2.3 Benefits
may be cost-shared for the treatment of the following conditions:
2.3.1 Intraoral
Abscesses
An intraoral abscess should be
considered a medical condition only when it extends beyond the dental
alveolus. These abscesses may require immediate attention in an
acute phase which would preclude preauthorization.
2.3.2 Extraoral
Abscesses
In some cases, it is necessary
to incise and treat abscesses extraorally; e.g., when the infection
follows the facial planes.
2.3.3 Cellulitis and Osteitis
Elimination of a non-local infection which
is clearly exacerbating and directly affecting a medical condition
currently under treatment.
2.3.4 Facial Trauma Requiring Removal
of Teeth or Tooth Fragments
2.3.4.1 Removal
of teeth and tooth fragments in order to treat and repair facial
trauma resulting from an accidental injury.
2.3.4.2 Removal
of an impacted tooth in the line of a fracture may be required in
order to treat the fracture.
2.3.5 Myofacial Pain Dysfunction
Syndrome, also known as Temporomandibular Joint (TMJ) Syndrome
2.3.5.1 Treatment
of this syndrome may be considered a medical problem only when it
involves immediate relief of pain.
2.3.5.2 Emergency
treatment may include initial radiographs, up to four office visits
and the construction of an occlusal splint, if necessary to relieve
pain and discomfort.
2.3.5.3 Treatment
beyond four visits, or any repeat episodes of care within a six
(6) month period, must receive individual consideration and be documented
by the provider of services.
Note: Occlusal equilibration
and restorative occlusal rehabilitation are specifically excluded
for myofacial pain dysfunction syndrome and TMJ syndrome. See
Chapter 4, Section 7.1.
2.3.6 Total or
Complete Ankyloglossia
This condition is
commonly known as tongue-tie. It involves the lingual frenum resulting
in fixation of the tip of the tongue to the degree that it interferes
with swallowing and speech. Surgery for total, complete,
or partial ankyloglossia may be covered
when medically necessary (e.g., feeding, eating, swallowing, or
speech difficulties exist).
2.3.7 Severe Congenital
Anomaly
Adjunctive dental and orthodontia
is covered when directly related to, and an integral part of, the
medical and surgical correction of a severe congenital anomaly.
2.3.7.1 Coverage
Guidelines
Depending on the severity or degree
of involvement of the congenital anomaly, the patient may require
adjunctive dental or orthodontic support from birth until the medical/surgical
treatment of the anomaly has been completed; i.e., until the dentoalveolar
arch discrepancies and/or maxillomandibular disharmonies are corrected
through a combined effort of the surgeon and orthodontist. Treatment
may include the fabrication of obturators early in life, and splints
at the time of surgical treatment for stabilization of the maxilla
and mandible. As the arches develop and teeth erupt, orthodontic
treatment may be required to establish a functional relationship
of the dental arches. When the deformity is severe and function
is greatly impaired, obturators and pharyngeal bulb appliances may
be required to assure proper nutrition, deglutition and to avoid
aspiration of foreign matter during the intake of food.
2.3.7.1.1 Vestibuloplasty
(Current Procedural Terminology (CPT) procedure codes 40840 - 40845) may
be considered adjunctive dental when it is determined to be an appropriate
and medical necessary surgical procedure for correction of a severe
cleft lip/cleft palate.
Note: Vestibuloplasty
is EXCLUDED when performed to prepare the mouth for dentures.
2.3.7.1.2 Orthodontics
should be a covered treatment in any congenital deformity of the
head and neck, wherein the orthodontia:
2.3.7.1.2.1 Corrects
dentoalveolar arch discrepancies that are part of, or the result
of, the congenital anomaly and are severe enough to prevent the
usual and normal action of mastication and ingestion of normally
solid foods.
2.3.7.1.2.2 Corrects
dentoalveolar arch discrepancies, the correction of which is necessary
to satisfactorily correct other aspects of the general deformity,
or to prevent relapse of such treatment.
2.3.7.1.2.3 Corrects
dentoalveolar arch discrepancies that are, in themselves, severe
enough to obviously disfigure the face.
2.3.7.1.2.4 The following
is a listing of congenital anomalies that affect the face and possibly
the dentoalveolar arches, or their relationships to each other:
• Cleft
palate isolated.
• Lateral or oblique
facial clefting.
• Cleft mandible.
• Klippel-Fiel Syndrome.
• Pierre Robin Syndrome.
• Trisomies 18, 21,
13 - 15.
• Chondroectodermal
dysplasia (Ellis-van Creveld Syndrome).
• Bird headed dwarfism
(Nanocephalic or primordial dwarfism).
• Turner’s Syndrome
(X-0 Syndrome).
• Klinefelter’s Syndrome.
• Craniofacial dysostosis
(Crouzon’s Syndrome).
• Occuloauriculovertebral
dysplasia (Goldenhar’s Syndrome).
• Occulamandibulofacial
Syndrome (Hallerman Striff Syndrome, Ullrich et al Syndrome).
• Treacher Collins
Syndrome.
• Hemifacial
microsomia.
• Hemifacial
hyperplasia.
2.3.7.1.2.5 Coverage
of orthodontia for congenital anomalies of the head and/or neck
which do not appear in the above listing must be evaluated to assess
the significance of their functional impairments related to the
dentoalveolar arch discrepancies described in
paragraphs 2.3.7.1.2.1 and
2.3.7.1.2.2;
i.e., the dentoalveolar arch discrepancies of an unlisted congenital
anomaly must impose a significant functional impairment in order
for coverage of orthodontia under TRICARE.
