Prior authorization request form Form

Dental Care or Treatment Necessary Due to Congenital Disease

Last Review Date: April 10, 2026 
Number: MG.MM.ME.73aC

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 Congenital Disease1 A disease that is present at birth. It may be due to hereditary factors, prenatal infection, injury, or the effect of a drug the mother took during pregnancy

Related Medical Guidelines Dental Trauma Guidelines for Medical Plans Orthognathic Surgery General Statement Regarding Coverage Dental services are generally not covered under medical insurance. There are several exceptions including trauma, congenital diseases, and orthognathic surgery. Guideline To qualify for coverage for dental care due to congenital disease, all the following criteria must be met: I. The patient must have an underlying congenital disease
II. The dental care is necessary when an individual experiences or is reasonably expected to experience substantial and long-term deficits in the ability to eat or speak due to multiple missing or malformed teeth III. The dental care is appropriate for the condition

1 https://medical-dictionary.thefreedictionary.com/congenital+disease

I. Qualifying congenital diseases
The following non-inclusive list of congenital conditions may qualify for coverage: 2  Albright Osteodyastrophy  Amelogenesis Imperfecta  Branchio-Oto-Renal dysplasia (BOR0-EYA 1 gene mutation)  Caffey's Disorder  Cherubism-Abnormal Sh3BP2 gene  Cleft Lip/ Palate  Cleidocranial Dysplasia/Dysostosis  Crouzon Syndrome or Disease  Down's Syndrome (Trisomy 21)  Dentinogenesis Imperfecta  Edward's syndrome (Trisomy 13)
 Ectodermal dysplasia  Hemifacial microsomia  Hypophosphatasia  Hypopituitarism  Hypothyroidism  Incontinentia Pigmenti  Klinefelter's Syndrome (47, XXY)  Nevoid Basal Cell Carcinoma Syndrome- PITCH gene mutation  Patau Syndrome (Trisomy 18)  Pierre Robin Sequence  Smith-Lem Li Opitz Syndrome  Stickler syndrome  Treacher-Collins syndrome or Mandibulofacial Dysostosis  Turner Syndrome (45, X)-females  Velocardiofacial Syndrome Chromosome 22(22q11)  47, XXX  47 XXY

A reviewer may require:  Geneticist verification of underlying congenital condition  X-rays indicating that teeth are congenitally missing and not missing due to extraction  Additional supporting documentation including photos as needed  A comprehensive treatment plan

II. Definition of necessary dental care  EmblemHealth considers coverage under this policy necessary when an individual experiences or is reasonably expected to experience substantial and long-term deficits in the ability to eat or speak due to multiple missing or malformed teeth.

2 NYS Dental Journal June/July 2007

 Orthodontic cases will be considered necessary if they are the result of a congenital disease and meet the requirements of a severe physically handicapping malocclusion as defined by New York State Medicaid Program Dental Policy and Procedure Code Manual. 3

III. Dental care appropriate for the condition  In all cases EmblemHealth reserves the right to evaluate treatment options on a case- by-case basis and to substitute least costly alternatives.  Dental anomalies such as missing lateral incisors or bicuspid teeth, while reviewed on a case-by-case basis taking into account all presenting factors do not generally meet the criteria of “causing a reasonable expectation to experience substantial and long term deficits in the individuals ability to eat or speak” and will not be covered. Limitations/Exclusions

1. Temporary restorations are inclusive in the fee for all final restorations.
2. Dental implants will not be considered for coverage when: a. Abutment teeth (either abutment for a fixed bridge) have crowns or in the opinion of our consultants require crowns. b. Unless they are part of a clinically acceptable treatment plan. c. Replacing third molars. d. When replacing primary teeth

3. 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. Revision History Apr. 11, 2025 Removed “Anomaly” from title, definition, and content of policy

   3 https://www.emedny.org/ProviderManuals/Dental/PDFS/Dental_Policy_and_Procedure_Manual.pdf