Subject:
General Guideline for the Delineation of Medical vs. Dental and Accidental Dental Benefits
Description:
_______________________________________________________________________________________
IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
__________________________________________________________________________________________________________________________
This policy outlines basic principles applicable in determining whether a service or procedure is eligible under the medical or dental benefit. It also provides guidance related to accidental dental benefit.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
Delineation of Medical vs. Dental Benefit
Medical conditions exist that exhibit one or more dental components. These dental components/conditions may be the cause of the medical problem, completely unrelated, or the sequelae of the medical condition or its treatment. Except for several instances: TMJ dysfunction, accidental dental injuries and impacted wisdom teeth (still subject to contract eligibility), dental procedures are not covered. These guidelines are being formulated because it is important from an eligibility standpoint to define what procedures fall under the definition of dental procedures, regardless of the causative factor except where explicitly stated in the contract.
One must also keep in mind that all dentists are licensed and that the practicing status of the dentist, i.e. specialist vs general practitioner, is not a factor in determining whether a claim is paid under dental or medical, since all dentists are licensed to perform these procedures (although certain specialties do subject their licensees to limitations).
A broad definition of dental services is those procedures used to treat the dental structures including primary and permanent dentition and supporting structures including the periodontium and alveolar bone.
Specific procedures that fall under the category of dental treatment are:
- Restoration or rebuilding of tooth structure lost by decay, fracture, attrition, or erosion using synthetic materials or chemical agents. This can include intra-coronal restorations such as amalgam, gold, or composite, full or partial coverage crowns and tooth strengthening and retention enhancement for endodontically treated teeth.
- Endodontic treatment of teeth including re-treatment, if necessary, and any necessary periapical or sectioning surgical intervention.
- Surgical services and post-op treatment performed on the dental supporting structures that include treatment of periodontal disease, osseous surgery and any other surgery to the periodontium or alveloar process.
- Replacement of missing teeth using full dentures, removable partial dentures or fixed prostheses and related services.
- Removal of teeth and re-implantation of teeth and associated services.
- Orthodontic treatment, even if a component of an eligible medical condition or treatment.
- Dental implants and related services are not eligible under the medical benefit.
(NOTE: Cephalometric tracings, x-rays, photographs, models, and other dental diagnostics are not reimbursable under the medical benefit unless they are performed to determine medical necessity for orthognathic surgery and the surgery is deemed to be medically necessary as approved by Horizon Blue Cross Blue Shield of New Jersey. Panorex x-rays required for trauma and diagnosis of intraoral lesions may also be reimbursable under the medical benefit.)
Accidental Dental Benefit
For purposes of definition under any accidental dental benefit - an accident is a bodily injury to a sound and natural tooth (a sound and natural tooth is defined as a tooth that, unless contractually stipulated, whose prognosis is good prior to the accident. It does not have to be a tooth with no fillings, etc, but it has to be one that would have been retained for a long period of time) from an outside source. Injury either directly or indirectly as a result of chewing or biting is not considered an accidental injury. In order to be reimbursed, all treatment must be finished within one year of the date of the accident (or less as defined in the members contract).
Horizon Blue Cross Blue Shield of New Jersey will not further indemnify a repair due to an accident after the initial repair. Dental implants and related services are not eligible benefits under the accidental dental provision.
Medicare Coverage:
Under the CMS Dental Services Exclusion, items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered. An exception to the CMS requirement that to be covered, a noncovered procedure or service performed by a dentist must be an incident to and an integral part of a covered procedure or service performed by the dentist. For example, an x-ray taken in connection with the reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered.
For additional information, refer to Medicare Benefit Policy Manual Chapter 16 - General Exclusions From Coverage. Section 140 - Dental Services Exclusion. Available to be accessed at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html
Per National Coverage Determination (NCD) for Dental Examination Prior to Kidney Transplantation (260.6), despite the "dental services exclusion", an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery. For additional information and eligibility, refer to National Coverage Determination (NCD) for Dental Examination Prior to Kidney Transplantation (260.6). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Also see, Novitas Solutions, Inc., the Local Medicare Carrier for jurisdiction JL, Claims Article: Dental Services: Coverage and Exclusions Dental Services. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00087934.
Medicaid Coverage:
FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
________________________________________________________________________________________
Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
___________________________________________________________________________________________________________________________
Index:
General Guideline for the Delineation of Medical vs. Dental and Accidental Dental Benefits
Guideline for the Delineation of Medical vs. Dental and Accidental Dental Benefits
Delineation of Medical vs. Dental Benefit, Guideline for
Medical vs. Dental Benefit, Guideline for Delineation of
Dental vs. Medical Benefit, Guideline for Delineation of
Accidental Dental Benefit Guideline
References:
Not applicable to this policy.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
_________________________________________________________________________________________
Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
____________________________________________________________________________________________________________________________ |