CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dental Services for Accidental Injury

Governs coverage of initial dental care for accidental injuries to sound natural teeth under the medical benefit for BCBSRI members; affects dental providers submitting claims for such injuries.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDental Services for Accidental Injury

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 19, 2007

Next Review DateN/A

Key ActionProvide treatment for accidental injury to sound natural teeth within 72 hours of onset to meet medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72timely treatment window (hrs)

Not requiredprior authorization

D0210–D0277example procedure codes

S01.532A, S02.5XXAexample diagnosis codes

Coverage Criteria — Accidental Injury to Sound Natural Teeth

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Timely treatment and condition: Treatment is for accidental injury to sound natural teeth and is received within 72 hours of the onset of the accidental injury.received within 72 hours

Applies to Commercial products as specified.

Permitted treatments: Treatment is one or more of the following: extraction to avoid infection of teeth damaged in the injury; suturing; reimplanting and stabilization of dislodged teeth; repositioning and stabilization of partly dislodged teeth; dental X-rays.

Tooth condition: Injury involves sound natural teeth (teeth free of active or chronic clinical decay, with at least 50% bone support and functional in the arch).

Exclusion note: Any dental services other than those listed above are contract exclusions under the medical benefit for accidental injury treatment.

Benefits may vary by group/contract; refer to applicable benefit documents.

BlueCHiP for Medicare restricted coverage

BlueCHiP for Medicare coverage limits

Scope of covered services: Non-routine dental care to treat illness or injury may be covered only when it involves surgery of the jaw or related structures or setting fractures of the jaw or facial bones.N/A

BCBSRI follows CMS guidelines; BlueCHiP policies may differ from Commercial products.

Regulatory note: BCBSRI must follow CMS national or local coverage determinations for BlueCHiP for Medicare; in some instances BlueCHiP benefits may differ from Commercial product benefits.

Coverage under the medical benefit for Commercial products is limited to treatment of accidental injury to sound natural teeth when care is received within 72 hours of the onset of the injury. Covered treatments include: extraction to avoid infection of teeth damaged in the injury; suturing; reimplanting and stabilization of dislodged teeth; repositioning and stabilization of partly dislodged teeth; and dental X‑rays. Any dental services other than these listed emergency treatments are contract exclusions and may be denied.

Coding — Typical Procedure and Diagnosis Codes

Typically covered dental radiography codesCPTCovered

D0210	Intraoral-complete series (radiographic image)
D0220	Intraoral-periapical-first radiographic image
D0230	Intraoral-periapical-each additional radiographic image
D0240	Intraoral-occlusal radiographic image
D0250	Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector
D0270	Bitewing-single radiographic image
D0272	Bitewings-two radiographic image
D0273	Bitewings-three radiographic image
D0274	Bitewings-four radiographic image
D0277	Vertical bitewings - 7 to 8 radiographic images

Typically covered procedural dental codes for accidental injuryCPTCovered

D7210	Surgical removal of erupted tooth requiring removal of bone and/or section of tooth, and elevation of mucoperiosteal flap
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7272	Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue
D7540	Removal of reaction-producing foreign bodies, musculoskeletal system
D7910	Suture of recent small wounds up to 5 cm
D7911	Complicated suture - up to 5 cm
D7912	Complicated suture - greater than 5 cm

Typically used ICD-10-CM diagnosis codesICD-10

S01.532A
S01.542A
S01.552A
S02.5XXA
S02.5XXB
S03.2XXA

Provider Actions — Billing, Timing, and Authorization

Note

Prior Authorization

Prior authorization is not required for these services.

Note

When services for treatment of accidental injury to sound natural teeth are billed under the medical benefit, providers should file claims using the CMS 1500 form. If dentally necessary services are received in a doctor's or dentist's office due to an accidental injury, the member is responsible for any applicable office visit copayment. Benefits may vary between groups/contracts — refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable Emergency Dental Condition and Dental Services benefits/coverage.

Billing Rule

Claim form and member cost-sharing

Providers should file claims using the CMS 1500 form when services are covered under the medical benefit. If services are received in a doctor's or dentist's office due to an accidental injury, the member is responsible for any applicable office visit copayment. Benefits may vary between groups/contracts; refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.

Denial Risk

Timely treatment requirement

Treatment for accidental injury is considered medically necessary only when received within seventy-two (72) hours of the onset of the accidental injury.

Denial Risk

Scope exclusion

Any dental services other than the listed emergency treatments (extraction to avoid infection, suturing, reimplanting and stabilization of dislodged teeth, repositioning and stabilization of partly dislodged teeth, and dental X-rays) are considered contract exclusions and may be denied.

Extraction of teeth needed to avoid infection of teeth damaged in the injury
Suturing
Reimplanting and stabilization of dislodged teeth
Repositioning and stabilization of partly dislodged teeth
Dental X-rays

Background

Coverage under the medical benefit applies when an accidental injury damages sound natural teeth — injuries must be unexpected and unintentional and do not include those sustained while biting or chewing. Sound natural teeth are defined clinically as teeth free of active or chronic decay, with at least 50% bone support and functional in the arch. Treatment (including management of facial fractures when directly caused by the injury) is covered only when the injury is the direct cause for treatment and the services are among the emergency treatments listed in this policy and rendered within the required 72‑hour timeframe.

Definitions

Sound natural teeth

DefinitionTeeth free of active or chronic clinical decay; at least 50% bone support; functional in the dental arch.

Context for coverageApplies when accidental injury to sound natural teeth is caused by unexpected, unintentional means (excludes injuries from biting or chewing).

Treatment settingTreatment for accidental injury to sound natural teeth and facial fractures is covered in the hospital or emergency room when the injury is the direct cause for treatment.

Billing guidanceBecause these services are covered under the medical benefit, providers should file claims using the CMS 1500 form.

Member cost-sharing noteIf services are received in a doctor’s or dentist’s office due to accidental injury, the member may be responsible for applicable office visit copayment.