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Dental Trauma Guidelines for Medical Plans

Last Review Date: April 10, 2026 
Number: MG.MM.ME.74C7

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Dental trauma due to an accident For the purposes of this policy, dental trauma due to an accident must be from a substantial external force and cause need to repair teeth where the need for the repair was not previously present.
Sound natural teeth Teeth that are stable, functional, free from decay, free from advanced periodontal disease and in good repair at the time of the accident.
A tooth is considered natural if it has a root that consists of dentin and cementum.  Pontics or prosthetic replacements for teeth are not considered natural teeth.  Dental implants are not considered natural teeth. A tooth is not considered sound if:
 It has active caries or other pathology, and accident requires restoration or treatment that would have otherwise been necessary  It has more than 50% bone loss
 It has pocket depths of greater than or equal to 6 mm.  It has untreated moderate to advanced periodontal disease
 It has Class II mobility or greater and/or furcal involvement

Related Medical Guidelines Dental Care or Treatment Necessary Due to Congenital Disease Orthognathic Surgery

General Statement Regarding Coverage Dental services are generally not covered under medical insurance. There are several exceptions including trauma, congenital anomalies, and orthognathic surgery.

Guideline Care or treatment due to accidental injury to sound natural teeth within 12 months of the accident are covered. This guideline is restricted to coverage of teeth. Coverage of other oral structures are guided by appropriate medical policy. Payment for dental services under this guideline can be approved when the medical documentation meets the defined standard for accident, sound teeth, and time elapsed since the injury.
Treatment  Replacement of teeth is covered only when repair is not possible.  While only the traumatized area will be considered for a restorative benefit, the restoration of the traumatized area shall be viewed in the context of patients overall oral condition.
 Dental implants and implant surgery, including preparation of alveolar process for the insertion of the dental implant will only be considered as replacements for teeth that at the time of dental trauma meet all of the following criteria: o Where the traumatized teeth were sound natural teeth as defined in this policy. o Where a traditional tooth supported fixed partial denture is not a reasonable alternative to an implant such as:  When the adjacent abutment teeth have minimal or no existing restorations.  When the adjacent abutment teeth do not otherwise require crowns, and are not already crowned (either singly or as part of a fixed bridge). o Where the patient does not already have a denture to which the lost teeth can be added. o Where the replacement of the implant is medically appropriate given the age, growth and development of the patient.
Treatment rendered within 12 months EmblemHealth will only cover treatment rendered within twelve (12) months of the date of an accident.  In all cases, once treatment is successfully completed EmblemHealth will not be responsible for the maintenance or replacement of future implant fixtures, implant abutments, dentures, partial dentures, crowns over implant or any other dental treatment performed as a result of the trauma.  Emblemhealth will not cover any treatment or diagnostic procedures that are required as a result of an accident (whether previously diagnosed or not) if it occurs beyond 12 months from the date of the accident.
 Pre-authorization for treatment that extend beyond the 12 month period will be honored in accordance with EmblemHealth medical policy guidelines.
Required documentation  Copy of Accident Report.  Copy of latest pre-accident dental x-rays.  Pre-operative x-rays taken after trauma.  If implant is placed x rays demonstrating implant placement are required.

Limitations/Exclusions  Work related injuries as well as Injuries incurred from auto accidents are not covered under these guidelines.
 Coverage is limited only to teeth directly impacted by trauma from an external force.  Trauma due to chronic habits or other chronic conditions are not covered.
 Damage to teeth due to mastication or biting on hard substances are not covered.  Treatment for prior existing conditions that would have already been needed or medically necessary in the absence of the accidental trauma will not be covered.
 Dental implants are not indicated until there is appropriate alveolar growth and will not be covered in age-inappropriate cases or in clinical circumstances where there is not a reasonable chance of success.
 Temporary restorations are inclusive in the fee for the final restoration.