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Accident Related Dental Services

Policy Number: MP-350

Latest Review Date: January 2020

Category:  Administrative                                                     

Policy Grade: N/A

POLICY:

Accident related dental services may be considered medically necessary when the following criteria are met:

  • Injury to the teeth must be caused from a force outside of the body or oral cavity; not caused by biting, chewing, clenching, grinding, etc.
  • Teeth must be free from gross decay and advanced periodontal disease in good repair and firmly attached to the maxilla and /or mandible at time of injury. Previous and /or current dental records and x-rays may be required to determine the patient’s condition prior to the accident.
  • For coverage of accidental injury of the teeth, the patient should receive initial treatment within 90 days of the accident. Subsequent covered treatment after the initial treatment can extend to within 180 days of the accident without preauthorization. Care can be extended to 18 months from the accident date if it is determined to be medically necessary to occur within this time period. Coverage for services will not be extended beyond 18 months from the accident date. Services after 18 months would not be considered as medical, but could be covered under a dental plan.

(One example for the need to extend to 18 months after the initial injury to teeth would be a severe injury requiring oral surgery/facial reconstruction where the surgery may need to be performed in stages and additional time would be required for healing before teeth restoration could be performed.)

The following limitations also apply to the dental care after accidents (This is not an all inclusive list).

The first denture, crown, in mouth appliance and/or fixed bridgework to replace teeth lost due to accidental injury would be covered when determined to be medically necessary.

Bone grafts to replace a large volume of lost bone due to accidental injury, prior to a covered restorative procedure would be covered when determined to be medically necessary.

Limited orthodontic treatment would be covered only to stabilize or reposition the injured teeth to their original position prior to the accident when determined to be medically necessary. Full mouth orthodontic therapy would not be a covered benefit unless the group has dental coverage for orthodontics. In no case would full orthodontic treatment be covered to correct a condition prior to injury or as a result of injury unless the group has dental coverage for orthodontics.

Most contracts do not cover replacement of teeth via surgical placement of a dental implant body. Any procedure (e.g., bone replacement graft, sinus lift surgery, soft tissue graft or barrier membrane placement) considered as adjunctive procedures to the surgical placement of the dental implant body are also not covered unless the members’ contract has coverage for dental implants.

Splinting of loose teeth for the purpose of stabilization would be covered as a medical benefit when these teeth meet the criteria for outside injury and are sound and free of prior dental disease.

DESCRIPITION OF PROCEDURE OR SERVICE:

Accident Related Dental Services are services which are needed due to an accidental injury caused by a force outside of the mouth or body.  These injuries frequently include jaw, mouth or face trauma.  It does not include injury sustained while biting, chewing, clenching, grinding, etc.  Usually if the injury is severe, the treatment plan has to be extended to allow for time for the tissue to heal before the entire dental repair can be completed. Most plans cover dental treatment as a medical benefit when needed to remove, repair, replace, or restore natural teeth damaged, lost or removed due to an injury, but some plans do not cover the removal, repair, replacement or restoration of teeth.

Limited orthodontic treatment would include treatment of only a few teeth for the purpose of stabilization.  Full or comprehensive orthodontic treatment would include full orthodontic care and could also be used to correct the malalignment of teeth or bite.

KEY POINTS:

A review was conducted through January 2020.

Summary of Evidence:

Accidental injury to the teeth can result from an external force or element such as a blow or fall. These injuries can occur due to auto accidents, falls, and injuries from sports. Significant head, neck or facial trauma may also be involved.

Injury to the teeth which is caused from biting, chewing or grinding teeth is not considered as an accidental injury for policy. Tooth fractures from these causes are not covered under accidental injury/medical coverage.

Treatment after injury may include such things as reimplanting and stabilization of dislodged teeth, repositioning and stabilization of partly dislodged teeth, extraction of teeth, etc.

A plan of treatment is usually developed in severe cases to outline the treatment plan. Frequently the treatment plan may need to be staged to allow for healing of tissues before the final restorative work is completed.

KEY WORDS:

Accidental injury to teeth, teeth injury, dental implants

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable. Some groups have specific benefits based on in-network versus out-of-network provider specifications.

ITS: Home Policy provisions apply.

FEP: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CURRENT CODING:

CPT Codes:     Specific codes are not listed. Coding varies based on the extent of injuries.

REFERENCES:

Not applicable.

POLICY HISTORY:

Medical Policy Group, March 2009 (3)

Medical Policy Administration Committee, May 2009

Available for comment May 14-June 26, 2009

Medical Policy Group, September 2018 (2): Policy reviewed by consensus without literature review; no changes in policy statement.

Medical Policy Group, January 2020 (6): Reviewed by consensus. Updates to Description and Key Points. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.