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.