ModifiedSelectHealthPolicy 549

Cone-Beam Computed Tomography (CBCT) for Dental/Oral-Maxillofacial Conditions

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Governs CBCT coverage determinations for dental/oral-maxillofacial conditions under SelectHealth medical benefits, states commercial noncoverage for dental CBCT, and references Medicare/Medicaid alignment; affects providers submitting CBCT claims.

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ModifiedSelectHealthPolicy 549

Cone-Beam Computed Tomography (CBCT) for Dental/Oral-Maxillofacial Conditions

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Policy Summary

PayerSelectHealth

PolicyCone-Beam Computed Tomography (CBCT) for Dental/Oral-Maxillofacial Conditions

Policy CodePolicy 549

Change TypeRevised coverage criteria for anesthesia indications

Effective DateFeb 7, 2023

Last ReviewFeb 4, 2025

Next Review Date

Key ActionVerify member benefits and obtain prior authorization when required; provide clinical documentation demonstrating criteria are met.

SourceLink

POLICY UPDATE CHANGES

Updated overall coverage criteria to specify when general anesthesia and monitored anesthesia care (MAC) are medically necessary for dental/OMS services in the outpatient and office settings.

Not coveredCommercial plan: CBCT for dental conditions

Multiple SRsEvidence summary identified

13Codes referenced for CBCT

3+Anesthesia criteria categories

2Related clinical policies

Coverage Criteria and Clinical Determinations

inv-01: Commercial plan: Not medically necessary

Coverage stance and evidence summary

Commercial plan stance: Select Health Commercial does NOT cover cone-beam computed tomography (CBCT) for the evaluation of dental conditions under the medical benefit because of lack of evidence supporting improved health outcomes compared to standard available technologies.

Claims for CBCT for dental evaluation under the medical benefit may be denied as not medically necessary.

inv-02: Dental Anesthesia - Medical Necessity

Dental anesthesia (general anesthesia or MAC) is considered medically necessary when ANY of the following are met:

Dental anesthesia indications: 1) Child up to 6 years old with complex dental conditions requiring extensive repair (multiple restorations, pulpal therapy, extractions, or combinations); 2) Members who exhibit physical, intellectual, or medically compromising conditions for which dental treatment under local anesthesia (with or without adjunctive techniques) cannot be expected to provide a successful result (examples include intellectual disability, autism spectrum disorder, cerebral palsy, epilepsy, cardiac problems, hyperactivity), or members who are extremely uncooperative, fearful, unmanageable, anxious, or non-verbal after documented conservative pharmaceutical interventions have been attempted and failed; 3) Members for whom local anesthesia is ineffective (anatomic variation or allergy); 4) Members with extensive oral-facial/dental trauma for which local anesthesia would be ineffective; or other documented clinical justifications.

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

inv-03: Orthognathic Surgery - Medical Necessity

Orthognathic surgery is considered medically necessary when BOTH of the following are met:

Orthognathic initial criteria: Criterion 1: At least one qualifying facial skeletal deformity (A–D) documented with clinical evaluation and medical imaging (cone-beam CT preferred). Deformities include: A) Anteroposterior discrepancies (maxillary/mandibular incisor relationship: overjet ≥ +3 mm or ≤ -1 mm); B) Vertical discrepancies (eg, open bite with no anterior overlap or posterior open bite > 2 mm; vertical facial skeletal deformity ≥2 SDs from norms; deep overbite with palatal soft tissue impingement; supraeruption of dentoalveolar segment); C) Transverse discrepancies (eg, total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm, unilateral discrepancy ≥ 3 mm, transverse skeletal discrepancy ≥2 SDs from norms, posterior crossbite); D) Asymmetries: AP, transverse, or lateral asymmetries > 3 mm with concomitant occlusal asymmetry.

Imaging documentation should be provided; cone-beam CT is preferred.

