: Procedure is intended primarily to improve or restore bodily function or to correct significant deformity resulting from accidental injury, trauma, or previous therapeutic process, or to correct congenital defects causing functional impairment, or is the direct or indirect result of cancer treatments (including chemotherapy, biotherapy, or radiation).

From 'When Reconstructive Dental Services are covered'

Examples of covered indications: Includes: 1) Accidental external traumatic injury to a sound tooth with services limited to those necessary to restore condition and function that existed immediately prior to the accident (does not include repair/replacement of dentures); 2) Dental and orthodontic care that is directly related to and an integral part of medical/surgical correction of a functional impairment from a congenital defect or anomaly; 3) Oral reconstruction after acute trauma to jaws, cheeks, lips, tongue, roof and floor of mouth (soft tissue, bone, or nerve injuries); 4) Reconstruction following excision of cancer or invasive tumors of the oral structures (e.g., alveolar ridge reconstruction after tumor removal); 5) Oral reconstruction using dental implants and related procedures (e.g., bone grafting) when related to covered medical conditions resulting in functional impairment; 6) Removal of exostoses or non-dental cysts when large enough to cause functional impairment; 7) Lingual frenectomy for total/complete ankyloglossia when causing speech impediment or difficulty with feeding/eating/swallowing.

Enumerated covered indications from policy

Orthodontic Criteria

Orthodontic-specific criteria

Orthodontics as medical necessity: Orthodontics may be considered medically necessary when used to correct dentoalveolar arch discrepancies that are part of or result from a congenital defect or anomaly and that prevent the usual and normal action of mastication and ingestion of normally solid foods, or when correction is necessary to satisfactorily correct other aspects of a general deformity resulting in functional impairment or to prevent relapse of such treatment. Treatment may include obturators, splints, and orthodontic therapy as adjunctive support from birth until completion of medical/surgical treatment to establish functional dental arch relationships.

From 'When Reconstructive Dental Services are covered' (orthodontics section)

Services are not covered when the primary purpose is cosmetic—that is, the procedure is not intended to improve or restore bodily function or to correct a significant deformity that resulted from accidental injury, trauma, or prior therapeutic processes, or to correct functional impairment related to congenital defects. (See policy exclusion language stating reconstructive services that are not primarily restorative or corrective.)

Injuries that occur while the member is in the act of chewing or biting are excluded from coverage and therefore are not considered accidental external traumatic injuries that would make reconstructive dental procedures eligible for medical benefit coverage.

Cleaning, routine maintenance, and the subsequent repair or replacement of a completed dental reconstruction are excluded from medical coverage and are not considered reconstructive services under the medical benefit.

When the member benefit booklet specifies a timeliness requirement for accidental-injury claims, charges related to that accidental injury must be submitted within the booklet’s stated time frame. BCBSNC added the statement that, when required by the member benefit booklet, charges related to an accidental injury must be submitted within 2 years of the accident to the Billing/Coding section; failure to meet such a timeliness requirement may result in denial.

Providers should confirm the member’s specific benefit booklet for the applicable timely-filing window for accidental-injury claims and submit supporting documentation within that period to avoid timeliness denials.

Procedures that are routine dental care, preventive services, diagnostic procedures, or treatment that relate solely to the teeth or gums (for example, treatment of periodontal disease, dental caries, or routine cleanings) are not covered as reconstructive dental services under the medical benefit and may be covered under the member’s dental benefit instead.

Procedures performed to prepare the mouth for dentures (including alveoplasty, removal of tori, vestibuloplasty, tissue conditioning, frenulectomy/frenectomy/frenotomy/frenuloplasty for diastema, and placement of dental implants or bone grafting performed solely to support a dental prosthesis) are excluded from medical coverage unless otherwise specified as covered for a medical condition that causes functional impairment.

Treatment of natural dental-root cysts (periodontal, periapical, primordial, and dentigerous cysts intrabony ≤ 2.5 cm) and dental care required in preparation for or as a result of radiation therapy, cardiac surgery, or transplant surgery are noted as services that are not considered reconstructive dental services under medical benefits and therefore may be covered under the dental benefit per the member’s booklet.

