Great news! Your patient’s medical insurance may cover Cone Beam Computed Tomography (CBCT). This information is especially intriguing for dental practices since many dental insurance companies do not offer CBCT reimbursement. Which brings us to the questions: how, why, and when will a patient’s medical plan cover CBCT?
Medical insurance plans often reimburse for a panorex view for various reasons, with no preauthorization. It is common to bill medical insurance for a panorex view when providing medically necessary care. If you would like to bill the CBCT as a higher-level CT scan, the codes are typically considered advanced imaging and may require a preauthorization for coverage.
In the dental practice, the CBCT preauthorization request typically requires information to establish why the CBCT is medically necessary in place of “lesser x-rays” such as a panoramic x-ray. So, suppose you wish to use advanced imaging codes. In that case, once the dentist determines why the CBCT is medically necessary, the practice can submit the preauthorization request.
First things first: the best starting point is to have the correct medical diagnosis and procedure codes for the preauthorization request or the medical claim. ICD-10 diagnosis codes define “why” the CBCT is needed. Keep in mind that diagnosis codes are not limited to diseases only. Diagnosis codes also represent conditions such as loss of function, symptoms (i.e., jaw pain), injuries (i.e., fractured teeth due to trauma), and abnormal findings.
A great example of when more advanced imaging is covered is United Healthcare’s (UHC) medical coverage policy. The example below covers radiology guidelines and describes CBCT as “An alternative to traditional CT imaging is in-office cone beam testing and possible decreased radiation dosage.” This policy by UHC includes a list of indications in which CBCT may be considered medically necessary:
Cone beam CT may be authorized for surgical planning when plain x-rays alone are insufficient. Potential indications include but are not limited to:
- Impacted teeth
- Supernumerary teeth
- Dentoalveolar trauma
- Root resorption
- Foreign body
- Odontogenic cysts, tumors, or other jaw pathology
- Cleft pathology
- Orthognathic surgery for dentofacial anomalies
- Osteomyelitis and odontogenic infections (X-ray not required)
- Bisphosphonate-related osteonecrosis of the jaw
- Salivary gland stones
- Maxillofacial bone graft planning
- Dental implants related to tooth loss from injury, trauma, or jaw pathology such as cysts, tumors, or cancer
Pro tip: be sure you are utilizing a system to make it easy for your dental practice team to identify and document these signs, symptoms, injuries, and diseases. Documentation will make or break your case for coverage of your CBCT!
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Article by: Rose Nierman and Courtney Snow