Orthognathic functional impairment: Criterion 2: At least one functional impairment present such as: persistent difficulties with mastication and swallowing after other causes are excluded; speech dysfunction directly related to jaw deformity as determined by a speech and language pathologist; malnutrition, significant weight loss, or failure-to-thrive secondary to facial skeletal deformity; myofascial pain secondary to facial skeletal deformity as determined by a qualified professional; or obstructive sleep apnea when intolerance to or failure of CPAP is documented.

Functional impairments must be documented by appropriate specialists and supported by clinical documentation and imaging.

inv-04: Not covered indications

Not covered indications and application of Medicare/Medicaid guidance

Not covered indications: SelectHealth does NOT cover orthognathic surgery when performed for any of the following: 1) Correction of temporomandibular joint (TMJ) disease (considered experimental/investigational); 2) Correction of speech distortions that do not cause functional impairment (eg, sibilant class distortions, hyper-nasal or hypo-nasal speech); 3) Solely to improve individual appearance or profile (cosmetic), including isolated mentoplasty/genioplasty; additionally, adjunctive procedures intended solely for cosmetic improvement performed with orthognathic surgery are considered cosmetic and not medically necessary.

From policy exclusions.

inv-05: Medicare and Medicaid determination rules

Application of alternative authorities

Medicare/Medicaid application: For Medicare members, coverage is determined by the Centers for Medicare & Medicaid Services (CMS); if CMS has not adopted a coverage determination and InterQual criteria are not available, the SelectHealth Commercial policy applies. For Medicaid members (Community Care), coverage is determined by the State Medicaid program (Utah); if the state has no published position and InterQual is not available, the SelectHealth Commercial criteria apply.

Guidance when external determinations exist or are absent.

Select Health Commercial does NOT cover cone-beam computed tomography (CBCT) for the evaluation of dental conditions under the medical benefit. This exclusion is based on the policy determination that current evidence does not demonstrate improved patient health outcomes for CBCT compared with standard radiographic technologies; therefore use of CBCT for routine dental evaluation will be denied as not medically necessary.

Surgery performed to correct temporomandibular joint (TMJ) disease is considered experimental/investigational by Select Health and is not covered because effectiveness for this indication has not been established.

Procedures performed solely to correct distortions of speech quality (for example, sibilant class distortions or hyper-nasal/hypo-nasal speech) are not covered when the speech distortion does not cause a documented functional impairment.

Procedures performed solely for cosmetic improvement of appearance or facial profile are not covered. This includes isolated genioplasty/mentoplasty and other procedures whose primary intent is aesthetic enhancement rather than the correction of a medical or functional problem.

Select Health does not cover orthognathic surgery when performed for any of the following: correction of TMJ disease (considered experimental/investigational), correction of speech distortions that do not cause functional impairment, or when the procedure is performed solely for cosmetic improvement of appearance/profile (including isolated mentoplasty/genioplasty).

The policy’s noncoverage determinations are grounded in a review of the available literature which identified multiple systematic reviews and peer‑reviewed studies but found limited and low‑quality evidence that CBCT improves diagnostic or patient‑centered outcomes compared with standard panoramic or cephalometric radiographs. The evidence base is heterogeneous, lacks randomized prospective head‑to‑head trials, and contains insufficient data on radiation dose comparisons; therefore Select Health concludes that the evidence is inadequate to demonstrate clinical benefit and deems CBCT for routine dental evaluation not medically necessary.

Orthognathic procedures and adjunctive surgeries performed solely for cosmetic reasons are considered not medically necessary. Isolated chin surgeries (mentoplasty/genial osteotomies) are always considered cosmetic when done only to address chin size or shape and therefore will not be covered.

Isolated cosmetic chin procedures (mentoplasty/genial osteotomy) performed to address genial hypoplasia, hypertrophy, or asymmetry are considered cosmetic and are not covered. When chin surgeries are performed only to improve appearance/profile they are excluded from coverage.

