CurrentAnthemPolicy Clinical Policy - 01

Generally Accepted Standard of Dental Care

Defines the plan's review criteria for determining whether proposed or rendered dental services meet generally accepted standards of dental care for covered members and may affect benefit/payment determinations.

Policy Summary

PayerAnthem

PolicyGenerally Accepted Standard of Dental Care

Policy CodePolicy Clinical Policy - 01

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateJan 1, 2026

Key ActionObtain prior review and submit current (within 12 months) dated pretreatment radiographs and periodontal charting when requested to support benefit determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsrecency for radiographs and charting

1:1crown-to-root ratio threshold

multipleexample situations

Clinical Policy - 03-001related policy

Coverage Criteria — Generally Accepted Standard of Dental Care

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Not meeting standards — examples/criteria

A service may be considered not meeting generally accepted standards of dental care when any of the following apply:

Periodontal disease considerations: Teeth demonstrating uncontrolled or untreated periodontal disease (evidenced by radiographic or periodontal charting findings or loss of supporting bone including furcation) may not be considered for approval unless definitive periodontal therapy and periodontal maintenance have been successfully performed, or the treatment plan includes periodontal therapy; success will be evaluated prior to approval for indirect restoration.

Current (within 12 months) 6-point periodontal charting may be requested.

Endodontic status issues: Endodontic status must be considered: untreated or unresolved periapical/periradicular pathology will not be considered for benefits other than endodontic therapy; unresolved lesions near the pulp without planned endodontic therapy, overfill/underfill root canal obturation or poor condensation, and internal or external resorption may not be considered for benefit.

See Dental Clinical Policy 03-001 Endodontic Therapy for related criteria.

Sub-gingival/sub-osseous carious lesions affecting STA: Treatment of teeth with sub-gingival/sub-osseous carious lesions that compromise the supracrestal tissue attachment (STA) is considered not appropriate unless restorative and periodontal considerations are addressed.

Significant coronal structural loss: A tooth exhibiting significant coronal structural loss that appears unrestorable may not meet standards for coverage.

Root fracture/defect/perforation: Teeth that exhibit root fracture, root defects, or root perforation may not be considered for benefit.

Furcation involvement/caries into furcation: A tooth that exhibits caries into the furcation may not be considered for approval.

Extensive root caries: A tooth appearing unrestorable due to the extent and location of root caries may not meet standards for benefit.

Procedures intended to salvage teeth that are non-functional or appear non-restorable may be deemed not medically/dentally necessary and may not qualify for benefits. The plan will consider the tooth’s overall prognosis, including structural loss, root fracture/defect/perforation, furcation involvement, and extensive root caries when determining benefit eligibility.

Specific conditions that commonly lead to denial or noncoverage include: untreated or unresolved endodontic pathology (benefit limited to endodontic therapy when appropriate), unresolved lesions near the pulp without planned endodontic treatment, teeth with unfavorable crown-to-root ratios (poorer than 1:1), uncontrolled or untreated periodontal disease (including loss of supporting bone or furcation involvement), sub-gingival or sub-osseous caries compromising the supracrestal tissue attachment, significant coronal structural loss making a tooth unrestorable, and teeth with root fracture, defects, perforation, caries into the furcation, or extensive root caries.

When these conditions are present, the treating dentist should document the planned or completed definitive periodontal and endodontic therapies (as applicable) and include supporting records (radiographs, periodontal charting, and clinical notes) so the plan can evaluate whether the proposed treatment meets generally accepted standards of dental care and is eligible for benefits.

Coding, Measurement Thresholds, and Documentation Timeframes

inv-04: Crown-to-root ratio

ThresholdCrown-to-root ratios poorer than 1:1 are considered less than ideal

Assessment contextAssessment must include full mouth dental condition, medical/dental/periodontal history, periodontal continuing care, age, and occlusion

Coverage implicationTeeth with unfavorable crown-to-root ratios may not meet standards for coverage

inv-05: Recency requirement for radiographs/periodontal charting

Recency requirementRadiographs and 6‑point periodontal charting must be current within 12 months

Required documentationMust be dated, properly identified pretreatment diagnostic radiographic image(s) that include the radiographic apex

Use in reviewCurrent periodontal status and history of periodontal therapy may be requested prior to benefit determination

Provider Requirements, Prior Review, and Denial Risk

Prior Authorization

Prior Review and Contractual Standards

Prior review may be required. Requests for services must include documentation that supports that proposed treatment meets generally accepted standards of dental care and contract terms. The plan may deny services that are primarily cosmetic, intended for convenience, or directed at salvaging non-functional or non-restorable teeth.

