ARCHIVED

Medical Policy

Policy Num:      13.007.001
Policy Name:     Maxillofacial Prosthesis
Policy ID:          [13.007.001]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:       October 24, 2024
Next Review:       Policy Archived
 

Related Policies: None

Maxillofacial Prosthesis

Summary

These are specialized and extensive prosthesis services to replace the loss of a great part of the facial and oral tissue caused by, disease, trauma, surgery, radiation and birth defects.

Objective

To improve the quality of life of the patient with maxilofacial defects by using prosthesis services caused by and not limited to; congenital malformations, trauma or oral neoplasms.

Policy Statements

The maxillofacial prosthesis services require predetermination.

1. The maxillofacial prosthesis services require predetermination.

2. Procedure codes D5982 and D5986 are considered for payment one per arch every 5 years. All other codes are considered for payment to 1 service every 5 years. Check benefits and coinsurance in the Coverage Table.

3. Codes D5951 and D5952 are considered for payment until 14 years of age.

4. Code D5953 is considered for payment from 14 years of age and older.

Policy Guidelines

1-    All Maxillofacial Prosthetics services require predetermination.

2-    The benefit of the Surgical Stent and the radiation carrier is considered for payment one per arch every 5 years. All the other codes are considered for payment one (1) every 5 years.

3-    Feeding aid and speech aid prosthesis (pediatric), are considered for payment until, 14 years of age.

4-    Speech aid prosthesis (adult) is considered for payment from 14 years and older.

Benefit Application

BlueCard/National Account Issues - N/A

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Definition of interest;

Cleft lip

       A congenital deformity where there is non-union or inadequacy of soft and / or hard tissue. It may be unilateral or bilateral.

Cleft palate

      Congenital fissure of the roof of the mouth produced by failure of the two maxillae to unite during embryonic development and often associated with cleft lip.

Malignant neoplasm

      Cancerous tumor or abnormal growth of cells.

Surgical stent

      Is and appliance used for implant placement and during surgical procedures to locate optimal implant placement site.

Radiation shield

      Is an accessory that serve to decrease the amount of radio frequency (RF) energy in radiation therapy.

Regulatory Status

N/A

Rationale

    Appliance to aid patients with different medical conditions.

    Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American];LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflectiveof and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g.,women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population Reference No. 1 

Individuals: With Infant cleft palate. Intervention of interest: Feeding aid Prosthesis. Comparators of interest: Surgical intervention. Relevant outcomes include: Enhance sucking and swallowing.

Population Reference No. 2 

Individuals: With Cleft palate. Intervention of interest: Speech aid Prosthesis (pediatric and adult). Comparators of interest: Surgical intervention. Relevant outcomes include: Improve speech.

Population Reference No. 3 

Individuals: With Surgery involving soft tissue. Intervention of interest: Surgical Stent. Comparators of interest: Cicatrization without surgical stent. Relevant outcomes include: Utilized to apply pressure to soft tissue to facilitate healing and prevent cicatrization or collapse.

Population Reference No. 4 

Individuals: With Radiation Therapy. Intervention of interest: Radiation carrier. Comparators of interest: Radiation therapy without radiation carrier. Relevant outcomes include:To hold the radiation source securely in the same location during the entire period of treatment.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Participating Prosthodontist Manual 2024. Maxillofacial Prosthesis Rules and Limitations.

2. Participating Oral and Maxillofacial Surgeon Manual 2024. Maxillofacial Prosthesis Rules and Limitations.

Codes

Appplicable Modifiers

N/A

Policy History