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.