CurrentExcellus Health Plan IncPolicy 7.01.21

Dental and Oral Care under Medical Plans

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This policy governs when dental and oral procedures may be covered under a member's medical/surgical contract rather than dental benefits. It addresses oral surgery, cyst removal, oral biopsies, accidental injury to sound natural teeth, and treatment of congenital anomalies or disease.

Policy Summary

PayerExcellus Health Plan Inc

PolicyDental and Oral Care under Medical Plans

Policy CodePolicy 7.01.21

Change TypeAnnual review — no material change

Effective DateMay 21, 2026

Last ReviewMay 21, 2026

Next Review DateMay 1, 2027

Key ActionDocument the congenital anomaly and resulting functional impairment when requesting coverage for congenital anomaly services.

SourceLink

POLICY UPDATE CHANGES

The policy underwent an annual review with the policy intent unchanged.

A format correction was recorded in the policy history.

12 monthsAccidental-injury treatment window

3 CPTCovered lingual frenum procedure codes

2Functional impairments specified for ankyloglossia

10Routine dental services generally ineligible

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CurrentExcellus Health Plan IncPolicy 7.01.21

Dental and Oral Care under Medical Plans

Customize your policy alerts

Sign up for excellus_health_plan_inc Policy 7.01.21 alerts

Get alerted when Policy 7.01.21 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerExcellus Health Plan Inc

PolicyDental and Oral Care under Medical Plans

Policy CodePolicy 7.01.21

Change TypeAnnual review — no material change

Effective DateMay 21, 2026

Last ReviewMay 21, 2026

Next Review DateMay 1, 2027

Key ActionDocument the congenital anomaly and resulting functional impairment when requesting coverage for congenital anomaly services.

SourceLink

POLICY UPDATE CHANGES

The policy underwent an annual review with the policy intent unchanged.

A format correction was recorded in the policy history.

12 monthsAccidental-injury treatment window

3 CPTCovered lingual frenum procedure codes

2Functional impairments specified for ankyloglossia

10Routine dental services generally ineligible

Medical and Surgical Coverage Criteria

Non-tooth-related developmental cysts

Removal is medically appropriate under a medical/surgical contract when the cyst meets the following criterion and the member’s contract provides the applicable benefit.

Non-tooth-related developmental cyst: The cyst consists of epithelial remnants and is not tooth related.

Examples include globulomaxillary, median alveolar, median palatine, and nasopalatine cysts.

Tooth-related cysts

Removal is medically appropriate under a dental contract; dental benefits are contract-specific and the service is not eligible as a medical/surgical benefit.

Tooth-related cyst: The cyst is tooth related.

Examples include follicular-dentigerous, primordial, multilocular, Mallassez, radicular, residual cysts, and odontomas. Removal is ineligible under the medical/surgical benefit.

Oral biopsies

Oral biopsies may be medically appropriate under a medical/surgical contract when either of the following circumstances applies.

Covered oral biopsy circumstance

Anatomic-site criterion: The biopsy is of the buccal mucosa, tongue, palate, or floor of the mouth.
Gingiva or tooth-supporting structures: The biopsy is of the gingiva or supporting structures of the teeth and the tissue was not obtained as part of a routine tooth extraction or routine periodontal procedure.
If the biopsy reveals only a dental condition, subsequent care or treatment of that condition is ineligible under the medical/surgical contract unless otherwise stated.

Accidental injury to sound, natural teeth

Coverage under the medical/surgical contract is provided only when ALL of the following criteria are met.

Subscriber-contract benefit: The service falls within a category of services for which the member's subscriber contract provides a benefit.
Medical necessity: The service is deemed medically necessary according to the criteria set forth in Corporate Medical Policy 11.01.15, Medically Necessary Services.
Treatment timeframe: The service is rendered within 12 months of the accidental injury.Within 12 months of the injury
Exceptions to the 12-month timeframe are not granted for staging of procedures.
Sound, natural tooth:

Congenital anomaly or disease

Services for treatment of a congenital anomaly or disease are eligible under the medical/surgical contract only when ALL of the following criteria are met.

Congenital anomaly or disease treatment

Subscriber-contract benefit: The service falls within a category of services for which the member's subscriber contract provides a benefit.
Medical necessity: The service is medically necessary according to the criteria set forth in Corporate Medical Policy 11.01.15, Medically Necessary Services.
Functional impairment: The service treats or corrects functional impairment caused by an underlying congenital anomaly or disease that was present at birth.
Documentation: Medical documentation of the congenital anomaly or disease is provided.

Congenital ankyloglossia

For congenital ankyloglossia, medical/surgical coverage is limited to the specified lingual frenum procedures when ALL of the following criteria are met.