2.3.7.1.2.6 The severity
and functional impairment of a given congenital anomaly must be assessed
on a case-by-case basis from a series of medical records over a
period of time. The congenital impairment of the head and/or neck
must be at a level resulting in an inability of a beneficiary to perform
normal bodily functions (e.g., the inability to eat, breathe, and/or
speak normally) in order for coverage to be extended. The functional
impairment must be disabling and ongoing.
2.3.7.2 Preauthorization
Requirements
2.3.7.3 Preauthorization
is required for all adjunctive dental and orthodontia directly related
to, and an integral part of, the medical and surgical correction
of a severe congenital anomaly.
2.3.7.4 Orthodontia
benefits for severe congenital anomalies of the head and neck will
be continued as long as the primary physician requires support of
his/her treatment or until the best reasonably attainable results
have been achieved by the orthodontist. Once active orthodontic treatment
has been completed and the patient is placed in the retention phase
of treatment, benefit payment ends. If the primary physician or
dentist subsequently determines that additional orthodontia work
is required, a new preauthorization is required.
2.3.8 Iatrogenic
Dental Trauma
Dental care which is prophylactic,
restorative, prosthodontic (e.g., dentures and bridge work) and/or
periodontic qualifies as adjunctive dental care when performed in
preparation for, or as a result of, trauma to the teeth and supporting
structures caused by medically necessary treatment of an injury
or disease. There must be a direct cause-effect relationship between
the otherwise covered medical treatment and the ensuing dental trauma,
and the ensuing dental trauma must be functionally associated
(adjunct) with the treatment of the physician induced trauma. This
must be based on sound medical practice and substantiated in the
current medical literature. The following are examples of conditions
which are eligible for payment under the iatrogenic dental trauma
provision. Because these examples are not meant to be all-inclusive,
similar conditions or circumstances may be brought to the attention
of the Defense Health Agency (DHA), or designee, for consideration.
2.3.8.1 Radiation
Therapy for Oral or Facial Cancer
2.3.8.1.1 It is generally
recognized that certain dental care may be required in preparation
for or as a result of in-line radiation therapy for oral or facial
cancer.
2.3.8.1.2 Treatment may include dental prophylactic,
restorative, periodontic and/or orthodontic procedures. Without
this necessary care, patients who undergo radiation therapy around the
head may be at risk for development of osteonecrosis because their
dental needs were not met either prior to, or in conjunction with,
radiation therapy. Since the problem here deals with cancer, it may
not be possible to wait for prior authorization before beginning
radiation therapy. Out of necessity, dental care may have to be
initiated before benefit authorization is granted. Extraction of affected
teeth due to poor dental health (e.g., multiple dental caries and/or
periodontal disease) may necessitate the coverage of dentures or
bridge work.
2.3.8.2 Gingival Hyperplasia
2.3.8.2.1 Gingival
hyperplasia, or overgrowth of the gingival tissues, occurs frequently
in patients who have undergone prolonged Dilantin therapy for epilepsy
or seizure disorders. The incidence of this problem can be reduced
by good oral hygiene and prophylactic gum care. Severe cases of
gingival overgrowth may require surgical intervention to reduce
the excessive fibrous tissue growth. The problem is more prevalent
among young children, as the older population is not prone to the condition.
Also, there is an important difference in the character of tissue
between gingival hyperplasia and periodontal disease. Because of
this, care needs to be taken in differentiating true gingival hyperplasia
from periodontally diseased tissue.
2.3.8.2.2 Treatment
usually entails excision of the hyperplastic tissue; however, in
some severe cases, free soft tissue grafts may be required.
Note: Because the above
examples are not meant to be all-inclusive, similar conditions or circumstances
may be brought to the attention of the contractors for review and
consideration. Coverage will again be based on whether a direct
cause-effect relationship can be established between the treatment
of an otherwise covered medical condition and the ensuing dental
trauma. Dental procedures will only apply when required to treat
or rectify the dental trauma/damage resulting from the treatment
of an underlying medical condition. For instance, if a beneficiary
cracks or chips a tooth as a result of a fall, coverage would not
be extended under the iatrogenic provision, since the trauma was
purely dental in nature (i.e., trauma to the teeth and/or dental
alveoli) and not related to the treatment of an underlying medical
condition. The only possible coverage that could be extended would
be for removal of teeth fragments from surrounding oral tissue other
than the dental alveolus (e.g., from the tongue or inside of the
cheek) resulting from the accident. On the other hand, if a beneficiary
sustained a fracture to the mandible or maxilla requiring the extraction
of a tooth for stabilization of the jaw (i.e., removal of a tooth
to allow for wiring of the fracture site), coverage would be allowed
since the resulting physician or oral surgeon induced dental trauma
was directly related to the treatment of an otherwise covered medical
condition. In this particular case, adjunctive dental coverage would
extend up through prosthodontic restoration of the missing tooth.
2.3.8.3 Preauthorization
Requirements
The preauthorization criteria
for dental care required in preparation for, or as a result of, trauma
to the teeth and supporting structures caused by medically necessary
treatment of an injury or disease are the same as those described
in
paragraphs 2.3.7.3 and
2.3.7.4.
2.3.9 Dental Metal
Amalgam/Alloy Hypersensitivity
The removal
of dental metal amalgam/alloy source may be cost-shared for procedures rendered
after April 18, 1983, under the following conditions:
2.3.9.1 Independent
diagnosis by a physician allergist based upon generally accepted
test(s) for any dental metal amalgam/alloy hypersensitivity, and
2.3.9.2 Contemporary
clinical record documentation which reasonably rules out sources
of metal exposure other than the dental amalgam/alloy.