This notification was originally posted Sept.11, 2024. Please note clarification to information on Codes (D4381 and D4910).
EmblemHealth is committed to maintaining the highest level of quality in our dental plan(s) and compliance with state and federal regulations. We also strive to improve member and provider experience. To support our participating dentists and help ensure our dental plans continue to cover appropriate, affordable care, EmblemHealth commercial dental plans has made the following changes on Dec. 6, 2024.
Frequency Changes/Limitations
- The frequency of exposure of an unerupted tooth (D7280) will add a frequency limitation of once per lifetime, from having no frequency limit.
- The frequency of vestibuloplasty (D7340-D7350) will add a frequency limitation of once per lifetime, from having no frequency limit.
- The frequency of prefabricated abutment (D6056) and custom fabricated abutment (D6057) will add a frequency limitation of once every 60 months, from having no frequency limit.
- Limited oral evaluation problem focused (D0140) if billed with any other service besides x-rays on the same date of service, D0140 will be denied as “Inclusive to the Other Service" with no patient liability. The other services are paid. X-rays and other services are only paid when they are a covered service and frequency limitations have not been met for that service.
- Retreatment of previous root canal therapy (D3346, D3347, or D3348) if billed within 24 months of initial root canal therapy by the same provider, codes D3346, D3347, or D3348 are denied as "Inclusive to the root canal therapy" without patient liability.
Non-Covered Services
- Closed reduction of a mandibular dislocation (D7820) is only covered if patient presents to office with a mandibular dislocation. This service is not covered if dislocation occurs during dental treatment. Presentation of dislocation twice in a year is suggestive of a medical issue.
- Pulp vitality test (D0460) is inclusive with all examinations and procedure codes without patient liability. D0460 will no longer deny as non-covered, but no separate allowance is payable.
- EmblemHealth considers the laser-assisted new attachment procedure (LANAP®) to be an adjunctive service and not a required procedure to complete periodontal procedures.
- Dentists must have the patient sign an informed consent and payment agreement prior to LANAP treatment. Since it is an additional service, patients may be charged for LANAP above and beyond what EmblemHealth pays for D4341/D4342.
- EmblemHealth will pay contracted benefit for D4341/D4342 if LANAP is utilized.
- EmblemHealth will not pay any other code when LANAP is utilized.
- EmblemHealth does not consider it appropriate to bill any other codes when LANAP is utilized.
Reminders
Services Requiring History of Other Codes Prior to Allowing Service
- Localized delivery of antimicrobial agents (D4381) requires a history within 36 months of the initial periodontal therapy. The periodontal therapy includes codes: D4341, D4342, D4910.
- Periodontal maintenance (D4910) requires a history of periodontal therapy, which includes codes: D4260, D4261, D4341, and D4342. Periodontal maintenance is allowed 90 days after the periodontal therapy has been performed, and will be covered once every six months. D4910 can be alternated with D1110, which is covered twice per calendar year, allowing periodontal patients to be covered for four cleanings per year.
Services Not Allowed with History of Other Services
- Alveoloplasty (D7321) is not covered for post-prosthetic implant placement or uncovering the implant. D6010 includes implant placement, uncovering implant, and all pre-prosthetic and post-prosthetic implant surgical procedures.
- Deep sedation general anesthesia (D9222-D9223) is not covered on the same date of service as D9239-D9243.
- IV moderate sedation (D9239-D9243) is not covered on the same date of service as D9222-D9223.
JP65396 09/2024
Updated JP68205 01/2024