Medical Policy
Medical Policy
Policy Num: 13.009.002
Policy Name: Oral Surgical Splint, Impression and Preparation
Policy ID: [13.009.002] [Ar / L / M+ / P+] [0.00.00]
Last Review: November 11, 2020
Next Review: Policy Archived
Issue: 11:2020
ARCHIVED
Related Policies BCBS: None
Related Policies TSSS: None
| Population Reference No. | Populations | Interventions | Comparators | Outcomes |
| 1 | Individual: · With needs of orthognathic Surgery | Intervention of interest is: · Oral Surgical Splint, impression and preparation | Comparators of interest: · Surgical intervention without surgical splint | Relevant outcomes include: · Used to Stabilize structures · Guide for replacement of the mandibular and maxillary segment |
The oral splints are molds manufactured by the Oral and Maxillofacial Surgeon prior to surgery. These molds are used as a guide for the replacement of the mandibular and maxillary segments (after these have been segmented). The splint can also be used to stabilize the segments after surgery.
The splint is as a template during surgery and to stabilize structure following surgery
This service is considered as surgical guidance and stabilization for orthognathic surgery (surgical splint).
For orthognathic surgery only when physician or other qualified health care professional design and prepare the surgical splint.
· Can be design for maxillary and mandibular bilateral orthognathic surgery.
· Are used as a guide for orthognathic surgery.
· Can be used to stabilize structure after orthognathic surgery.
BlueCard/National Account Issues
N/A
Definition of interest
Surgical splint
Is an impression is made of the area and the physician customized the splint from the cast model of the impression. The splint maybe used in orthognathic reconstruction jaw surgery.
N/A
Needed for guidance in orthognathic surgery for repositioning of jaws and stabilization.
Population Reference No. 1
Individual: With needs of orthognathic surgery. Intervention of interest is: Oral Surgical Splint, impression and preparation. Comparators of interest: Surgical intervention without surgical splint. Relevant outcomes include: Used to stabilize structures, guide for replacement of the mandibular and maxillary segment.
| Population Reference No. 1 Policy Statement | [X] MedicallyNecessary | [ ] Investigational | [ ] Not Medically Necessary |
N/A
N/A
N/A
1. Coding Companion for Plastics, OMS and Dermatology, 2019.
2. CPT - 2019, Surgical/Musculoskeletal System.
3. LeResche L. Epidemiology of temporomandibular disorders: implications for the investigation of etiologic factors. Crit Rev Oral Biol Med 1997; 8:291.
4. Auerbach SM, Laskin DM, Frantsve LM, Orr T. Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients. J Oral Maxillofac Surg 2001; 59:628.
5. Campbell LC, Riley JL 3rd, Kashikar-Zuck S, et al. Somatic, affective, and pain characteristics of chronic TMD patients with sexual versus physical abuse histories. J Orofac Pain 2000; 14:112.
6. Ferrando M, Andreu Y, Galdón MJ, et al. Psychological variables and temporomandibular disorders: distress, coping, and personality. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98:153.
