Clinical Policy Bulletins

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Dental - Clinical Policy Bulletins

Diagnostic

• 017 - Adjunctive Prediagnostic Test
• 028 - Laser Fluorescence Caries Detection

Preventive

• 030 - Space Maintenance (Passive Appliances)
• 032 - Preventive Resin Restorations
• 033 - Space Maintenance in Primary Dentition – Loss of Primary Incisors

Endodontics

• 001 - Bone Graft Policy

Periodontics

• 001 - Bone Graft Policy
• 002 - Guided Tissue Regeneration
• 003 - Local Chemotherapeutic/Antimicrobial Agents
• 004 - Clinical Crown Lengthening
• 005 - Biologic Materials To Aid in Soft and Osseous Tissue Regeneration
• 007 - Soft Tissue Graft Procedures
• 008 - Full Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis
• 009 - Immediate Surgical Placement of Implant Body with Soft Tissue Grafting, Osseous Grafting and Guided Tissue Regeneration
• 012 - Osseous Surgery
• 013 - Bone Replacement Grafts for Periodontal Surgical Procedures

Implant Services

• 009 - Immediate Surgical Placement of Implant Body with Soft Tissue Grafting, Osseous Grafting and Guided Tissue Regeneration

Oral Surgery

• 001 - Bone Graft Policy
• 006 - Brush Biopsy -- Transepithelial Sample Collection
• 009 - Immediate Surgical Placement of Implant Body with Soft Tissue Grafting, Osseous Grafting and Guided Tissue Regeneration
• 010 - Alveoloplasty -- Surgical Preparation of Ridge in Preparation for a Prosthesis
• 011 - Frenulectomy (Frenectomy, Frenotomy) or Frenuloplasty
• 015 - Criteria for the Removal of Impacted Teeth
• 031 - Odontogenic Cysts

Orthodontics

• 014 - Tooth Positioners For Orthodontic Treatment (Invisalign®)

Adjunctive General Services

• 016 - Deep Sedation/General Anesthesia and I.V. Sedation for Oral and Maxillofacial Surgery and Dental Services
• 029 - Occlusal Adjustment

Medical in Nature

• 004 - Obstructive Sleep Apnea
• 028 - Temporomandibular Joint Syndrome (TMJ) and Temporomandibular Disorders (TMD)
• 082 - Dental Services and Oral and Maxillofacial Surgery: Coverage under Medical Plans
• 021 - Speech Therapy
• 022 - Electrical Stimulations (Salitron System) for Xerostomia
• 023 - Therabite Jaw Motion Rehabilitation System
• 024 - Speech Generating Devices
• 025 - Distraction Osteogenesis for Craniofacial Skeletal Deformities
• 026 - Facial Prostheses, External
• 027 - Intra-oral Appliances for Migraines