Lingual frenum procedure for congenital ankyloglossia

Specified procedure: The procedure is a frenectomy of the lingual frenum (CPT 41115), frenotomy of the lingual frenum (CPT 41010), or frenoplasty of the lingual frenum (CPT 41520).
Congenital condition: The procedure addresses congenital ankyloglossia.
Restricted tongue movement: The ankyloglossia restricts movement of the tongue.
Functional impairment: The restriction leads to problems with newborn feeding and speech articulation in children.

Congenital anomaly or disease services

Services are covered under the medical/surgical contract when all applicable criteria are met.

Underlying condition: The service treats or corrects functional impairment resulting from an underlying congenital anomaly or disease that was present at birth.
Examples include cleft palate, ectodermal dysplasia, and ankyloglossia.
Medical documentation of the congenital anomaly or disease is provided.
Examples include genetic testing records or birth-defect documentation.
Lingual frenum functional impairment: When the service is a lingual frenectomy, frenotomy, or frenoplasty, the congenital ankyloglossia restricts tongue movement and leads to problems with newborn feeding and speech articulation in children.
Applicable CPT codes are 41115, 41010, and 41520.

Oral surgical procedures are generally ineligible under the medical portion of the subscriber contract unless otherwise stated. Dental-origin services, including dental extractions, periodontal treatment, and biopsies involving dental-related cysts or tissue of dental origin, are generally handled under dental benefits rather than the medical/surgical benefit.

Removal of a tooth-related cyst is ineligible for coverage as a medical/surgical benefit. Coverage may be considered under the member’s dental contract, subject to that contract’s terms.

When an oral biopsy reveals only a dental condition, subsequent care or treatment of that condition is ineligible under the medical/surgical contract, unless otherwise stated in the policy or applicable contract.

Frenectomy, frenotomy, and frenoplasty of the lingual frenum are not medically necessary when performed prophylactically to promote speech development or articulation in children or adults.

X-rays, including cone beam imaging for implant placement and computed tomography (CT) scans, are ineligible under the medical benefit, unless otherwise stated.

Dental services rendered by a dental provider that are not listed in the policy statements are ineligible under the member’s medical/surgical contract, unless otherwise stated.

Examples of routine dental procedures excluded from medical/surgical coverage include correction of impactions, endodontic therapy, tooth extraction, implant placement, oral biopsies with a dental diagnosis, periodontal treatment, placement of fillings, preventive care, and prosthetics.

Under the referenced New York Insurance Law § 3217 provision, dental care or treatment may be excluded except when it is required because of an accidental injury to sound natural teeth within 12 months of the accident, or when the dental care or treatment is necessary because of a congenital disease or anomaly.

Lingual frenectomy, frenotomy, and frenoplasty are excluded as prophylactic procedures when performed to promote speech development or articulation in children or adults.

Prophylactic lingual frenum procedures—including frenectomy, frenotomy, and frenoplasty—are considered not medically necessary when performed to promote speech development or articulation because the effectiveness of this approach has not been established.

Covered and Excluded Coding

Covered lingual frenum procedures when criteria are metCPTCovered

41115	Frenectomy of the lingual frenum related to congenital ankyloglossia
41010	Frenotomy of the lingual frenum related to congenital ankyloglossia
41520	Frenoplasty of the lingual frenum related to congenital ankyloglossia

Not medically necessary prophylactic lingual frenum proceduresCPTNot Covered

41115	Frenectomy of the lingual frenum when performed prophylactically to promote speech development or articulation
41010	Frenotomy of the lingual frenum when performed prophylactically to promote speech development or articulation
41520	Frenoplasty of the lingual frenum when performed prophylactically to promote speech development or articulation

Lingual frenum procedures related to congenital ankyloglossiaCPTCovered

41115	Frenectomy
41010	Frenotomy
41520	Frenoplasty

Lingual frenum procedures performed prophylactically to promote speech development or articulationCPTNot Covered

41115	Frenectomy
41010	Frenotomy
41520	Frenoplasty

CPT CodesCPT

41010	Incision of lingual frenum (frenotomy)
41115	Excision of lingual frenum (frenectomy)
41520	Frenoplasty (surgical revision of frenum, eg, with Z-plasty)

HCPCS CodesHCPCS

Multiple Codes

ICD10 CodesICD-10

P92.2	Slow feeding of newborn
P92.3	Underfeeding of newborn
P92.4	Overfeeding of newborn
P92.5	Neonatal difficulty in feeding at breast
P92.6	Failure to thrive in newborn
P92.8	Other feeding problems of newborn
P92.9	Feeding problem of newborn, unspecified
Q35.1	Cleft hard palate
Q35.3	Cleft soft palate
Q35.5	Cleft hard palate with cleft soft palate

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Accidental-injury treatment timeframe

Required treatment windowWithin 12 months from the date of the accidental injury

Timeframe basisThe period is measured from the date of injury

Staging exceptionExceptions to the 12-month timeframe are not granted for staging procedures

Documentation and Denial Risks

Documentation Required

Document Congenital Origin

For congenital anomaly or disease claims, document that the condition was present at birth and submit medical evidence supporting the congenital diagnosis.