Coding and Procedure Codes

Applicable dental CPT/Dental codesCPT

D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250

1–10 of 63

1/7

Applicable surgical CPT codesCPT

21025
21031
21032
21040
21044
21045
21046
21047
21048
21049

1–10 of 68

1/7

Billing/Coding updatesCPT

D6011	Dental code D6011 (added 2014)
D6013	Dental code D6013 (added 2014)
D6052	Dental code D6052 (added 2014, deleted effective 1/1/21)

Applicable dental CPT/Dental codesCPT

D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250

1–10 of 63

1/7

Applicable surgical CPT codesCPT

21025
21031
21032
21040
21044
21045
21046
21047
21048
21049

1–10 of 68

1/7

Billing/Coding updatesCPT

D6011	Dental code D6011 (added 2014)
D6013	Dental code D6013 (added 2014)
D6052	Dental code D6052 (added 2014, deleted effective 1/1/21)

Billing/Coding updatesCPT

D6011	Dental code D6011 (added 2014)
D6013	Dental code D6013 (added 2014)
D6052	Dental code D6052 (added 2014, deleted effective 1/1/21)

Dentigerous cyst size — documentation requirement

RequirementOperative report required to confirm size for dentigerous cysts

Size threshold referencedIntrabony dentigerous cysts <= 2.5 cm are noted in exclusions under medical benefits

Where documentedBilling/Coding section note: operative report needed for review to confirm size

Policy historyStatement regarding operative report for dentigerous cysts added 11/9/18 and reiterated in updates

Provider Actions, Prior Auth & Documentation

Prior Authorization

Applicable service codes — PA may be required; inclusion does not guarantee reimbursement

This policy lists applicable dental and surgical procedure codes; inclusion of a code does not guarantee reimbursement and prior authorization may be required per BCBSNC administrative policies. Providers should consult BCBSNC Administrative Policies for reimbursement and preauthorization rules before billing.

Applicable service codes are listed in the Billing/Coding section and may require prior authorization.
Inclusion of a code in the list does not guarantee reimbursement; see BCBSNC Administrative Policies at www.bcbsnc.com.

Billing Rule

Billing/coding updates and PA implications — follow payer billing guidance

Background and Scope

Reconstructive dental services are those procedures intended primarily to improve or restore bodily function or to correct significant deformity resulting from accidental injury, trauma, previous therapeutic processes, congenital defects causing functional impairment, or that are the direct or indirect result of cancer treatments (including chemotherapy, biotherapy, or radiation).

Covered examples include restoration of a sound tooth to its pre-accident condition after external trauma (limited to restoration of function), dental and orthodontic care integral to surgical correction of congenital defects, oral and maxillofacial reconstruction after acute trauma to the jaws, soft tissues or nerves, reconstruction following excision of cancer or invasive tumors, and placement of implants or bone grafting when directly related to a covered medical condition causing functional impairment.

Coverage decisions focus on whether the procedure is medically necessary to restore pre-injury function or to address functional impairment; purely cosmetic procedures and routine dental care are not considered reconstructive for purposes of the medical benefit.

Definitions

Reconstructive dental services — definition and intent

DefinitionProcedures intended primarily to improve or restore bodily function or to correct significant deformity resulting from accidental injury, trauma, previous therapeutic process, congenital defects causing functional impairment, or as a result of cancer treatments.

Examples of indicationsOral reconstruction after acute trauma; reconstruction after excision of cancer or invasive tumors; dental implants and related procedures when related to covered medical conditions causing functional impairment.

Non-covered/cosmetic noteServices performed primarily for cosmetic purposes are not considered reconstructive under medical benefits.

Policy scopeApplies when procedure is determined to be medically necessary and intended to restore function or correct significant deformity.

Frenal surgical procedures — scope

Revision History & Policy Changes

Billing Rule

Billing/coding updates and PA implications (historical notes)

Historical/administrative updates include adding dental codes D6011 and D6013 (and D6052 which was later deleted) to the Billing/Coding section; providers should follow current BCBSNC billing guidance and any applicable PA rules for these codes.

