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ModifiedSelectHealthPolicy 549

Cone-Beam Computed Tomography (CBCT) for Dental Conditions Under the Medical Benefit

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SelectHealth policy governing coverage of CBCT imaging for dental, oral and maxillofacial conditions under the medical benefit across plan types (Commercial, Medicare, Medicaid/Community Care). It states coverage determinations and rationale for when CBCT is considered medically necessary or not.

Policy Summary

PayerSelectHealth

PolicyCone-Beam Computed Tomography (CBCT) for Dental Conditions Under the Medical Benefit

Policy CodePolicy 549

Change TypeCriteria clarifiedColorado requirements added

Effective DateFeb 7, 2023

Last ReviewFeb 4, 2025

Next Review Date

Key ActionObtain and submit required clinical documentation (including imaging) and prior authorization when requesting coverage for anesthesia or orthognathic procedures.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, updated overall coverage criteria and clarified that anesthesia coverage criteria apply in an office setting.

Added corresponding requirements for Colorado-based plans.

Not coveredCommercial plan stance for CBCT

GRADE 2CEvidence quality

YesCPT/CDT codes listed

00170Anesthesia CPT listed

≤6 yrsPediatric anesthesia age threshold

Coverage Criteria

Commercial Plan - Not Covered

Covered when ALL of the following are met

Commercial plan coverage stance: Select Health does NOT cover cone-beam computed tomography (CBCT) for the evaluation of dental conditions under the medical benefit.

Rationale: lack of evidence supporting improved health outcomes compared to standard technologies; evidence quality limited (GRADE 2C).

Medicare and Community Care (Medicaid) Guidance

Medicare/Medicaid application: Medicare coverage is determined by CMS; if CMS has not adopted a coverage determination and InterQual criteria are not available, the Select Health commercial policy applies. Community Care (Medicaid) policies typically align with State of Utah Medicaid and may use InterQual or NCD/LCD criteria when applicable.

Providers should consult CMS and state Medicaid sources for up-to-date determinations.

Dental anesthesia (Utah/Idaho/Nevada)

Policy Summary

PayerSelectHealth

PolicyCone-Beam Computed Tomography (CBCT) for Dental Conditions Under the Medical Benefit

Policy CodePolicy 549

Change TypeCriteria clarifiedColorado requirements added

Effective DateFeb 7, 2023

Last ReviewFeb 4, 2025

Next Review Date

Key ActionObtain and submit required clinical documentation (including imaging) and prior authorization when requesting coverage for anesthesia or orthognathic procedures.

SourceLink

On This Page

Utah/Idaho/Nevada anesthesia criteria: 1) Member is a child up to 6 years old with a dental condition requiring repairs of significant complexity (e.g., multiple restorations, pulpal therapy, extractions); OR 2) Member has physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia is unlikely to succeed (examples: intellectual disability, autism spectrum disorder, cerebral palsy, epilepsy, cardiac problems, hyperactivity) with verification; OR 3) Member who, after conservative pharmaceutical interventions have failed, is extremely uncooperative, fearful, unmanageable, anxious, or non-verbal with dental needs that cannot be deferred; OR 4) Local anesthesia is ineffective (anatomic variation or allergy); OR 5) Member has sustained extensive oral-facial and/or dental trauma for which local anesthesia would be ineffective.

Applies when anesthesia is administered by an anesthesiologist or CRNA in inpatient, outpatient, or office settings.

Orthognathic deformity subcriteria

Qualifying facial skeletal deformities — at least one of A, B, C, or D:

A. Anteroposterior discrepancies: Maxillary/mandibular incisor relationship: overjet of ≥ +3 mm or ≥ -1 mm.>= +3 mm or >= -1 mm

Documented with imaging (CBCT preferred).

B. Vertical discrepancies: Any one of: (i) vertical facial skeletal deformity ≥ 2 standard deviations from published norms; (ii) open bite with no anterior vertical overlap or posterior open bite > 2 mm; (iii) deep overbite with palatal soft tissue impingement; (iv) supraeruption of a dentoalveolar segment due to lack of occlusion.2 SD or >2 mm

Provider-submitted measurements required.

C. Transverse discrepancies: Any one of: (i) transverse skeletal discrepancy ≥ 2 standard deviations from norms; (ii) total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm or unilateral ≥ 3 mm given normal posterior tooth axial inclination; (iii) posterior crossbite on one or both sides.>=2 SD or >=4 mm or >=3 mm

Measurements should be submitted by provider and supported by imaging.

D. Asymmetries: Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.> 3 mm

Documented asymmetry must be supported by imaging and measurements.