7. Parameter of Care AAOMS Clinical Practice Guidelines for Oral and Maxillofacial Surgery Sixth Edition 2017
| Codes | Number | Description |
| CDT | 21085 | Impression and custom preparation; oral surgical splint |
| ICD-10 CM | M26.00 | Unspecified anomaly of jaw size |
| | M26.01 | Maxillary hyperplasia |
| | M26.02 | Maxillary hypoplasia |
| | M26.03 | Mandibular hyperplasia |
| | M26.04 | Mandibular hypoplasia |
| | M26.05 | Macrogenia |
| | M26.06 | Microgenia |
| | M26.07 | Excessive tuberosity of jaw |
| | M26.09 | Other specified anomalies of jaw size |
| | M26.10 | Unspecified anomaly of jaw-cranial base relationship |
| | M26.11 | Maxillary asymmetry |
| | M26.12 | Other jaw asymmetry |
| | M26.19 | Other specified anomalies of jaw-cranial base relationship |
| | M26.20 | Unspecified anomaly of dental arch relationship |
| | M26.211 | Malocclusion, Angle's class I |
| | M26.212 | Malocclusion, Angle's class II |
| | M26.213 | Malocclusion, Angle's class III |
| | M26.220 | Open anterior occlusal relationship |
| | M26.221 | Open posterior occlusal relationship |
| | M26.23 | Excessive horizontal overlap |
| | M26.24 | Reverse articulation |
| | M26.25 | Anomalies of interarch distance |
| | M26.29 | Other anomalies of dental arch relationship |
| | M26.33 | Horizontal displacement of fully erupted tooth or teeth |
| | M26.34 | Vertical displacement of fully erupted tooth or teeth |
| | M26.36 | Insufficient interocclusal distance of fully erupted teeth (ridge) |
| | M26.37 | Excessive interocclusal distance of fully erupted teeth |
| | M26.39 | Other anomalies of tooth position of fully erupted tooth or teeth |
| | M26.4 | Malocclusion, unspecified |
| | M26.50 | Dentofacial functional abnormalities, unspecified |
| | M26.51 | Abnormal jaw closure |
| | M26.52 | Limited mandibular range of motion |
| | M26.53 | Deviation in opening and closing of the mandible |
| | M26.54 | Insufficient anterior guidance |
| | M26.55 | Centric occlusion maximum intercuspation discrepancy |
| | M26.56 | Non-working side interference |
| | M26.57 | Lack of posterior occlusal support |
| | M26.59 | Other dentofacial functional abnormalities |
| | M26.69 | Other specified disorders of temporomandibular joint |
| | M26.70 | Unspecified alveolar anomaly |
| | M26.71 | Alveolar maxillary hyperplasia |
| | M26.72 | Alveolar mandibular hyperplasia |
| | M26.73 | Alveolar maxillary hypoplasia |
| | M26.74 | Alveolar mandibular hypoplasia |
| | M26.79 | Other specified alveolar anomalies |
| | M26.89 | Other dentofacial anomalies |
| | M26.9 | Dentofacial anomaly, unspecified |
| ICD-10 CM (Effective date 10/01/16) | M26.601 | Right temporomandibular joint disorder, unspecified |
| | M26.602 | Left temporomandibular joint disorder, unspecified |
| | M26.603 | Bilateral temporomandibular joint disorder, unspecified |
| | M26.611 | Adhesions and ankylosis of right temporomandibular joint |
| | M26.612 | Adhesions and ankylosis of left temporomandibular joint |
| | M26.613 | Adhesions and ankylosis of bilateral temporomandibular joint |
| | M26.621 | Arthralgia of right temporomandibular joint |
| | M26.622 | Arthralgia of left temporomandibular joint |
| | M26.623 | Arthralgia of bilateral temporomandibular joint |
| | M26.631 | Articular disc disorder of right temporomandibular joint |
| | M26.632 | Articular disc disorder of left temporomandibular joint |
| | M26.633 | Articular disc disorder of bilateral temporomandibular joint |
Text
| Date | Action | Description |
| 11/11/20 | Annual review Policy archived. | Reviewed by the Providers Advisory Committee. Archived policy. No changes on policy statement. |
| 11/14/19 | Annual review | Reviewed by the Providers Advisory Committee. No changes on policy statement. |
| 11/14/18 | Annual review | Reviewed by the Providers Advisory Committee. Included another reference number 17. |
| 09/05/17 | | Coding Companion for Plastics, OMS and Dermatology, 2017, CPT 2017 Surgical/Musculoskeletal System |
| 02/17/17 | | ICD-10 added |
| 11/28/16 | | |
| 09/20/16 | | ICD-10 added |
| 03/15/16 | | |
| 08/25/14 | | ICD-10 added |
| 07/16/13 | | ICD-10 added |
| 12/12/11 | | ICD-10 added |
| 01/26/09 | | (iCES |
| 02/21/08 | | |
| 07/21/04 | Created | New Policy |