Examples include genetic testing records or documentation of a birth defect.
Congenital conditions include abnormalities of structure or function present at birth, such as cleft palate, ectodermal dysplasia, or ankyloglossia.

Documentation Required

Document Accidental Injury to a Sound Tooth

For accidental injury claims, document a blow to the face involving a sound, natural tooth and identify the injury date and treatment provided.

Biting injuries do not qualify as accidental injuries.
The tooth must have no prior restorative treatment or disease at the injury site, including no crown, root canal, periodontal condition, or untreated fracture.
Services must be rendered within 12 months of the injury; exceptions are not granted for staging procedures.

Policy Scope and Benefit Distinction

The policy distinguishes conditions arising from dental tissue or routine dental care from oral conditions that require medical/surgical treatment. Medical coverage may apply to selected non-tooth-related oral conditions, oral biopsies meeting policy circumstances, accidental trauma to previously sound natural teeth, and functional impairment caused by congenital anomalies or disease. Coverage remains subject to the member’s contract and medical-necessity requirements.

Terms Used in the Policy

Accidental injury

DefinitionA blow to the face

Included injury typeAn injury involving treatment of sound, natural teeth

Excluded injury typeBiting injuries are not included

Sound and natural tooth

Natural supportThe tooth is sufficiently supported by its natural structure, including bone and gum tissue

OriginThe tooth was formed by the human body

Condition before injuryThe tooth was not decayed or weakened by previous dental work at the injury site

Policy Summary

PayerExcellus Health Plan Inc

PolicyDental and Oral Care under Medical Plans

Policy CodePolicy 7.01.21

Change TypeAnnual review — no material change

Effective DateMay 21, 2026

Last ReviewMay 21, 2026

Next Review DateMay 1, 2027

Key ActionDocument the congenital anomaly and resulting functional impairment when requesting coverage for congenital anomaly services.

SourceLink

On This Page

The affected tooth was sound and natural before the injury, with no restorative treatment or disease at the injury site.

A sound tooth is supported by its natural bone and gum tissue and is not decayed or weakened by prior dental work; examples of disqualifying conditions include a crown, root canal, periodontal condition, or fracture requiring treatment for a reason other than the accidental injury.

Examples include genetic testing records and birth-defect documentation.

Documentation Required

Provide Congenital-Anomaly Documentation

Submit acceptable medical documentation of the congenital anomaly or disease when requesting coverage for treatment or correction of related functional impairment.

Acceptable examples include genetic testing records and birth-defect documentation.
The documentation must establish that the abnormality of structure or function was present at birth.

Documentation Required

Document Functional Tongue Restriction

Document the functional impairment caused by congenital ankyloglossia. For lingual frenectomy, frenotomy, or frenoplasty, show that restricted tongue movement causes clinically significant problems with newborn feeding and/or speech articulation in children.

Describe the tongue-movement restriction and the resulting feeding or speech-articulation impairment.
Coverage applies to lingual-frenum procedures for congenital ankyloglossia when the restriction produces these functional problems.

Documentation Required

Establish Frenulum-Related Restriction

Document that the lingual frenulum is the exclusive cause of the restricted tongue movement. An evaluation tool may support the assessment, but the record must demonstrate both restricted movement and causation.

The Hazelbaker Assessment Tool for Lingual Frenulum Function evaluates frenulum anatomy and function; the Coryllos classification describes frenulum type but does not evaluate function or establish ankyloglossia.
Record why other causes do not account for the tongue restriction.

Billing Rule

Routine Dental-Origin Care Is Excluded

Oral surgical procedures are generally ineligible under the medical portion of the member’s contract unless the policy states otherwise. Bill qualifying services to the appropriate benefit and do not submit routine dental-origin care as a medical benefit.

Excluded examples include dental extractions, periodontal treatment, and biopsies for dental-related cysts or tissue of dental origin.
Removal of tooth-related cysts is ineligible under the medical/surgical benefit.

Denial Risk

Dental Biopsy Findings May Be Ineligible

A gingival or tooth-supporting-structure biopsy may be medically appropriate unless the tissue was obtained during a routine extraction or periodontal procedure. If the biopsy shows only a dental condition, subsequent treatment of that condition is ineligible under the medical/surgical contract.

Do not bill a routine dental procedure or a dental-only biopsy finding as covered medical care.
Apply any stated contract exceptions where applicable.