Medically Necessary Criteria

Covered when ALL of the following are met:

Anatomic Criteria: Presence of at least one qualifying skeletal/anatomic finding: (i) transverse skeletal discrepancy ≥ 2 SDs from published norms; OR (ii) total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral ≥ 3 mm given normal posterior tooth axial inclination; OR (iii) posterior crossbite on one or both sides; OR (iv) asymmetries (AP, transverse, or lateral) > 3 mm with concomitant occlusal asymmetry.see text

Based on provider-submitted measurements and imaging.

Functional Impairment: At least one documented functional impairment: persistent mastication or swallowing difficulties after exclusion of other causes; OR malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity; OR speech dysfunction directly related to jaw deformity with determination by a speech-language pathologist; OR myofascial pain secondary to facial skeletal deformity as determined by a qualified medical professional; OR obstructive sleep apnea with documented CPAP intolerance or failure.1 of the listed impairments required

Obstructive sleep apnea requires documentation of CPAP intolerance or failure.

Coding

CPT CODESCPT

70486	Computed tomography, maxillofacial area; without contrast material
76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post processing on an independent workstation
76377	3D rendering with interpretation and reporting; requiring image post processing on an independent workstation
76380	Computed tomography, limited or localized follow-up study
D0364	Cone beam CT capture & interpretation
D0365	Cone beam CT interpretation mandible
D0366	Cone beam CT interpretation maxilla
D0367	Cone beam CT interpretation both jaws
D0368	Cone beam CT interpretation TMJ
D0380	Cone beam CT capture limited

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HCPCS CODESHCPCS

No codes listed

CPT CodesCPTCovered

00170

Anesthesia for intraoral procedures, including biopsy

CDT CodesCDTCovered

D9210	Local anesthesia not in conjunction with operative or surgical procedures
D9211	Regional block anesthesia
D9212	Trigeminal division block anesthesia
D9215	Local anesthesia in conjunction with operative or surgical procedures
D9222	Deep sedation/general anesthesia - first 15 minutes
D9223	Deep sedation/general anesthesia - each subsequent 15 minute increment
D9230	Inhalation of nitrous oxide/analgesia, anxiolysis
D9239	Intravenous moderate (conscious) sedation/analgesia - first 15 minutes
D9243	Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment
D9248	Non-intravenous conscious sedation

Listed CPT Codes for orthognathic and related proceduresCPT

21141	Reconstruction midface, Lefort I; single piece, segment movement in any direction, without bone graft.
21142	2 pieces, segment movement in any direction, without bone graft.
21143	3 or more pieces, segment movement in any direction, without bone graft.
21145	Single piece, segment movement in any direction, requiring bone grafts (includes obtaining graft).
21146	2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts).
21147	3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts).
21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation.
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation.
21198	Osteotomy, mandible, segmental.
21199	With genioglossus advancement.

1–10 of 16

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Orthognathic deformity thresholds

Incisor overjetMaxillary/mandibular incisor relationship: overjet of ≥ +3 mm or ≥ -1 mm.

Transverse discrepancy (SD)Transverse skeletal discrepancy defined as ≥ 2 standard deviations from published norms (provider-submitted measurements).

Palatal cusp to fossa discrepancyTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral discrepancy ≥ 3 mm (with normal posterior tooth axial inclination).

Asymmetry thresholdAnteroposterior, transverse, or lateral asymmetries > 3 mm with concomitant occlusal asymmetry.

Vertical discrepancy thresholdsVertical facial skeletal deformity ≥ 2 standard deviations from norms; or open bite with no anterior vertical overlap or posterior open bite > 2 mm; or deep overbite with palatal soft tissue impingement; or supraeruption of dentoalveolar segment due to lack of occlusion.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required and coverage is conditional on the member meeting the specific indications and documentation requirements listed in this policy.

Commercial plans: CBCT for evaluation of dental conditions is NOT covered under the medical benefit and may be denied when billed for dental indications.
Medicare: Coverage follows CMS determinations; if CMS has no determination and InterQual criteria are available, InterQual is used; if CMS and InterQual criteria are not available, SelectHealth commercial criteria apply.

Documentation Required

Documentation & Imaging Required

Services billed without required documentation demonstrating that the listed indications/criteria are met may be denied. For orthognathic surgery, documentation must include clinical records and supporting medical imaging (cone‑beam CT preferred) showing the objective skeletal discrepancy.

Orthognathic surgery: must be supported by documentation and medical imaging; objective measurements (e.g., overjet, transverse discrepancy, vertical deviation, asymmetry) must be documented per policy criteria.
Cosmetic-only procedures (e.g., solely to improve appearance/profile, isolated genioplasty/mentoplasty) are not covered and may be denied.

Denial Risk

Denial Risk — Coverage Not Supported

Denials will be issued for services that do not meet the listed indications or that are excluded (for example, CBCT for dental conditions on commercial plans and cosmetic-only orthognathic procedures).

