Coverage Policies

1. Dental services provided for the routine care, treatment, or replacement of teeth or structures (e.g., root canals, fillings, crowns, bridges, dental prophylaxis, fluoride treatment, and extensive dental restoration) or structures directly supporting the teeth are generally excluded from coverage under QualChoice`s medical plans.
2. Dental services for other problems may be covered after pre-authorization.

3.    Members should refer to their plan documents for information regarding applicable terms and limitations of coverage.

1.     Treatment of Jaw and Contiguous Structures:

Some QualChoice medical plans provide coverage for some dental related services, and for certain "dental-in-nature" oral and maxillofacial surgery (OMS) services that are related to the jaw or facial bones. Reduction of any facial bone fracture is covered under all QualChoice medical plans, as well as the removal of tumors, treatment of dislocations, facial and oral wounds/lacerations, and removal of cysts or tumors of the jaws or facial bones, or other diseased tissues.

 

2.     Medical Services Provided by a Dentist:

Medically necessary medical services that could be performed by a physician (M.D. or D.O.) but are performed by a dentist are covered if performance of those services is within the scope of the dentist`s license, according to state law. These services may include, but are not limited to, the following:

1. Dental examinations to detect infection prior to certain surgical procedures;
2. Diagnostic x-rays in connection with services covered under the medical plan;

C.    Treatment of oral infections in connection with services covered under the medical plan.

3.     Removal of Impacted Teeth:

QualChoice plans usually exclude coverage of services related to the care, filling, removal, or replacement of impacted teeth. See BI207 Dental Impacted Teeth.

Note: In general, placement of bone grafts into extraction sites is considered not medically necessary.

4.     Repair of Cleft Palate:

Medical management of children with cleft palate may involve what might otherwise be considered dental care. The following policies apply to the correction of this congenital defect.

1. Alveolar ridge closure is covered under QualChoice medical plans as part of the cleft palate repair.
2. An appliance for palatal expansion in preparation for bone graft surgery of the alveolar cleft may be covered in the pre-surgical and post-surgical period for primary and mixed dentitions. Later orthodontic care, including full braces for the permanent dentition, is not covered.

C.    Orthognathic surgery is covered for these members if the functional impairment to be corrected results from the cleft palate and/or its treatment. For plans with precertification provisions, a proposed treatment plan must be submitted to QualChoice for review.

 

5.     Dental Services that are Integral to Medical Procedures:

A dental service that would otherwise be excluded from coverage under QualChoice`s medical plans may be a covered medical expense if the dental service is medically necessary and is incident to and an integral part of a service covered under the medical plan. Coverage requires prior authorization by QualChoice.

Examples of dental services that are integral to medical procedures include the following:

1. Extraction of teeth prior to radiation therapy of the head and neck. Note: Dental reconstruction for the replacement of extracted teeth is not covered by the medical plan.
2. Reconstruction of a dental ridge distorted as a result of removal of a tumor (including bone grafting and dental implants if necessary to stabilize a maxillofacial prosthesis such as an obturator).

C.    Removal of broken teeth necessary to reduce a jaw fracture.

In these examples, the dental or OMS service is either a part of the medical procedure or is done in conjunction with and made necessary solely because of the medical procedure and the dental or OMS service does not treat dental.

6.     Diagnostic Services:

Whether ancillary services and procedures, such as diagnostic x-rays, are covered under the medical plan depends upon whether the primary procedure is covered under the medical plan.

7.     Dental Services Not Integral to Medical Services:

Dental services and dental-in-nature OMS services do not become eligible for medical coverage merely by virtue of their being performed prior to a covered medical service for the treatment of systemic disease, even if the medical service makes the dental service medically necessary. Removal of teeth at risk of infection, periodontal therapies, and subsequent oral rehabilitation reconstruction (i.e., the replacement of teeth) are not covered under medical plans even where these services are medically necessary prior to major surgical procedures such as open heart surgery, organ transplantation, joint reconstructive surgery or other types of surgery.

