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Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (CPB 0082, reviewed 2026-03-18)
Aetna·Oral & Maxillofacial Surgery, Pediatrics, General Surgery +1 more·Surgery
Effective date
Mar 18, 2026
We identified it
Aug 14, 2026
Summary
Aetna updated CPB 0082 (reviewed 2026-03-18) clarifying coverage criteria for dental services and oral and maxillofacial surgery under medical plans. Key updates include: pediatric orthodontics are covered only for severe handicapping malocclusions related to specific medical conditions (cleft palate, trauma, skeletal anomalies) with Modified Salzmann Index ≥42 points and physician documentation; bone grafting at extraction sites is generally not covered except for impacted third molars in patients ≥26 years; and dental services integral to medical procedures (e.g., tooth extraction prior to head/neck radiation, ridge reconstruction post-osteonecrosis) require prior authorization from Aetna's OMS Unit. Routine dental care remains excluded from medical coverage.
Action Required
By March 18, 2026: (1) Billing team must update prior authorization requirements in billing system: require OMS Unit pre-authorization for all dental services integral to covered medical procedures (tooth extraction pre-radiation, ridge reconstruction, tumor removal dental work). (2) Coding staff must add documentation checklist for pediatric orthodontics claims—require Modified Salzmann Index assessment (≥42 points), completed Salzmann form, and written physician report to support medical necessity before claim submission; reject claims without these documents. (3) Update denial protocols: flag all claims for bone grafting at extraction sites as non-covered unless patient is ≥26 years AND extraction is for impacted third molar with clinically significant bony defects; require documentation of patient age and clinical indication. (4) Providers and front office staff must update intake/referral forms to clarify that routine dental services (fillings, crowns, root canals, prophylaxis) are NOT covered under medical plans and should be billed to dental insurance. (5) OMS practices specifically must establish pre-authorization submission process with Aetna for all 'dental-in-nature' OMS services. Failure to obtain required prior authorization will result in claim denials.