Commercial CBCT for dental conditions: not medically necessary — subject to denial.
Orthognathic surgery billed for cosmetic indications or excluded indications (e.g., TMJ disease correction) may be denied as not medically necessary or investigational.

Note

Medicare / InterQual Fallback Guidance

When Medicare (CMS) criteria are not available, SelectHealth will apply InterQual criteria when available; if InterQual criteria are also unavailable, SelectHealth commercial policy criteria will be applied as the fallback for coverage decisions.

Providers should verify whether a CMS coverage determination exists for Medicare members. If none exists, confirm whether InterQual criteria apply; otherwise, the commercial policy criteria govern.
SelectHealth applies requirements after evidence review; always consult current CMS and InterQual sources for the latest guidance.

Note

Documentation and Contact

Providers must consult member benefits and obtain prior authorization when required. For benefit questions or to confirm prior authorization requirements, contact SelectHealth Provider Relations or Member Customer Service.

Providers: verify individual member benefits and eligibility prior to rendering services.
Provider Relations (questions): (801) 442-3692. Members: call the number on the member ID card to discuss benefits.

Documentation Required

Objective Skeletal Discrepancy — Documentation Required

Provider must document objective skeletal discrepancies and functional impairments when requesting orthognathic surgery; include measurements and specialist assessments as applicable.

Objective measurements to document may include: overjet (≥ +3 mm or ≥ -1 mm), transverse discrepancies (e.g., bilateral palatal cusp to mandibular fossa ≥4 mm or unilateral ≥3 mm), vertical deviations ≥2 standard deviations from norms, asymmetries >3 mm.
Functional impairments required per policy (e.g., persistent mastication/swallowing difficulties, malnutrition/weight loss, speech dysfunction with SLP assessment, myofascial pain diagnosis, obstructive sleep apnea with documented CPAP intolerance/failure) must be clearly documented.

Definitions

CBCT definition — cone-beam CT description

DefinitionCone-beam computed tomography (CBCT) systems rotate around the patient using a cone-shaped X-ray beam to capture data and reconstruct three-dimensional images of the dental, oral and maxillofacial region, and ears/nose/throat.

Image scopeReconstructs 3D images of teeth, mouth, jaw, neck, and ENT areas for diagnostic and planning purposes.

System characteristicCBCT is a variation of traditional CT using a cone-shaped X-ray beam and rotating acquisition specific to dental/maxillofacial imaging.

Radiographic examinations definition

Radiographic examinationsInclude digital imaging or conventional film; digital imaging may reduce radiation exposure and offers image analysis advantages that can enhance sensitivity and reduce subjective error.

UsesRadiographs and other imaging modalities are used to diagnose and monitor oral diseases, dentofacial development, and therapy progress or prognosis.

Modality noteEither digital or conventional film is considered suitable based on available evidence.

Orthognathic surgery definition

DefinitionCorrective jaw surgery (orthognathic surgery) is performed by oral and maxillofacial surgeons to correct skeletal and dental irregularities and improve chewing, speaking, and breathing; the primary purpose is to correct functional problems, though appearance may be enhanced.

ScopeAddresses a range of minor to major misalignments of jaws and teeth impacting function.

ProviderTypically performed by oral and maxillofacial surgeons.

Monitored anesthesia care definition

DefinitionMonitored anesthesia care (MAC) and general anesthesia are considered medically necessary for dental/OMS services when administered by an anesthesiologist or CRNA in inpatient, outpatient, or office settings if listed clinical criteria are met.

SettingsCan be provided in inpatient, outpatient, or office settings when criteria apply.

ProvidersAdministered by an anesthesiologist or certified registered nurse anesthetist (CRNA).

Transverse skeletal discrepancy definition

DefinitionTransverse skeletal discrepancy is defined as a skeletal width discrepancy measuring two or more standard deviations from published norms, as submitted by the provider.

Alternate measurementTotal bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, or unilateral ≥ 3 mm, given normal posterior tooth axial inclination.

Clinical signPosterior crossbite on one or both sides may indicate a transverse discrepancy.

Functional impairments qualifying for orthognathic surgery

Scope of impairmentsFunctional impairments include persistent difficulties with mastication and swallowing after exclusion of other causes; malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity; speech dysfunction directly related to jaw deformity with speech-language pathologist determination; myofascial pain secondary to facial skeletal deformity as determined by a qualified medical professional; or obstructive sleep apnea with documented CPAP intolerance or failure.

Documentation requirementAt least one of these functional impairments must be documented to meet orthognathic surgery medical necessity criteria.

Exclusion considerationOther potential causes (e.g., neurologic or metabolic diseases) must be excluded for mastication/swallowing difficulties prior to attributing them to skeletal deformity.