12/31/13 added D6011, D6013, D6052; D6052 deleted effective 1/1/21.
Follow current Administrative Policies on the BCBSNC website for billing and prior authorization requirements.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyReconstructive Dental Services

Policy CodePolicy N/A

Change TypeClarifications and coding updates

Effective Date

Last ReviewOct 29, 2025

Next Review DateOct 1, 2025

Key ActionSubmit operative reports to confirm dentigerous cyst size and follow billing guidance for codes that may require prior authorization.

SourceLink

On This Page

Certain dental procedure codes were added or updated in the Billing/Coding section; providers must follow BCBSNC billing guidance and any prior authorization requirements indicated elsewhere in the policy when submitting these codes.

Dental codes D6011 and D6013 were added in the 2013/2014 updates; D6052 was later deleted effective 1/1/21.
Follow BCBSNC administrative policies for PA and reimbursement determinations for these and other listed codes.

Step Therapy

Step therapy — none specified

No step therapy rules are specified in this policy document.

Step Therapy

Step therapy — no requirements specified

No step therapy requirements are specified in the provided sections of this policy.

Documentation Required

Required documentation — operative report and supporting records may be requested

For dentigerous cysts, an operative report is required for review to confirm cyst size; BCBSNC may request medical records and supporting documentation to determine medical necessity.

Include the operative report specifically documenting cyst dimensions when submitting claims for dentigerous cysts.
BCBSNC may request full medical records; letters of support are useful but are not sufficient unless all required information is included.

Documentation Required

Operative report required to confirm dentigerous cyst size

An operative report is required for review to confirm size for dentigerous cysts (intrabony measurement documentation should be included).

Provide operative report measurements to document whether a dentigerous cyst is intrabony and its size (policy references intrabony <= 2.5 cm in exclusions).

Denial Risk

Cosmetic-only services — may be denied or directed to dental benefit

Services performed primarily for cosmetic purposes are not covered under medical benefits and may be denied or may be considered for coverage under the member’s dental benefit instead.

If the procedure is not intended primarily to improve/restore bodily function or correct significant deformity, do not bill under medical benefits.
When items are excluded as medical services (e.g., extractions prior to radiation or cardiac/transplant surgery), inform providers/administrative staff that these may be billed to the member’s dental benefit per the member booklet.

Denial Risk

Procedures for denture preparation — not covered under medical benefits; may be denied

Procedures performed solely to prepare the mouth for dentures (for example, alveoplasty, removal of tori, vestibuloplasty, frenulectomy, placement of dental implants or bone grafting to support a dental prosthesis) are not covered under medical benefits and may be denied.

Do not submit claims for denture-preparation procedures under medical benefits unless clearly meeting medical necessity criteria in the policy.
Examples listed that are not covered: alveoplasty; removal of torus mandibularis or maxillary torus; vestibuloplasty; tissue conditioning; frenulectomy (including labial/buccal frenectomy, frenotomy, frenuloplasty); placement of dental implants/bone grafting to support a dental prosthesis.

Denial Risk

Timely filing risk for accidental injury — 2-year submission window when stated in benefit booklet

Charges related to an accidental injury may be denied if not submitted within 2 years of the accident when the member benefit booklet requires such timeliness; verify the member’s booklet for the applicable claim submission window.

When the member benefit booklet specifies a 2-year claim window for accidents, ensure claims for accidental injury are submitted within that 2-year period to avoid denial.
Confirm benefit booklet language prior to claim submission for injuries to determine applicable timeliness requirements.

Labial or buccal frenectomy, frenotomy, frenuloplasty

Policy clarificationFrenal surgical procedures explicitly clarified in Policy Guidelines item 3 to include labial or buccal frenectomy, frenotomy, frenuloplasty.

Clinical contextFrenal procedures may be considered reconstructive when intended to correct functional impairment related to congenital defects or trauma.

Documentation/coverage considerationCoverage determined by medical necessity; providers should document functional impairment or related medical indication.