QUEST Integration – Dental Procedures Covered Under QUEST Medical Plan

Original Effective Date:

09/01/1997

Current Effective Date:

01/01/2015

Services determined by the medical plan to be medically necessary, such as general anesthesia, hospital or surgicenter services, prescription drugs, etc. are covered under the medical plan. Services normally provided by a general dentist are covered by the dental plan when provided in a medical facility. The facility must be precertified by the dental benefits third party administrator (Hawaii Dental Services) for the Medicaid fee-for-service and QUEST Integration populations. A referral to the medical facility must also be registered with HMSA's QUEST Integration plan so that claims may be processed for payment.

The dental procedures listed below are primarily medical in nature and will be covered under the QUEST Integration medical plan when performed by an oral surgeon or physician. These services must be billed using the applicable CPT procedure code on the CMS 1500 claim form. Dental claim forms and CDT-2 dental procedure codes are not acceptable for processing under the QUEST Integration medical plan.

Vestibuloplasty

• Vestibuloplasty – ridge extension
• Vestibuloplasty – ridge extension, including soft tissue grafts, muscle reattachments, revision of soft tissue attachment, and management of hypertrophied and hyperplastic tissue

Excision of Tumors

• Excision of malignant tumor – lesion diameter up to 1.25 cm
• Excision of malignant tumor – lesions diameter over 1.25 cm

Removal of Cysts and Neoplasms

• Removal of benign odontogenic cyst or tumor lesion diameter up to 1.25 cm
• Removal of benign odontogenic cyst or tumor lesion diameter over 1.25 cm
• Removal of benign non-odontogenic cyst or tumor lesion diameter up to 1.25 cm
• Removal of benign non-odontogenic cyst or tumor lesion diameter over 1.25 cm
• Destruction of lesions by physical methods: electrosurgery, chemotherapy, cryotherapy or laser

Excision of Bone Tissue

• Removal of lateral exostosis – mandible or maxilla
• Removal of torus palatinus
• Removal of torus mandibularis
• Radical resection of mandible or maxilla

Surgical Incision

• Incision and drainage of abscess – intraoral soft tissue, complicated
• Incision and drainage of abscess – extraoral soft tissue
• Removal of foreign body, skin, or subcutaneous areolar tissue
• Removal of reaction-producing foreign bodies, musculoskeletal system
• Sequestrectomy for osteomyelitis
• Maxillary sinusotomy for removal of tooth fragment or foreign body

Treatment of Fractures – Simple

• Maxilla – open reduction (teeth immobilized if present)
• Maxilla – closed reduction (teeth immobilized if present)
• Mandible – open reduction (teeth immobilized if present)
• Mandible – closed reduction (teeth immobilized if present)
• Malar and/or zygomatic arch – open reduction
• Malar and/or zygomatic arch – closed reduction
• Alveolus – stabilization of teeth, open reduction, splinting
• Facial bones – complicated reduction with fixation and multiple surgical approaches

Treatment of Fractures – Compound

• Maxilla – open reduction
• Maxilla – closed reduction
• Mandible – open reduction
• Mandible – closed reduction
• Malar and/or zygomatic arch – open reduction
• Malar and/or zygomatic arch – closed reduction
• Alveolus – stabilization of teeth, open reduction, splinting
• Facial bones – complicated reduction with fixation and multiple surgical approaches

Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions:

• Open reduction of dislocation
• Closed reduction of dislocation
• Manipulation under anesthesia
• Condylectomy
• Surgical discectomy, with or without implant
• Disc repair
• Synovectomy
• Myotomy
• Joint reconstruction
• Arthrotomy
• Arthrocentesis
• Arthroscopy – diagnostic, with or without biopsy
• Arthroscopy – surgical lavage and lysis of adhesions
• Arthroscopy – surgical disc repositioning and stabilization
• Arthroscopy – surgical synovectomy
• Arthroscopy – surgical discectomy
• Arthroscopy – surgical debridement
• Occlusal orthotic device, by report

Other Oral Surgery – Repair of Traumatic Wounds

• Suture of recent small wounds up to 5 cm
• Complicated suture up to 5 cm
• Complicated suture over 5 cm
• Skin grafts (identify defect covered, location, and type of graft)

Other Repair Procedures

• Osteoplasty for orthognathic deformities
• Osteotomy – mandibular rami
• Osteotomy, mandibular rami with bone graft, including obtaining the graft
• Osteotomy, segmented or subapical, per sextant or quadrant
• Osteotomy, body of mandible
• Le Fort I (maxilla – total)
• Le Fort I (maxilla – segmented)
• Le Fort II or Le Fort III – (osteoplasty of facial bones for midface hypoplasia retrusion) without bone graft
• Le Fort II or Le Fort III – with bone graft
• Osseous, osteoperiosteal, periosteal, or cartilage graft of the mandible – autogenous or nonautogenous
• Repair of maxillofacial soft and hard tissue defects
• Sialolithotomy
• Excision of salivary gland, by report
• Sialodochoplasty
• Closure of salivary fistula
• Emergency tracheotomy
• Coronoidectomy
• Synthetic graft – mandible or facial bones, by report
• Implant – mandible for augmentation purposes (excluding alveolar ridge), by report
• Appliance removal (not by dentist who placed appliance), includes removal of archbar
• Unspecified oral surgery procedure, by report

Adjunctive General Services

• General anesthesia – first 30 minutes (limitation: nitrous oxide for unruly children or highly apprehensive adults; attach report or a note)
• General anesthesia – each additional 15 minutes
• Hospital calls (limitation: confinement must be approved; only under physician’s request, no routine or follow-up visits)

Revision History