Point32 Dental Benefit Clinical Review Form

Adult and Pediatric Dental and Oral Surgery Services

Includes emergency dental care, extractions, periodontal surgery, inpatient hospital and surgical day care services, preventive services and surgical treatment of certain mouth/jaw injury or disease based on certain indications.

Clinical Guideline Coverage Criteria

The Plan considers surgical extraction of bony impacted teeth as reasonable and medically necessary and are indicated for ONE of the following:

1. Facilitate the management or limit progression of periodontal disease; or
2. Ectopic position; or
3. Facilitate prosthetic rehabilitation; or
4. Facilitate orthodontic tooth movement and promote dental stability; or
5. Tooth interfering with orthognathic and/or reconstructive surgery; or
6. Fractured tooth; or
7. Removal risks fracture of the mandible; or
8. Is adjacent to a neuro-vascular bundle; or
9. Non-restorable caries; or
10. Internal or external resorption of tooth or adjacent teeth; or
11. Tooth involved in tumor resection; or
12. Prophylactic removal in patients with certain medical or surgical conditions or treatments (e.g., organ transplants, alloplastic implants, chemotherapy, radiation therapy); or
13. Non-treatable pulpal lesion; or
14. Acute or chronic infection (e.g., cellulitis, abscess); or
15. Findings of periodontal disease; or
16. Findings of periapical pathology; or
17. Elective therapeutic removal; or
18. Tooth in the line of a jaw fracture complicating fracture management; or
19. Pathology associated with tooth follicle (e.g., cysts, tumors); or
20. Facilitate management in trauma, orthognathic or reconstructive surgery; or
21. Insufficient space to accommodate erupting tooth or teeth; or
22. Orthodontic abnormalities (e.g., arch length/tooth size discrepancies)

The Plan considers dental services resulting from an accidental injury to sound natural teeth and gums as reasonable and medically necessary when documentation confirms member has received a course of treatment for the accidental injury within three months of the date of injury.

Note: Refer to Schedule of Benefits or Benefit Handbook for state-specific month limits on emergency dental services.

Note: Necessary treatment due to injury to the jaw and oral structures other than teeth are covered without time limit.

The Plan considers the use of general anesthesia and monitored anesthesia care (MAC), including facility charges, as reasonable and medically necessary when ONE of the following are met:

1. Member is categorized as certain American Society of Anesthesiologists (ASA) III - individual with severe systemic disease (individual case consideration); or
2. Member is categorized as ASA IV (individual with severe systemic disease that is a constant threat to life) severe systemic requiring removal of pathologic wisdom tooth, or multiple pathologic teeth (e.g. caries, periodontal disease, cystic involvement); or
3. Developmental disability/exceptional medical circumstances; or
4. Member is pregnant; or
5. Medical conditions such as:
   • History of stridor
   • Dysmorphic facial features
   • Oral abnormalities (e.g., macroglossia)
   • Neck abnormalities (e.g., neck mass)
   • Jaw abnormalities (e.g., micrognathia)
6. Member has ONE of the following:
   • History of adverse reaction to sedation; or
   • History of inadequate response to sedation; or
   • Obstructive sleep apnea; or
   • Morbid obesity (e.g., BMI >40); or
   • Active or history of alcohol or substance abuse
7. For children enrolled in a New Hampshire plan, HPHC considers general anesthesia or MAC as reasonable and medically necessary when ALL the following are met:
   • Child is 13 years old or younger; and
   • Primary Care Provider (PCP)/Attending provider confirms through documentation that member has ANY of the following:
     1. Complex dental condition; or
     2. Developmental disability; or

Exceptional medical circumstance(s)NOTE: Clinical notes must clearly describe the member’s condition or exceptional medical circumstances, and how/why the member’s condition or circumstance inhibits the safe delivery of care in an office setting.

The Plan considers general anesthesia or monitored anesthesia care (MAC) as reasonable and medically necessary when ONE of the following are met:

1. Member with functional or behavioral impairment when documentation confirms the member has an impairment due to a medical or behavioral condition (e.g. autism, developmental delay) manifesting as severe oppositional and uncooperative behavior and ONE of the following:
   • Rampant decay, or dental needs of high complexity; or
   • History of two or more unsuccessful attempts to treat in the office setting and documentation includes an evaluation by an oral maxillofacial surgeon (OMFS) or dentist who is certified in office based procedural sedation and analgesia; or
   • The Primary Care Physician (PCP) or attending practitioner clearly describes how/why the member’s functional or behavioral impairment inhibits the safe delivery of care in an office setting considering the level of dental needs.
2. Member with extreme apprehension and anxiety when documentation confirms ALL the following:
   • Member with rampant decay and/or highly complex dental needs has extreme apprehension and anxiety manifesting as significant oppositional and uncooperative behavior during treatment; and
   • History of at least two unsuccessful attempts to treat in the office setting, including an evaluation by an OMFS or dentist who is certified in office based procedural sedation and analgesia; and
   • The PCP or attending practitioner clearly describes why the member’s functional or behavioral impairment inhibits the safe delivery of care in an office setting.
3. Member with coexisting medical condition, comorbidity, or physical disability when documentation confirms ALL the following:
   • Member has ONE of the following conditions that might inhibit the safe delivery of care in an office setting:
     1. Medical condition(s) resulting in American Society of Anesthesiology (ASA) physical status classification Class III or higher; or
     2. Pulmonary function measurement of FEV1 < 60% of predicted; or
     3. Moderate to severe asthma that is poorly controlled; or
     4. Acute cardiac disease, current angina, or class III or IV congestive heart failure (CHF); or
     5. Moderate to severe aortic stenosis, or symptomatic mitral stenosis; or
     6. Myocardial Infarction (MI) within past six months; or
     7. Poorly controlled hypertension; or
     8. Poorly controlled diabetes, or diabetes with vascular complications; or
     9. Morbid Obesity (BMI > 40); or
     10. Bleeding disorder that cannot be improved sufficiently to safely perform the procedure in an office setting; or
     11. Uncontrolled seizures; or
     12. Potential for difficult airway management (i.e., history of difficult intubation, neuromuscular disease, significant cervical spinal disease, deformities of the mouth or jaw impeding airway); or
     13. Other medical conditions felt to inhibit the safe delivery of care in an office setting
   • Member has dental needs, and treatment cannot be safely delayed in order to try to stabilize the member’s medical condition; or
   • Primary care provider (PCP) or appropriate specialist consultant clearly documents why the dental procedure cannot be safely and effectively performed in an office setting.