8.     Dental Services Accompanying Reconstructive Surgery:

Dental services performed in conjunction with medically necessary reconstructive surgery (e.g., reconstructive surgery following ablative surgical procedures) are covered according to the guidelines below:

The following dental services are covered in conjunction with medically necessary reconstructive surgery:

1. Nasal, aural, orbital, and ocular prostheses;
2. Radiation stents;
3. Some medical plans include optional coverage for preventive or other dental services. The Preventive Dental Care Benefit (for members under 12 years of age) is a standard benefit in many QualChoice plans. In addition, some medical plans include a dental services rider. Refer to the individual plan documents for a description of covered services;
4. Surgical, intermediate, and permanent obturators;

E.    Surgical splints.

9.     Other coverage options:

QualChoice medical plans generally provide medical coverage for the following dental and oral and maxillofacial surgery services;

A.    Surgery needed:

1. To alter the jaw, jaw joints or bite relationships by a cutting procedure when non-surgical management (including appliance, medical, physical, and behavioral therapies) cannot result in functional improvement, not related to TMJ treatment, See BI231 TMJ.
2. To remove cysts, tumors or other diseased tissues;
3. To surgically remove teeth that will not erupt through the gum, teeth partly or completely impacted in the bone of the jaw, and teeth that cannot be removed without cutting into bone; charges for routine tooth removal not needing cutting of bone is specifically excluded under standard traditional plans;

4.     To treat a fracture, dislocation or wound.

1. Charges for repairing or replacing the first free standing crown or abutment for fixed bridge prostheses, but only when accidental injury requires re-preparation of the natural tooth. Note: Charges to remove, repair, replace, restore, or reposition teeth lost or damaged in the course of biting or chewing are not covered medical expenses. Sound natural teeth are defined as teeth that were stable, functional, and free from decay and advanced periodontal disease, and in good repair at the time of the accident.

1. Dental treatment needed to remove, repair, replace, restore, or reposition natural teeth damaged, lost, or removed due to an injury occurring while the person is covered under the medical plan. Standard traditional plans also cover dental work to restore, repair, remove, reposition, or replace other body tissues of the mouth fractured or cut. Any such teeth must be free from decay, in good repair and firmly attached to the jawbone at the time of injury. In general, most plans require restoration or replacement in the calendar year of the accident or the next calendar year. Coverage requires prior authorization. The cost of installing the first denture, crown, in-mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury is covered.
   Charges for repairing or replacing the first free standing crown or abutment for fixed bridge prostheses, but only when accidental injury requires re-preparation of the natural tooth.
   
   Note: Charges to remove, repair, replace, restore, or reposition teeth lost or damaged in the course of biting or chewing are not covered medical expenses.
   
   Sound natural teeth are defined as teeth that were stable, functional, and free from decay and advanced periodontal disease, and in good repair at the time of the accident.

1. Orthodontic therapy used in the first course of treatment to correct a malocclusion caused by accidental injury (this does not include benefits for full mouth orthodontic therapy).

E.    The cost of installing the first denture, crown, in-mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury.

10. General Anesthesia Accompanying OMS and Dental Services:

QualChoice medical plans cover the use of general anesthesia for OMS and dental services if the member meets the selection criteria (See BI104 Dental Anesthesia).

11. Bone Grafting of Extraction Sites:

In general, placement of bone grafts into extraction sites is considered not medically necessary. Exception can be made for bone grafting of impacted third molar extraction sites when bony defects are clinically significant and the patient is 26 years of age or older (American Association of Oral and Maxillofacial Surgeons, 2006).

Codes Used In This BI:

The following dental services are considered not covered under the medical plan regardless of whether they accompany medically necessary reconstructive surgery:

1. Dental implants (except as specified in the certificate of coverage). Most medical plans do not cover the routine replacement of teeth via surgical placement of a dental implant body. In addition, any procedures (e.g., bone replacement graft, sinus lift surgery, soft tissue graft, and barrier membrane placement) considered as adjunctive procedures to the surgical placement of the dental implant body are also not covered. For those medical plans that do cover routine replacement of teeth by dental implants, the only procedure covered by the medical plan related to the dental implant is the surgical placement of the dental implant body (replacement of the missing root). The restorative procedure (replacement of the missing crown) is considered a dental expense;

B.   Fluoride carrier.