CurrentBlue Cross Blue Shield - WisconsinPolicy Clinical Policy - 01

Generally Accepted Standards of Dental Care - Clinical Policy 1 (2022 Policy) PDF. Opens in a new window

Defines the plan's review process and criteria for determining whether dental services meet generally accepted standards of dental care and therefore qualify for dental benefits; outlines documentation required and specific clinical situations that may render proposed dental treatment non-covered or not meeting standards.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyGenerally Accepted Standards of Dental Care - Clinical Policy 1 (2022 Policy) PDF. Opens in a new window

Policy CodePolicy Clinical Policy - 01

Change TypeRevised (Publish Date 01/01/2022; last review 10/06/2021)

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit recent, dated, properly identified pretreatment radiographic images including the radiographic apex and provide required clinical documentation (chart notes, intra-oral photos, current 6-point periodontal charting, periodontal/endodontic history) for benefit determination.

SourceLink

POLICY UPDATE CHANGES

Status marked as Revised with Publish Date 01/01/2022 and last review 10/06/2021.

7Explicit clinical exclusion criteria listed

5Required documentation items listed

Coverage Summary

Defines the plan's review process and criteria for determining whether dental services meet generally accepted standards of dental care and therefore qualify for dental benefits. Dental review evaluates whether services provided by a dental professional, exercising prudent clinical judgment, are in accordance with accepted standards, effective in type/frequency/extent for the patient’s condition, not primarily for convenience, not cosmetic, and not more costly than an appropriate alternative. Documentation requirements may include recent, dated, properly identified pretreatment radiographic images that include the radiographic apex, clinical chart notes, intra-oral photographs, current dated 6-point periodontal charting, and history of periodontal therapy. A determination that a service is medically or dentally necessary does not guarantee coverage; services must also meet contractual definitions and cost-effectiveness considerations to be payable.

Medical Necessity / Review Criteria

General Definition of Generally Accepted Standards of Dental Care

Dental services meet generally accepted standards of dental care when ALL of the following are met:

ALL of the following

A dental professional, exercising prudent clinical judgment, provides the service to evaluate, diagnose or treat a dental injury or disease or its symptoms.
The service is in accordance with the generally accepted standards of dental care.
The service is, in terms of type, frequency and extent, considered effective for the patient's dental injury or disease.
The service is not primarily performed for the convenience of the patient or dental professional.
The service is not cosmetic.
The service is not more costly than an alternative service that properly addresses the patient's condition.

Documentation Required for Review

Coverage determinations require submission of relevant documentation including but not limited to:

ALL of the following

Recent, dated, properly identified pretreatment diagnostic radiographic image(s) that include the radiographic apex.
Clinical chart notes.
Intra-oral photographs.
Current dated 6-point periodontal charting.
History of periodontal therapy when applicable.

Situations Where a Service May Be Considered Not Meeting Standards

A service may be considered not meeting generally accepted standards of dental care when ANY of the following are present:

ANY of the following

Crown-to-root ratio poorer than 1:1, taking into account full mouth dental condition, medical history, dental history, periodontal history, periodontal continuing care, age, and occlusion.1:1
Unfavorable crown to root ratios must include assessment of listed factors.
Uncontrolled or untreated periodontal disease evidenced by radiographic or periodontal charting, loss of supporting bone including furcation, unless treating dentist demonstrates definitive periodontal therapy and maintenance have been successfully performed or the treatment plan includes periodontal therapy with success to be evaluated prior to approval for indirect restoration.
Current periodontal status, history of periodontal therapy, presence of tooth mobility, and continuous maintenance therapy may be requested prior to benefit determination.
Endodontic problems including but not limited to: untreated or unresolved periapical or periradicular pathology (benefits limited to endodontic treatment); unresolved lesion near pulp chamber without planned endodontic therapy; overfill/underfill root canal obturation or poor condensation; teeth with internal or external resorption.

Provider Actions & Documentation Requirements

Documentation Required

Submit pretreatment radiographs and clinical documentation

Providers must submit recent, dated, properly identified pretreatment diagnostic radiographic images including the radiographic apex and may be required to submit clinical chart notes, intra-oral photographs, current dated 6-point periodontal charting, and history of periodontal therapy for benefit determination.

Recent, dated, properly identified pretreatment diagnostic radiographic images that include the radiographic apex
Clinical chart notes
Intra-oral photographs
Current dated 6-point periodontal charting
History of periodontal therapy (when applicable)

Documentation Required

Provide periodontal and endodontic status when requested

When periodontal disease or endodontic status is relevant, the treating dentist must demonstrate definitive periodontal therapy and maintenance have been successfully performed or include a treatment plan addressing periodontal/endodontic therapy; current periodontal status and history, and evidence of tooth mobility and maintenance may be requested prior to approval.

Evidence that definitive periodontal therapy and periodontal maintenance have been successfully performed
Documentation of ongoing periodontal maintenance
A treatment plan that addresses required periodontal and/or endodontic therapy when applicable
Current periodontal status and history (may include current dated 6-point periodontal charting)
Evidence of tooth mobility

Denial Risk

Risk of non-coverage for restorative procedures on unrestorable teeth

Claims for procedures intended to salvage non-functional, non-restorable teeth, or for teeth with unfavorable crown-to-root ratios, significant coronal loss, root fracture/defects/perforation, or uncompensated endodontic/pathologic conditions may be denied as not meeting generally accepted standards of dental care.

Crown-to-root ratio poorer than 1:1 (unfavorable crown-to-root ratio)
Significant coronal structural loss making a tooth appear unrestorable
Root fracture, root defects, or root perforation
Uncompensated endodontic/pathologic conditions (e.g., untreated or unresolved periapical or periradicular pathology, unresolved lesion near the pulp without planned endodontic therapy, overfill/underfill root canal obturation, internal or external resorption)
Treatment aimed at salvaging non-functional, non-restorable teeth

Background & Definitions

The guideline explains that dental review determines whether proposed or rendered treatments meet plan contractual requirements for generally accepted standards of dental care. It states that services must meet those standards (based on credible scientific evidence, specialty society recommendations, and recognized clinical opinion) and the plan may require submission of pretreatment radiographs and other clinical documentation for benefit determination. The document emphasizes that a finding of medical/dental necessity does not constitute a warranty of coverage; services must also satisfy contract terms and cost-effectiveness requirements before benefits are payable.

Definitions

Thresholds / Operational Notes