ModifiedAnthemPolicy Clinical Policy - 02

Accidental Dental Injury Guideline

Defines when dental services to treat accidental dental injuries to sound natural teeth and supporting oral tissues are considered medically/dentally necessary, documentation requirements, timing (initial/emergency and definitive treatment windows), examples of covered procedures, and coding guidance for Anthem members.

Policy Summary

PayerAnthem

PolicyAccidental Dental Injury Guideline

Policy CodePolicy Clinical Policy - 02

Change TypeRevised (non-material)

Effective DateJan 1, 2025

Next Review Date

Key ActionInclude diagnostic pre- and post-trauma radiographs, chart notes, intra-oral and facial photos when appropriate, accident/ER report, and a treating dentist's letter describing the accident, injuries, and proposed treatment plan when submitting claims.

SourceLink

POLICY UPDATE CHANGES

Policy status indicates Revised; publish date 01/01/2025 and last review 11/05/2024.

72 hoursInitial treatment window

12 monthsDefinitive treatment eligibility window

1Example CDT code listed

Coverage Summary

Policy Clinical Policy - 02 addresses treatment of Accidental Dental Injury. Coverage stance: mixed. Status: MODIFIED (Revised). Effective date: 2025-01-01. Last review date: 2024-11-05. This policy defines when services to treat accidental dental injuries to sound natural teeth and supporting oral tissues are considered medically/dentally necessary, applicable documentation and timing requirements, examples of covered procedures, and coding guidance for Anthem members. Policy number: Clinical Policy - 02.

Medically Necessary / Initial / Definitive Treatment Criteria

Medically Necessary Criteria for Accidental Dental Injury Treatment

Treatment is considered medically/dentally necessary when ALL of the following are met:

ALL of the following

Injury results from extra-oral blunt force trauma (not due to chewing or biting forces) to sound natural teeth and/or supporting hard and soft tissue structures
Teeth were sound natural teeth (stable, functional, free from decay, fracture and advanced periodontal disease) at time of the accident
Treatment is generally rendered within seventy-two (72) hours of onset of the injurywithin 72 hours
Clinical documentation available including diagnostic pre- and post-trauma radiographs (properly oriented, labeled, dated) that reveal all existing and missing teeth in upper and lower arches, chart notes, intra-oral and facial photos when appropriate, accident/ER report, and letter from treating dentist describing accident, injuries, and proposed treatment plan

Initial / Emergency / Palliative Treatment

Prospective treatment review is NOT required for initial/emergency/palliative services. Services considered initial/emergency may include ANY of the following:

ANY of the following

Evaluation and diagnosis
Radiographic evaluation
Extraction
Suturing
Splinting
Re-implantation, repositioning, and stabilization of dislodged teeth

Definitive Restorative and Reconstructive Treatment (timing conditions)

Definitive restorative/reconstructive treatment may be considered when ALL of the following are met:

ALL of the following

Definitive restorative/reconstructive treatment performed within 12 months of the date of the accidental dental injurywithin 12 months
Procedures are directed at treating the accidental injury (not pre-existing/pre-accident dental conditions)
Examples of definitive procedures
- Extraction
- Endodontic services

Coding Guidance

CDT codes referenced for informational purposesmixed

D9110

Palliative treatment of dental pain - per visit

Procedure / service categories mentionedmixed

Oral surgical services	Includes extraction and bone grafting (category mention, not specific codes)
Endodontic services	Category reference
Restorative services	Category reference
Periodontic services	Soft tissue grafting; category reference
Implant services	Category reference
Fixed and removable prosthodontic services	Category reference

ICD-10 coding guidanceICD-10

ICD-10 CM

Appropriate medical ICD-10 codes should be used when services are reported to the member's medical plan; see current CDT and ICD-10 code books for specifics

Codes listed in this policy are provided for informational purposes only. Providers must report the appropriate CDT or ICD-10 codes for the specific dental service rendered when submitting claims to the member's medical plan; inclusion of codes here is not a guarantee of coverage. Prospective review is not required for initial/emergency/palliative services, and retrospective claim review will assess documentation and coding accuracy.

Provider Actions & Requirements

Documentation Required

Required clinical documentation for claim review

Include diagnostic pre- and post-trauma radiographs (properly oriented, labeled, dated) revealing all existing and missing teeth in both upper and lower arches, chart notes, intra-oral and facial photographs when appropriate, accident/ER report, and a letter from the treating dentist describing the accident, injuries, and the proposed treatment plan.

Prior Authorization

Prospective review not required for initial/emergency services

Prospective treatment review is not required for initial, emergency, or palliative services. Retrospective claim review will be conducted after care is provided, including evaluation of reimbursement levels, documentation accuracy, coding accuracy, and adjudication of payment.

Denial Risk

Services treating pre-existing conditions are not covered

Services rendered to treat pre-existing or pre-accident dental conditions are not considered appropriate and may be denied unless specified by the member's group contract.

Billing Rule

Provider responsible for correct procedure code reporting

The provider is responsible for reporting the appropriate CDT or medical/ICD-10 code for the specific dental service rendered when submitting to the member's medical plan. Codes listed in the policy are informational and do not guarantee coverage or reimbursement.

Affected code (informational): D9110 (Palliative treatment of dental pain - per visit)
Inclusion of codes in the policy does not constitute or imply member coverage; submit appropriate CDT and ICD-10 codes to the medical plan.

Background & Evidence

This policy provides clinical guidance for interpreting dental benefit application for accidental dental injuries, including initial and definitive treatment considerations and required clinical documentation. Applicability of coverage is subject to the member's contract and will be evaluated against prevailing standards and current practice in the dental community. The Plan reserves the right to modify its dental clinical policies and guidelines periodically and as necessary; federal and state law and contract language take precedence.

Referenced guidelines and articles include: AAPD Guideline on Management of Acute Dental Trauma; Journal of Endodontics (Epidemiology of Traumatic Dental Injuries); Dental Traumatology; and other listed references and guidelines for management of traumatic dental injuries.

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