Notification



Notification Issue Date:



Claim Payment Policy


Title:Reimbursement for Associated Services Performed in Conjunction with Dental Care

Policy #:00.01.18d


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

The Company covers associated services that are performed in conjunction with dental care (e.g., general anesthesia) along with hospitalization and all related medical expenses normally incurred as a result of general anesthesia in the ambulatory surgery center (ASC), short procedure unit (SPU), or outpatient hospital setting to ensure and safeguard the individual's health when any of the following conditions are met:
  • The individual has a comorbid medical condition (e.g. Alzheimer's disease, chronic obstructive pulmonary disease, and congestive heart failure) that would potentially increase the risk of the procedure if performed in a dental office.
  • The individual is developmentally disabled (e.g. cerebral palsy, autism, and trisomy 21) and a successful result of dental care cannot be expected for treatment under local anesthesia and a superior result can be expected for treatment under general anesthesia.
  • The individual is a child who is seven years of age or younger (or otherwise defined by state mandate) for whom a successful result of dental care cannot be expected with treatment under local anesthesia, and for whom a superior result can be expected for treatment under general anesthesia.

This policy applies regardless of whether the dental service is eligible under the medical benefits.

For information on dental services that are covered under the medical benefits, refer to the individual and/or group benefit contract.

Coverage for the specific dental procedure(s) is subject to the terms and conditions of the member's benefit plan.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, associated services performed in conjunction with non-covered dental services are covered under the medical benefits of the Company’s products.

MANDATES

This policy is consistent with applicable state mandates.

Description

Dental care refers to the diagnosis, treatment, planning, and implementation of services directed at the prevention and treatment of diseases, conditions, and dysfunctions relating to the oral cavity and its associated structures and their impact upon the human body.


At times, in order to ensure and safeguard an individual's health, it may be necessary to perform dental services (e.g., general anesthesia) in an ambulatory surgery center (ASC), short procedure unit (SPU), or outpatient hospital setting.

For the purpose of this policy, the term "general anesthesia" refers to a controlled state of unconsciousness that is produced by a pharmacologic method. It is accompanied by a complete or partial loss of protective reflexes that include the patient's ability to maintain an airway independently and to respond purposefully to physical stimulation or verbal command.


References

American Academy of Pediatric Dentistry. Policy on Medically Necessary Care 2007; revised 2015. http://www.aapd.org/media/Policies_Guidelines/P_MedicallyNecessaryCare.pdf. Accessed October 10, 2019.


American Academy of Pediatric Dentistry. General Anesthesia. Available at: http://www.ada.org/sections/about/pdfs/anesthesia_guidelines.pdf. Accessed October 10, 2019.

Company Benefit Contracts

NJ Perm Stat Title 26, 26:2J-4.19: Coverage for certain dental procedures for the severely disabled or child age five or under by hospital service corporation (2007). [NJ Legislature Web site]. 2007. Available at: ftp://www.njleg.state.nj.us/19981999/PL99/49_.pdf. Accessed October 10, 2019.

NJ Perm Stat Title 17, 17:48-6u: Coverage for certain dental procedures for the severely disabled or child age five or under by hospital service corporation (2007). [NJ Legislature Web site]. Available at: ftp://www.njleg.state.nj.us/19981999/PL99/49_.pdf. Accessed October 10, 2019.

The General Assembly of the Commonwealth of Pennsylvania. Children and Developmentally Disabled Patient Access to Quality Dental Care Act. Act of July 5, 2012. P.L 916, No. 94. Available at: http://www.legis.state.pa.us/WU01/LI/LI/US/HTM/2012/0/0094..HTM. Accessed October 10, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)





Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Coding and Billing Requirements


Cross References

Attachment A: Reimbursement for Associated Services Performed in Conjunction with Dental Care
Description: Diagnosis Codes



Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.


REVISIONS FROM 00.01.18d:
12/16/2019This version of the policy becomes effective 12/16/2019. This policy was updated to delineate the Company's reimbursement criteria of associated services performed in conjunction with dental care (e.g. general anesthesia) along with hospitalization and all related medical expenses for individuals who are developmentally disabled.

REVISIONS FROM 00.01.18c:
10/24/2018This policy became effective 11/07/2012. It has been reviewed and reissued to communicate the Company’s continuing position on Reimbursement for Associated Services Performed in Conjunction with Dental Care.
Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A



2017 AmeriHealth.