CurrentAnthemPolicy N/A

Accidental Dental Injury

Governs clinical indications, necessary documentation, and timing for initial and definitive treatment of accidental dental injuries to sound natural teeth and supporting oral tissues for Anthem members.

Policy Summary

PayerAnthem

PolicyAccidental Dental Injury

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review DateOct 30, 2025

Key ActionProvide required clinical documentation including pre- and post-trauma radiographs, chart notes, photos when appropriate, ER/accident report, and treating dentist letter to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72 hoursinitial treatment timeframe

12 monthsdefinitive treatment window

D9110example CDT code

NCapplicable state

Coverage Criteria for Accidental Dental Injury

Initial/Emergency Care

Covered when ALL of the following are met

Timing: Treatment is generally rendered within seventy-two (72) hours of the onset of the injury.<=72 hours

Exceptions allowed for hospitalization for other accident-related injuries

Tooth status: Injury to sound natural teeth (teeth that were stable, functional, and free from decay, fracture, and advanced periodontal disease at the time of the accident).sound natural teeth

Services treating pre-existing or pre-accident dental conditions are not considered appropriate

Injury caused by extra-oral blunt force trauma and not due to chewing or biting forces.

Policy Summary

PayerAnthem

PolicyAccidental Dental Injury

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review DateOct 30, 2025

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Definitive Restorative/Reconstructive Treatment

Covered when ALL of the following are met

Timing: Definitive restorative and reconstructive treatment is performed within 12 months of the date of the accidental dental injury.<=12 months

Includes services such as endodontics, restorative, implants, prosthodontics, bone grafting, and soft tissue grafting

Relation to injury: Services must be related to the accidental dental injury and not provided to treat pre-existing or pre-accident dental conditions.related to injury

When services are performed in conjunction with or in preparation for a non-covered or denied service, related services are also not covered/are denied

Provider Actions, Documentation & Authorization

Prior Authorization

Prior authorization for initial emergency care

Prior authorization is not required for initial, emergency, or palliative services. Retrospective claim review will be conducted after services are provided and may include evaluation of reimbursement, documentation accuracy, coding, and medical/dental necessity per prevailing dental standards.

Prospective review not required for initial/emergency/palliative care
Retrospective review will assess appropriateness and documentation

Documentation Required

PROVIDER ACTIONS — Required clinical documentation

Providers must submit complete clinical documentation to support emergency/accident-related dental services. Documentation should clearly demonstrate the injury was due to extra-oral blunt force trauma and that affected teeth were sound natural teeth prior to the accident.

Required: diagnostic pre- and post-trauma radiographs (properly oriented, labeled, dated). Include full mouth, panoramic, and/or other appropriate images that show all existing and missing teeth in upper and lower arches
Required: chart notes, intra-oral and facial photographs (when appropriate), accident or emergency room report, and a treating dentist letter describing the accident, injuries, and proposed treatment plan

Denial Risk

PROVIDER ACTIONS — Services treating pre-existing conditions and related services

Services that treat pre-existing or pre-accident dental conditions are not considered appropriate and may be denied. Additionally, when a service is performed in conjunction with or in preparation for a non-covered or denied service, all related services are also not covered or may be denied per contract.

Dental services addressing pre-existing/pre-accident conditions are not eligible for coverage unless specified by group contract
Related services performed with or to prepare for a non-covered/denied service are also not covered

Background

Accidental dental injuries result from extra-oral blunt force trauma to sound natural teeth and the supporting hard and soft tissues and are distinct from injuries caused by chewing or biting forces. Sound natural teeth are defined as teeth that were stable, functional, and free from decay, fracture, and advanced periodontal disease at the time of the accident. Initial/emergency care focuses on evaluation, stabilization, and preservation of dento-alveolar structures; definitive restorative or reconstructive treatment is performed when related to the accident and supported by required documentation.

Definitions

Sound natural teeth

DefinitionSound natural teeth: teeth that were stable, functional, and free from decay, fracture and advanced periodontal disease at the time of the accident.

Clinical contextApplies to teeth and supporting hard and soft tissues injured by extra‑oral blunt force trauma (not due to chewing or biting forces).

Coverage implicationServices treating pre‑existing or pre‑accident dental conditions are not considered appropriate unless specified by group contract.

Related policy noteWhen a service is performed in conjunction with or in preparation for a non‑covered or denied service, all related services are also not covered or denied.

OpenPayer

Accidental Dental Injury

Coverage Criteria for Accidental Dental Injury

Coding and CDT Codes

Provider Actions, Documentation & Authorization

Background

Definitions