Short title: Prior Review / Contractual Standards
Plan review ensures services meet generally accepted standards of dental care and lowest cost appropriate to condition
Services primarily for convenience, cosmetic purposes, or to salvage non-restorable/non-functional teeth may be denied

Documentation Required

Radiographic and Documentation Requirements

Must include current (within 12 months), dated, properly identified, pretreatment diagnostic radiographic image(s) that include the radiographic apex. Clinical chart notes, intra-oral photographs, and history of periodontal therapy may be required. Failure to provide required radiographs and documentation may result in denial or delay.

Current (within 12 months) dated, identified pretreatment radiographic images showing radiographic apex — REQUIRED
Clinical chart notes and intra-oral photographs as applicable
History of periodontal therapy and current (within 12 months) dated 6‑point periodontal charting may be requested

Documentation Required

Periodontal Therapy Requirement Prior to Indirect Restorations

Definitive periodontal therapy and ongoing periodontal maintenance may be required prior to approval for indirect restorations when periodontal disease, loss of supporting bone, furcation involvement, tooth mobility, or inadequate periodontal charting is present. Provide documentation of successful periodontal treatment and continuous maintenance or include periodontal therapy in the treatment plan with planned evaluation prior to approval.

Treating dentist must demonstrate definitive periodontal therapy and successful periodontal maintenance when indicated
Current (within 12 months), dated 6‑point periodontal charting may be required
If periodontal therapy is part of the plan, success will be evaluated prior to approval for indirect restoration

Denial Risk

Denial Risk — Services Not Meeting Accepted Standards

Services that do not meet generally accepted standards of dental care, or where clinical documentation is insufficient, may be denied. Examples include proposed treatment to salvage non-functional or unrestorable teeth (e.g., poor crown-to-root ratio, significant coronal loss, root fracture, root defects, resorption, caries into furcation, subgingival/subosseous lesions compromising supracrestal tissue attachment), untreated endodontic or periapical pathology, or inadequate radiographic/periodontal documentation.

Denial risk for attempts to salvage non-functional/non-restorable teeth (poor crown-to-root ratio, significant coronal loss, root fracture/defects/perforation, internal/external resorption)
Untreated or unresolved endodontic/periapical pathology will not be considered for restorative benefits
Teeth with caries into the furcation or extensive root caries appearing unrestorable may be denied
Lack of current radiographs, periodontal charting, or evidence of definitive periodontal therapy increases likelihood of denial

Definitions and Key Terms

inv-11: Generally accepted standards of dental care

DefinitionCare provided by a prudent dentist to evaluate, diagnose, or treat dental injury or disease consistent with accepted dental practice

Evidence baseStandards based on credible scientific evidence published in peer‑reviewed dental literature recognized by the practicing dental community

Professional guidanceIncludes specialty society recommendations and the views of recognized dentists practicing in the relevant clinical area

inv-12: Supracrestal tissue attachment (STA)

Term and former nameSupracrestal tissue attachment (STA), formerly referred to as biologic width

Clinical implicationSub‑gingival or sub‑osseous carious lesions that compromise the STA should not be treated without addressing restorative and periodontal considerations

Coverage implicationSuch lesions are considered not appropriate for treatment unless restorative and periodontal issues are addressed

OpenPayer

Generally Accepted Standard of Dental Care

Coverage Criteria — Generally Accepted Standard of Dental Care

Coding, Measurement Thresholds, and Documentation Timeframes

Provider Requirements, Prior Review, and Denial Risk

Background and Scope

Definitions and Key Terms