Akamai Advantage Plans Coverage for Dental Services Inextricably Linked to Covered Medical Services

Original Medicare considers dental services as medical coverage exclusions, except for inpatient hospital services related to dental services when the patient requires hospitalization because of below:

• The patient’s underlying medical condition and clinical status
• The severity of the dental procedure

Most HMSA Akamai Advantage plans cover routine dental services as a supplemental benefit. Refer to member’s Explanation of Coverage for more information.

Effective 1/1/2023, Akamai Advantage plans may cover, under medical, dental services that are “inextricably linked” and substantially related and integral to the clinical success of, a certain covered primary medical service.

Inextricably Linked Definition

For a dental service to be considered “inextricably linked” to a covered primary medical procedure or service:

• Evidence-based literature and/or clinical standard of care must be demonstrated such that the provision of these dental services prior to or contemporaneously with a covered primary medical procedure or service if not performed would result in a material difference in terms of clinical outcomes and success of the medical procedure or service.
• Care coordination (e.g. between the doctor and the dentist) must have occurred with documentation to support (e.g. referral or exchange of information).

Claim Submission Requirements

• Provider must be a Medicare-enrolled provider
• Submit Part A or Part B services using the institutional (837I) or professional (837P) claim forms
  • With valid CDT or CPT/HCPCS codes billed
  • With valid ICD-10 diagnosis code billed

Medical Necessity Requirements

• Physician claims must be billed with modifier KX to indicate below:

  • a service or item is medically necessary
  • The provider has appropriate documentation in the medical record to support or justify medical necessity

Non-covered services must be billed with modifier GY.

• An Item or service is statutorily excluded and does not meet the definition of any Medicare benefit

References

• Medicare Dental Coverage article
• Noridian Dental article

Revision History