130 CMR, § 420.430

Current through Register 1536, December 6, 2024

Section 420.430 - Covered Service Descriptions and Limitations: Oral and Maxillofacial Surgery Services

(A)General Requirements.

(1) The MassHealth agency pays for oral and maxillofacial surgery services for all members, regardless of age, subject to the service descriptions and limitations as described in 130 CMR 420.430. Payment for oral and maxillofacial surgery includes payment for local anesthesia, suture removal, irrigations, bony spicule removal, apical curettage of associated cysts and granulomas, enucleation of associated follicles, and routine preoperative and postoperative care.

(2) The MassHealth agency pays for routine extractions provided in an office, hospital, or freestanding ambulatory surgery center. Use of a hospital or freestanding ambulatory surgery center for extractions is limited to those members whose health, because of a medical condition, would be at risk if these procedures were performed in the provider's office. Member apprehension alone is not sufficient justification for use of a hospital or freestanding ambulatory surgery center. Lack of facilities for the administration of general anesthesia when the procedure can be routinely performed with local anesthesia does not justify the use of a hospital or a freestanding ambulatory surgery center.

(B)Extraction. The MassHealth agency pays for extractions. An extraction can be either the removal of soft tissue-retained coronal remnants of a deciduous tooth or the removal of an erupted tooth or exposed root by elevation or forceps, or both, including routine removal of tooth structure, minor smoothing of socket bone, and closure. The removal of root tips whose main retention is soft tissue is considered a simple extraction. All simple extractions may be performed as necessary. The MassHealth agency pays for incision and drainage as a separate procedure from an extraction performed on a different tooth on the same day.

(C)Surgical Removal of Erupted Tooth. The MassHealth agency pays for the surgical removal of an erupted tooth. Surgical removal of an erupted tooth is the removal of any erupted tooth that includes the retraction of a mucoperiosteal flap and the removal of alveolar bone to aid in the extraction or the sectioning of a tooth. The provider must maintain clinical documentation demonstrating medical necessity and a preoperative radiograph of the erupted tooth in the member's dental record to substantiate the service performed.

(D)Surgical Removal of Impacted Teeth. The MassHealth agency pays for the surgical removal of an impacted tooth/teeth in a hospital or freestanding ambulatory surgery center, when medically necessary. Member apprehension alone is not sufficient justification for the use of a hospital or freestanding ambulatory surgery center. Lack of facilities for administering general anesthesia in the office setting when the procedure can be routinely performed with local anesthesia does not justify use of a hospital or freestanding ambulatory surgery center.

(1) Circumstances under which the MassHealth agency pays for surgical removal of impacted teeth include, but are not limited to:

(a) full bony impacted supernumerary teeth, mesiodens, or teeth unerupted because of lack of alveolar ridge length;

(b) teeth involving a cyst, tumor, or other neoplasm;

(c) unerupted teeth causing the resorption of roots of other teeth;

(d) partially erupted teeth that cause intermittent gingival inflammation; or

(e) perceptive radiologic pathology that fails to elicit symptoms.

(2) The provider must maintain a preoperative radiograph of the impacted tooth in the member's dental record to substantiate the service performed. The radiograph must clearly define the category of impaction.

(3) A root tip is not considered an impacted tooth.

(4) Surgical extraction of an erupted tooth is the removal of bone and/or sectioning of the tooth, and including elevation of mucoperiosteal flap if indicated.

(5) Surgical extraction with soft tissue is the removal of a tooth in which the occlusal surface of the tooth is covered by soft tissue requiring mucoperiosteal flap elevation for removal.

(6) Surgical extraction with partial bony impaction is the removal of a tooth in which part of the crown is covered by bone and requires mucoperiosteal flap elevation and bone removal.

(7) Surgical extraction with complete bony impaction is the removal of a tooth in which most or the entire crown is covered by bone and requires mucoperiosteal flap elevation and bone removal.

(8) The MassHealth agency pays for surgical exposure of impacted or unerupted teeth to aid eruption only for members younger than 21 years old for orthodontic reasons. MassHealth agency payment for surgical exposure includes reexposure due to tissue overgrowth or lack of orthodontic intervention.

(E)Alveoloplasty.

(1) The MassHealth agency pays for alveoloplasty procedures performed in conjunction with the extraction of teeth.

(2) MassHealth agency payment for a quadrant alveoloplasty (dentulous or edentulous) includes any additional alveoloplasty of the same quadrant performed within six months of initial alveoloplasty.

(F)Vestibuloplasty . The MassHealth agency pays for vestibuloplasty ridge extension.

(G)Frenulectomy. The MassHealth agency pays for frenulectomy procedures. Frenulectomies may be performed to excise the frenum when the tongue has limited mobility, to aid in the closure of diastemas, and as a preparation for prosthetic surgery. If the purpose of the frenulectomy is to release a tongue, a written statement by a physician or primary care clinician and a speech pathologist clearly stating the problem must be maintained in the member's dental record. The MassHealth agency does not pay for labial frenulectomies performed before the eruption of the permanent cuspids, unless there is documentation that the frenum attachment is interfering with proper infant feeding or orthodontic documentation that clearly justifies the medical necessity for the procedure. Such documentation must be maintained in the member's dental record.

(H)Excision of Hyperplastic Tissue. The MassHealth agency pays for excision of hyperplastic tissue by report. The MassHealth agency does not pay separately for the excision of hyperplastic tissue when performed in conjunction with an extraction. This procedure is generally reserved for the preprosthetic removal of such lesions as fibrous epuli or benign palatal hyperplasia.

(I)Excision of Benign Lesion. The MassHealth agency pays for excision of soft tissue lesions.

(J)Removal of Exostosis and Tori. The MassHealth agency pays for removal of exostosis and tori once per arch per member.

(K)Tooth Reimplantation and Stabilization of Accidentally Avulsed or Displaced Tooth. The MassHealth agency pays for tooth reimplantation and stabilization of an accidentally avulsed or displaced tooth. The procedure includes splinting and stabilization.

(L)Treatment of Complications (Postsurgical). The MassHealth agency pays for nonroutine postoperative follow-up in the office as an individual-consideration service only for unusual services and only to ensure the safety and comfort of a postsurgical member. This nonroutine postoperative visit may include drain removal or packing change. The provider must include a detailed report for individual consideration in conjunction with the claim form for postoperative visit. The report must at a minimum include the date, the location of the original surgery, and the type of procedure.