NOTE: This medical policy does not address coverage under the dental benefit.

However, associated charges, such as Clinical Review of Dental Services in Medical Benefit3 general and MAC anesthesia, may be covered on individual consideration if above criteria are met.

NOTE: When a child is enrolled in a New Hampshire plan, HPHC considers inpatient hospital or Surgical Day Care (SDC) facility charges and administration of general anesthesia as medically necessary for children under the age of 13 with a dental condition of significant dental complexity, exceptional medical circumstances or a developmental disability.

Cleft Lip/Cleft Palate Procedures

The Plan considers the treatment of cleft lip and cleft palate for children under the age of 18 as reasonable and medically necessary for ONE of the following:

1. Medical, dental, oral and facial surgery, including surgery performed by oral and plastic surgeons and surgical management and follow-up care related to such surgery, or
2. Orthodontic treatment, or
3. Preventative and restorative dentistry to ensure good health and adequate dental structures to support orthodontic treatment or prosthetic management therapy, or
4. Speech therapy, or
5. Audiology services, or
6. Nutrition services

Pediatric Oral Health Services Under the Affordable Care Act (ACA)

The Plan considers the following pediatric oral health services as medically necessary:

1. Exams, cleanings, fluoride, sealants, X-rays

Periodontal Surgery

The Plan considers periodontal surgery for drug-induced gingival hyperplasia as reasonable and medically necessary when documentation confirms the presence of drug-induced gingival hyperplasia with ONE of the following:

1. Pocket depths > 5mm,
2. Difficulty with hygiene due to orthodontic brackets impinging on the gingiva,
3. A medication history including dosages of relevant drugs (e.g., Dilantin, Calcium Channel Blockers).

NOTE: Required documentation must represent the member’s current pre-operative condition and must include medication history including dosages or relevant drugs (e.g., Dilantin, Calcium channel blockers), periodontal charting, and photographs

Members with Serious Medical Conditions

Medical/Surgical Care for Osteonecrosis or Osteoradionecrosis

The Plan considers medical/surgical care for osteonecrosis or osteoradionecrosis of the jaw as reasonable and medically necessary when documentation confirms the presence of EITHER of the following:

1. Osteonecrosis of the jaw secondary due to ONE of the following:
   • Chemotherapy
   • Bone marrow or solid organ transplant
   • HIV immunodeficiency
2. Osteoradionecrosis due to either head and neck, or mantle field radiation.

NOTE: Required documentation must represent the member’s current pre-operative condition and must include narrative description of relevant clinical findings, x-rays and/or CT scan reports, and photographs demonstrating bone involvement (when applicable).

Tooth extraction

The Plan considers tooth extraction as reasonable and medically necessary when documentation confirms ONE of the following:

1. Member is pre-or post-head and neck/mantle field radiation therapy, pre-chemotherapy, or
2. Member is pre-bone marrow or solid organ transplant, or
3. Member has severe immunodeficiency (e.g., post organ transplant, peri-chemotherapy), or
4. Member has osteonecrosis of the jaw related to chemotherapy, bone marrow or solid organ transplant, HIV immunodeficiency, or IV bisphosphonate therapy, or
5. Member has osteoradionecrosis due to head and neck, or mantle field radiation.

NOTE: Required documentation must represent the member’s current pre-operative condition and must include narrative description of relevant clinical findings, x-rays and/or Computed tomography (CT) scan reports, and photographs demonstrating bone involvement (when applicable).

Limitations

The Plan considers all other dental services as a benefit contract exclusion. In addition, The Plan does not cover:

• Alveoloplasty and/or alveolectomy, for preparation of dentures or bridges, except as described above
• Cosmetic tooth implants
• Apicoectomy
• Bone grafting in conjunction with preparation for dental implants and/or dentures
• Brush biopsy – transepithelial sample collection
• Charges for restorative dental care or non-covered oral surgery when anesthesia and/or hospital care is authorized for members with special needs
• Dental treatment/consultation for temporomandibular joint disorders (TMD/TMJ)
• Endodontic care (i.e., root canals)
• Extraction of impacted teeth to prepare for or support orthodontic, prosthodontic, or periodontal procedures (except for cleft palate repair)
• Extraction of non-impacted teeth, except for high-risk members with serious immunodeficiency due to medical conditions (i.e., AIDS, human organ transplant, chemotherapy) or osteoradionecrosis due to head or neck radiation
• Cosmetic genioplasty
• Hospital or other ancillary costs associated with non-covered services
• Cosmetic labial frenectomies
• Operculectomy
• Oral surgery services
• General periodontal care, except as described above
• All services of a dentist for temporomandibular joint dysfunction (TMD/TMJ) Codes