1.0 BACKGROUND
Section 702 of the John Warner National Defense
Authorization Act for Fiscal Year 2007, (NDAA-07), Public Law 109-364,
amended paragraph (1) of section 1079(a) of title 10, United States
Code (USC) and provided that “in connection with dental treatment
for patients with developmental, mental, or physical disabilities
or for pediatric patients age five or under, only institutional
and anesthesia services may be provided.” The NDAA-07 was signed
into law on October 17, 2006.
2.0 POLICY
2.1 Medically
necessary institutional and general anesthesia services may be covered
in conjunction with non-covered or non-adjunctive dental treatment
for patients with developmental, mental, or physical disabilities
or for pediatric patients age five or under. Also, see
paragraph 2.2,
on additional hospital services benefit.
2.2 Patients
with diagnosed developmental, mental, or physical disabilities are
those patients with conditions that prohibit dental treatment in
a safe and effective manner. Therefore, it is medically or psychologically
necessary for these patients to require general anesthesia for dental
treatment.
2.3 The general anesthesia cannot be performed
by the attending dentist, but rather must be administered by a separate
anesthesiology provider.
2.4 Coverage of institutional
services will include institutional benefits associated with both hospital
and in-out surgery settings.
2.5 No
referrals are required for the above services. Preauthorization
is required for above outpatient care or inpatient stays to be covered
in the same manner as required for adjunctive dental care as provided
in
Section 13.1. No preauthorization will be
required for care obtained during the period from October 17, 2006
to the implementation date of this policy.
2.6 When the contractor receives
a claim for reimbursement for general anesthesia services in conjunction
with dental care that is covered under this section, the contractor
shall check with the appropriate TRICARE dental contractor to determine
if the general anesthesia charges have already been covered for
claims involving services during the period October 17, 2006 to
the implementation date of this policy. If the general anesthesia
services were provided in an institutional or in-out surgery setting,
then the contractor shall advise the sponsor of the right to file
a claim for the difference in the amount authorized under TRICARE
and the appropriate TRICARE Dental Plan (TDP), as well as the difference
in the amount of the anesthesia cost-share under the TDP, and the
cost-share the beneficiary has under the TRICARE plan in which they
were participating at the time.