Denial Risk

Accidental-Injury Criteria Must Be Met

Accidental-injury coverage may be denied when the event was a biting injury, the affected tooth was not sound and natural before the event, or treatment occurred outside the permitted time frame.

The qualifying mechanism is a blow to the face, not a biting injury.
A tooth weakened by decay, disease, prior dental work, a crown, root canal, periodontal condition, or fracture does not meet the sound-tooth requirement.
Treatment must occur within 12 months of the accidental injury, with no exception for procedure staging.

Denial Risk

Congenital Ankyloglossia Criteria Must Be Met

Congenital ankyloglossia claims may be denied when the record does not establish congenital origin, functional impairment, restricted tongue movement, or that the lingual frenulum exclusively causes the restriction.

Document the condition as present at birth and provide medical evidence of the anomaly.
Show resulting newborn-feeding or speech-articulation impairment, as applicable.
Do not rely solely on a frenulum classification that does not assess function or causation.

Denial Risk

Prophylactic Speech-Promotion Procedures Are Not Covered

Frenectomy (CPT 41115), frenotomy (CPT 41010), and frenoplasty (CPT 41520) are not medically necessary when performed prophylactically to promote speech development or articulation in children or adults.

Coverage is not supported for speech-promotion procedures without documented functional impairment and qualifying congenital ankyloglossia.
The policy states that the effectiveness of prophylactic treatment has not been established.

Billing Rule

Dental Imaging Is Generally Ineligible

X-rays, including cone-beam imaging for implant placement and CT scans, are ineligible under the medical benefit unless otherwise stated.

Apply any applicable contract or policy exception.

Billing Rule

Routine and Unlisted Dental Services Are Excluded

All other dental services rendered by a dental provider that are not listed in the policy statements are ineligible under the medical/surgical contract unless otherwise stated.

Routine excluded services include correction of impactions, endodontic therapy, tooth extraction, implant placement, oral biopsies with a dental diagnosis, periodontal treatment, fillings, preventive care, and prosthetics.
Do not bill routine or unlisted dental services as medical/surgical benefits.

Disqualifying examplesThe tooth had no crown, root canal, periodontal condition, or untreated fracture before the injury

Congenital anomaly or disease

DefinitionAn abnormality of structure or function that was present at birth

ExampleCleft palate

ExampleEctodermal dysplasia

ExampleAnkyloglossia

Congenital anomaly or disease

Core definitionAn abnormality of structure or function

TimingThe abnormality was present at birth

ScopeThe definition applies to congenital anomalies or disease

Congenital ankyloglossia

NatureA congenital condition involving restricted movement of the tongue

Feeding impactThe restriction leads to problems with newborn feeding

Speech impactThe restriction leads to problems with speech articulation in children

Developmental dentoalveolar bone cysts

OriginCysts arising from epithelial remnants

Relationship to teethThe cysts are not tooth-related

ExampleGlobulomaxillary cysts

ExampleMedian alveolar cysts

ExampleMedian palatine cysts

ExampleNasopalatine cysts

Tooth-related dentoalveolar bone cysts

OriginCysts arising from dental tissue

ExampleFollicular-dentigerous cysts

ExamplePrimordial or multilocular cysts

ExampleCysts of Mallassez

ExampleRadicular cysts, residual cysts, and odontomas

Congenital anomaly

DefinitionA structural or functional anomaly, including metabolic disorders, occurring during intrauterine life

When identifiedIt may be identified prenatally, at birth, or later in infancy

Meaning of congenitalCongenital refers to existence at or before birth

ExclusionA condition developing after birth from inherited factors, such as diabetes, is not considered congenital

Ankyloglossia

Also known asTongue tie

Range of conditionsFrom malposition of the lingual frenulum to partial or total fusion of the tongue to the floor of the mouth

Functional effectA short frenulum or attachment close to the tongue tip can restrict tongue movement

Clinical documentationRestricted tongue movement must be demonstrated, with the lingual frenulum established as the exclusive cause of the limitation

Frenectomy

ProcedureSurgical removal of the lingual frenum of the tongue

Anatomic siteThe lingual frenum

ResultThe procedure results in greater range of motion of the tongue

Frenotomy

ProcedureIncision of the lingual frenum without removing it

Distinction from frenectomyThe frenum is incised but not removed

ResultThe procedure results in greater range of motion of the tongue

Frenoplasty

ProcedureSurgical revision of the lingual frenum using Z-plasty

Anatomic siteThe lingual frenum

ResultThe procedure results in greater range of motion of the tongue

Traumatic dental injury

DefinitionTrauma involving the dento-alveolar region

Tooth effectsThe trauma may cause fracture or displacement of teeth

Bone effectsThe trauma may cause crushing or fracturing of bone

Soft-tissue effectsThe trauma may cause contusions, abrasions, or lacerations of soft tissue