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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 13.2
Dental Anesthesia And Institutional Benefit
Issue Date:  May 23, 2007
Authority:  32 CFR 199.4(e)(10)
Revision:  C-9, October 20, 2017
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.
2.1  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.
The professional services related to non-adjunctive dental care are not covered with the exception of coverage for general anesthesia services.
October 17, 2006.
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