 Dental vs Medical Policy CriteriaJune 07, 2016
To help the understanding of what is covered under Dental and what may be covered under Medical, review Regence's coverage criteria:
Coverage under medical or dental benefits is determined by the condition that is being diagnosed and treated, regardless of whether the service is provided by a dentist or a medical doctor.
MEDICAL POLICY CRITERIA
Note: Member contracts for covered services vary. Member contract language takes precedent over medical policy.
I. Dental Services
Services are covered under dental benefits when the condition being diagnosed and treated is contiguous or localized to the teeth and/or gums or when services are intended to restore lost function of the teeth.
Examples of dental services include but are not limited to:
A. Dental implant removal due to infection caused by the implant
B. Pathology studies for tooth-related conditions, such as apical cysts and odontogenic cysts. Note: Final determination of benefits (dental versus medical) is based on final pathology results.
C. Biopsies with extractions for cellulitis localized to the gums 2 – AH35
D. Pre-transplant evaluation and treatment related to: 1. Prophylactic work-up (i.e., exam, x-rays)
2. Prophylactic extractions of teeth which are necessary due to dental caries or periodontal infection
3. Treatment of caries due to xerostomia (dry mouth) caused by radiation or chemotherapy treatment
4. Pre-chemotherapy dentition history
II. Medical Services
Services are considered medical if the condition being diagnosed and treated is one which is noncontiguous to the teeth and/or gums or is systemic.
Examples of medical services include but are not limited to:
A. Treatment of a blocked salivary gland billed by a dentist
B. Cleft palate obturator devices made by a dentist to allow for proper swallowing
C. Closure of a cleft palate defect D. Construction and management of a Tongue Retaining Device (TRD)/sleep apnea appliance, when provided by a dentist as a treatment of documented obstructive sleep apnea
E. Soft tissue biopsies (tongue, cheeks, lips and floor of the mouth) except for gum tissues
F. Hospital emergency room treatment for a serious condition that is related to the teeth, gums or contiguous structures, such as an acute abscess that results in an extraction.
Note: Facility and professional physician ER charges are covered by medical benefits; however, follow-up services related to dental treatment are covered under dental benefits, if available.
G. Pre-transplant treatment and evaluation related to: Conditions where there is documentation of a direct link between destroyed bone or gums and chemotherapy or radiation and when there is documentation that the teeth were in reasonable condition prior to the initiation of the treatment(s); or
H. Treatment of leukoplakia or pigmented tissue, when confirmed on pathology as malignant III. General Anesthesia and Hospitalization Associated with Dental Procedures Note: Member contracts for covered services vary. Member contract language takes precedent over medical policy.
A. General anesthesia services and related facility charges provided in conjunction with any (i.e., covered or excluded) dental procedure that is performed in a hospital or
in an ambulatory surgery center are eligible for coverage under the medical benefit of a group health policy when one or more criteria below (1-3) are met:
1. The patient is under the age of seven, with a dental condition that cannot be safely and effectively treated in a dental office; or
2. The patient is physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office;or
3. The patient has a medical condition that the physician determines would place him/her at undue risk if the dental procedure is performed in a dental office. The procedure must be approved by the patient's physician. Reimbursement Note: If anesthesia is processed under the medical benefit, it is subject to anesthesia guidelines and must be performed by an independent anesthetist/anesthesiologist. Anesthesia will not be reimbursed to the physician or dentist performing the procedure. The dental procedure may be performed by a dentist or other appropriate provider.
B. General anesthesia services provided in a dental office in conjunction with any covered dental procedure are eligible for coverage under the dental benefit of a group dental plan if medically necessary when either criteria 1 or 2 below is met:
1. The patient is under the age of seven; or
2. The patient is physically or developmentally disabled.
Reimbursement Note: When anesthesia services are provided by a dentist, or under the direct supervision of a dentist, the anesthesia services as well as the dental procedure are eligible for dental coverage if applicable. The dentist must have appropriate state certification to perform general anesthesia.
C. Hospitalization with or without general anesthesia for non-preventive necessary dental treatment is eligible for coverage under the medical benefit when a patient has an existing medical condition for which dental treatment in an office setting is contraindicated and medical necessity exists for hospitalization and/or general anesthesia.
Examples of such medical conditions include but are not limited to hemophilia or malignant hyperthermia.
POLICY GUIDELINES
It is critical that the list of information below is submitted for review to determine if the policy criteria are met. If any of these items are not submitted, it could impact our review and decision outcome. • History and physical indicating if the condition is localized to the teeth and/or gums or contiguous structures. Or, indicate if non-contiguous to the teeth/gums or is systematic. Specify in detail. Indicate place of service (e.g., office, ER) and contributing factors such as cancer treatment or radiation etc. • If general Anesthesia is being used, indicate in the chart notes if the member is physically or developmentally disabled and has a documented dental condition that is not safe to treat in the dental office. Or the member has a documented condition that will place him/her at undo risk if in the dental office.
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