Procedure and Billing Codes

Covered CPT/Dental Codes referencedmixed

70486	Computed tomography, maxillofacial area; without contrast material (To report 3D rendering, see 76376, 76377)
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	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

1–10 of 13

1/2

CPI CODESCPTCovered

00170

Anesthesia for intraoral procedures, including biopsy

Dental anesthesia (CDL codes)HCPCSCovered

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

Procedure CPT codes listedCPT

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 (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	with internal rigid fixation
21198	Osteotomy, mandible; segmental;
21199	with genioglossus advancement

1–10 of 14

1/2

inv-18: Overjet / asymmetry thresholds — numeric thresholds for orthognathic criteria

Anteroposterior (overjet)Overjet ≥ +3 mm or ≤ -1 mm (maxillary/mandibular incisor relationship)

Transverse discrepancies (bilateral)Total bilateral maxillary palatal cusp to mandibular fossa discrepancy ≥ 4 mm

Transverse discrepancies (unilateral)Unilateral transverse discrepancy ≥ 3 mm given normal posterior tooth axial inclination

AsymmetryAnteroposterior, transverse, or lateral asymmetries > 3 mm with concomitant occlusal asymmetry

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Medicare coverage determination guidance

Coverage is determined by the Centers for Medicare & Medicaid Services (CMS). If CMS has an applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD), those rules apply. If a CMS coverage determination is not available and InterQual criteria are not available, the SelectHealth commercial policy applies. Providers should check current CMS policy resources for Medicare coverage guidance before submitting requests.

For the most up-to-date Medicare policies and coverage, consult the CMS Medicare Coverage Database.

Note

Verify benefits and eligibility at time of service

Providers must verify member benefits and eligibility at the time of service or prior authorization request. Coverage and benefit determination is dependent on the member’s individual benefit plan and the date of service. Coding lists in this policy are informational only and do not guarantee coverage or payment.

Verify whether the service is covered under the member’s medical benefit or excluded under their dental benefit.

Background and Context

Cone‑beam computed tomography (CBCT) is a three‑dimensional imaging modality that rotates a cone‑shaped X‑ray beam around the patient to reconstruct detailed 3D images of dental, oral/maxillofacial, and ENT anatomy; it is used for implant planning, impacted tooth assessment, trauma evaluation, endodontic planning, and dentofacial analysis.

Definitions

inv-32: Cone-beam computed tomography (CBCT) — definition and description

DefinitionCone-beam computed tomography (CBCT) is a variation of CT in which the system rotates around the patient capturing data with a cone-shaped X‑ray beam to reconstruct three-dimensional images of dental, oral/maxillofacial, and ENT anatomy.

Primary usesImaging for teeth, jaws, maxillofacial region, and ears/nose/throat — used in implant planning, impacted teeth assessment, trauma, endodontics, and dentofacial evaluation.

Image characteristicsProduces 3D reconstructions from volumetric data captured during a single rotation around the patient

inv-33: Orthognathic surgery definition — corrective jaw surgery affecting function

DefinitionOrthognathic surgery (corrective jaw surgery) is performed by oral and maxillofacial surgeons to correct skeletal and dental irregularities of the jaws and teeth that impair function (chewing, speaking, breathing).

Policy Summary

PayerSelectHealth

PolicyCone-Beam Computed Tomography (CBCT) for Dental/Oral-Maxillofacial Conditions

Policy CodePolicy 549

Change TypeRevised coverage criteria for anesthesia indications

Effective DateFeb 7, 2023

Last ReviewFeb 4, 2025

Next Review Date

Key ActionVerify member benefits and obtain prior authorization when required; provide clinical documentation demonstrating criteria are met.

SourceLink

On This Page

Contact member services or provider relations for plan-specific questions.

Denial Risk

Commercial noncoverage — CBCT for dental evaluation

Commercial SelectHealth does NOT cover cone‑beam computed tomography (CBCT) for evaluation of dental conditions under the medical benefit. CBCT for dental evaluation is considered not medically necessary due to limited evidence of improved health outcomes compared to standard imaging modalities.

Commercial and CHIP: CBCT for dental indications is not covered and may be denied when billed to the medical benefit.

