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.