Miscellaneous Section, TRG Dental Policy

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Miscellaneous Section - Administrative Guidelines to Determine Dental vs Medical Services

Topic: Administrative Guidelines to Determine Dental vs Medical Services	Last Reviewed Date: 01/2004
Section: Miscellaneous	Policy No: 64
Revised/Effective Date: 02/01/2008	Next Review Date: 01/2009

IMPORTANT INFORMATION
This Dental Policy has been developed through consideration of generally accepted standards of dental practice, review of dental literature, dental necessity, and as appropriate, government approval.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of dental policy is to provide a guide to coverage. Dental policy is not intended to dictate to providers how to practice dentistry. Providers are expected to exercise their clinical judgment in providing the most appropriate care.

Description

The purpose of the Dental versus Medical Services procedure is to establish consistent practices for reimbursement determinations for these services.

Definition of Dental versus Medical Services:

The condition that is being diagnosed and treated determines whether a service is dental or medical. Regardless of whether the service is provided by a dentist or a medical doctor, the condition, not the specialty of the provider, will determine if the service will be covered under the dental benefits or the medical benefits. If the condition being diagnosed and treated is one which is contiguous to or localized to the teeth and/or gums is of dental origin, or is to restore function of the teeth, the services are considered dental and applied to the dental benefits. If the condition being diagnosed and treated is one which is non-contiguous to the teeth and/or gums or is systemic, the services are considered medical and applied to the medical benefits.

Dental services include but are not limited to:
A.	Dental implant removals billed under the diagnosis of foreign body with infection are considered dental, as the implants and the source of the infection are dental related.
B.	Pathology studies done for tooth related conditions are considered dental and should not be applied to the medical benefits unless systemic disease is identified on the pathology report. This includes hard tissue biopsies for such conditions as apical cysts and odontogenic cysts. **Note: Reimbursement is based on the final pathology results, not on the remove intent and use differential diagnosis "intent" at the time the services are rendered.
	Biopsies with extractions being billed under cellulitis are considered dental, as extractions are tooth related and the cellulitis is localized to the gum.
	**Note: The facility charge and the physician ER professional charges will be covered by the medical benefit. However, the follow-up dental charges will be covered under the dental benefit, if such a benefit is available.
Medical services include but are not limited to:
A.	A blocked salivary gland billed by a dentist. The salivary gland is non-contiguous to teeth and therefore, considered medical.
B.	Cleft palate obturator devices made by a dentist to allow for proper swallowing are considered medical.
C.	Closure of a cleft palate defect is considered medical.
D.	Tongue Retaining Device (TRD)/sleep apnea appliance, when it meets the established medical necessity guidelines. This is medical in nature as sleep apnea appliances treat a medical condition. This device, however, can only be provided by a dentist.
E.	Soft tissue biopsies except for gum tissues are medical. Medical biopsies include the areas of the tongue, cheeks, lips and floor of the mouth
F.	A visit to a hospital emergency room for a serious condition that is tooth related, such as an acute abscess that results in an extraction will be covered by the medical benefit.
General anesthesia and/or inpatient/outpatient hospitalization associated with dental treatment:
A.		General anesthesia services and related facility charges provided in conjunction with any dental procedure that is performed in a hospital, medical office, or in an ambulatory surgery center are eligible for coverage under the medical benefit of a group health policy if medically necessary because the covered person:
		1.	is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or
		2.	has a medical condition that the person's physician determines would place him/her at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the covered person's physician.
B.		General anesthesia services provided in a dental office in conjunction with any covered dental procedure are eligible for coverage under the medical benefit of a group health or group dental policy if medically necessary because the covered person is:
		1.	under the age of seven, or
		2.	is physically or developmentally disabled.
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, such as (including, but not limited to) hemophilia, or malignant hyperthermia which makes dental treatment in an office setting contraindicated and medical necessity exists for hospitalization and/or general anesthesia.
D.		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 shall have appropriate state certification to perform general anesthesia.
E.		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 performing the procedure.
F.		The dental procedure may be performed by a dentist or other appropriate provider.

Policy/Criteria

Procedure is in accordance with generally accepted standards of dental practice.

Administrative Guidelines

Standard dental treatment will be covered under the dental benefit.
Anesthesia administered by a physician and any hospital or ambulatory surgery setting charges will be covered under the medical benefit when above listed criteria are met.
If the patient has medical coverage only, medical benefits for anesthesia and hospital or ambulatory surgery setting charges will be allowed when medical necessity is demonstrated, as per above criteria
Determinations regarding the medical necessity of hospitalization for dental treatment will be made by the Medical Department, with consultation with the Dental Department as needed.
Pre-Transplant Treatment:
- Dental benefit coverage:
  - Prophylactic work-up (i.e., exam, x-rays)
  - Prophylactic extractions of teeth, which are necessary due to dental caries or periodontal infection, are to be paid as dental. Extractions of healthy teeth because of a direct link with chemotherapy or radiation are to be paid medical
  - Pre chemotherapy dentition history may be necessary on a case by case basis
- Medical benefit coverage:
  - documentation of a direct link between destroyed bone, gums and chemotherapy or radiation—when the teeth were in reasonable condition prior to the initiation of the treatment(s)
Leukoplakia or pigmented tissue, when confirmed on pathology as malignant, can be allowed under the medical benefit.

Codes	Number	Description
CDT		See above

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