Denial Risk

Denial triggers for noncompliance with coverage criteria

SelectHealth may deny claims or prior authorization requests when coverage criteria are not met or when required documentation, benefit eligibility, or prior authorization is not obtained. Services billed under the medical benefit that meet dental-only indications, cosmetic-only indications, or investigational/experimental indications will be denied.

Claims may be denied if: the member’s benefits do not cover the service; prior authorization was not obtained when required; required clinical documentation is missing or insufficient; or the procedure is cosmetic, experimental, or for dental-only indications.
Examples of noncovered indications that trigger denial include cosmetic improvements, TMJ disease correction (considered experimental), and CBCT for dental evaluations.

Documentation Required

Required clinical documentation for orthognathic surgery

When orthognathic surgery is requested, include comprehensive clinical documentation. Imaging and objective measurements are required to support medical necessity; cone‑beam CT is preferred when available. Document prior conservative management attempts and rationale for surgery.

Clinical history describing functional impairment (e.g., significant masticatory dysfunction) and impact on conservative care.
Objective measurements and imaging supporting facial skeletal deformity (CBCT preferred) and documentation of the specific anteroposterior, vertical, transverse, or asymmetry criteria met.
Records demonstrating that conservative dental/orthodontic treatments were tried and were inadequate or not feasible.

Note

Policy basis for noncoverage

SelectHealth considers certain procedures or indications not medically necessary (noncoverage) due to limited or insufficient evidence of clinical benefit. When a policy states 'not covered' or 'experimental/investigational,' that is a definitive noncoverage basis for commercial plans. Providers should not bill the medical benefit for services defined as noncovered under this policy.

Policies label CBCT for dental evaluation as not medically necessary for commercial plans due to insufficient evidence.
TMJ correction via orthognathic surgery is considered experimental/investigational and not covered.

Documentation Required

Conservative management and documentation before anesthesia

Conservative management should be attempted and documented prior to general anesthesia or monitored anesthesia care for dental procedures when clinically appropriate. Document trials of conservative pharmaceutical interventions, behavioral management, or local anesthesia attempts and the reasons these measures were inadequate or contraindicated.

Document prior attempts at local anesthesia and adjunctive techniques, and note when local anesthesia is ineffective (anatomic variation, allergy) or when patient factors (e.g., developmental disability, severe anxiety, uncooperative behavior) necessitate anesthesia.
For members with special needs or extensive trauma where local anesthesia is ineffective, document justification and supporting medical records.

Note

Documentation and benefits note

Benefits and eligibility determinations are made according to the member’s individual benefit plan in effect at the time services are rendered. This policy is informational and does not replace benefit verification. Providers and members may contact SelectHealth Customer Service or Provider Relations for plan-specific benefit questions.

Members may contact Customer Service using the number on their ID card; providers may contact Provider Relations at (801) 442-3692 for questions about coverage.
Inclusion or exclusion of codes in this policy does not guarantee coverage—refer to the member’s contract.

Clinical purposeDirected at correcting functional disorders (significant masticatory dysfunction or other functional disorders) when conservative dental/orthodontic therapy is inadequate.

DocumentationFacial skeletal deformities contributing to functional impairment must be clinically documented and supported by imaging (cone‑beam CT preferred).

inv-34: Cosmetic procedure definition — surgical procedures solely to improve appearance

DefinitionCosmetic procedures are surgical interventions performed solely to improve individual appearance or facial profile (e.g., isolated mentoplasty/genioplasty).

Coverage implicationProcedures performed solely for cosmetic improvement of appearance/profile are not covered and are considered not medically necessary.

ExampleIsolated chin surgeries (mentoplasty/genial osteotomies) are always considered cosmetic when performed alone.

inv-35: Experimental/Investigational definition — treatments without established effectiveness

DefinitionExperimental or investigational treatments are interventions for indications where effectiveness has not been established (for example, orthognathic surgery to correct temporomandibular joint [TMJ] disease).

Coverage implicationProcedures considered experimental/investigational are not covered under the policy.

ExampleCorrection of TMJ disease by orthognathic surgery is considered experimental/investigational and not covered.