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    v1.0.31
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialDelta Dental Ohio Care Criteria Update | OpenPayer
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    CurrentDelta Dental of OhioPolicy 282.23.v2

    Clinical Criteria for Appropriateness of Care

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    This policy establishes clinical criteria used by Delta Dental of Ohio dental peer reviewers to evaluate whether dental procedures were inadvisable, clinically deficient, inadequately documented, incomplete, or never performed. It applies when benefit payment requires an appropriateness-of-care review and does not determine whether a procedure is covered under an individual dental plan.

    Policy Summary
    PayerDelta Dental of Ohio
    PolicyClinical Criteria for Appropriateness of Care
    Policy CodePolicy 282.23.v2
    Change TypeNo material change
    Effective DateJun 21, 2025
    Next Review DateN/A
    Key ActionMaintain complete, organized, consistent clinical documentation and submit appropriate dental-record information when peer review is required.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    23Conditions that may support disapproval
    5Clinical criteria pages
    5Documentation categories
    2Contextual factors

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    AnnualUpdate cycle

    Appropriateness-of-Care Review Criteria

    Appropriateness-of-care review and potential benefit disapproval

    When payment of benefits requires evaluation of appropriateness of care, benefit payment may be disapproved after review of the patient's unique circumstances and mitigating factors if credible evidence supports the applicable conditions below.

    title

    A determination that a dental procedure is clinically appropriate—including a determination that supporting documentation is adequate—does not guarantee that the procedure is a covered benefit. Coverage must be determined under the member’s dental plan documents in effect on the date of service.

    Documentation and Disapproval Considerations

    Documentation Required

    Records Supporting Appropriateness of Care

    A dental procedure should be supported by a thorough clinical and radiographic examination and a treatment plan consistent with appropriate care. Maintain complete, organized, and consistent clinical documentation throughout treatment to support continuity of care, professional decision-making, and dental health outcomes.

    • Preoperative radiographic and/or photographic imaging supporting the procedure.
    • Relevant information about the patient's overall medical and dental history.
    • Documentation of the present condition of the teeth and surrounding tissues.
    • Explanation of the diagnostic rationale for performing the procedure.
    • Documentation that the procedure was performed and completed, including associated procedures provided concurrently, such as anesthesia or intravenous sedation.
    Denial Risk

    Clinical Conditions Supporting Disapproval

    When credible evidence shows that a procedure was inadvisable, deficient in clinical quality, inadequately documented, incomplete, or never performed, benefit payment may be disapproved after review of the patient's unique circumstances and any mitigating factors. Examples of conditions that may support disapproval include:

    • Unresolved active periodontal disease; advanced loss of periodontal attachment with insufficient bony support; advanced furcation involvement; or advanced mucogingival defects.
    • Unresolved periapical pathology; inadequate or unsuccessful endodontic therapy or periradicular surgery; improperly aligned post; unfavorable root morphology or root resorption; iatrogenic root perforation; or failed root integrity due to fracture or resorptive defect.
    • Structural breakdown from caries, extensive restoration, or tooth fracture with insufficient sound tooth structure; or fracture, breakdown, or perforation through the furcation of a multirooted tooth.
    • A primary tooth nearing exfoliation with more than half of the roots resorbed and the tooth mobile.
    • Allergy to a material used in the procedure, such as nickel.
    • Inadequate tooth preparation, inadequate marginal adaptation, or inadequate healing time following surgical crown lengthening.
    • A compromised temporomandibular joint or a coexisting major systemic disease or other health condition that makes treatment inadvisable.
    • An alternative procedure is the appropriate treatment for the patient's condition or circumstances.
    Denial Risk

    Insufficient Supporting Records

    When a procedure is subject to dental peer-review evaluation for benefit payment, the treating practitioner should submit appropriate information from the patient's dental record. If the practitioner cannot provide the required supporting information, benefit payment may be disapproved.

    • Submit relevant clinical, radiographic, photographic, diagnostic, medical-history, and procedure-completion records with the claim when required for review.
    • Ensure records are complete, organized, consistent, and sufficient to establish the condition treated, the rationale for treatment, and completion of the procedure.
    Billing Rule

    Applicable Requirements Take Precedence

    These clinical criteria do not override other applicable requirements. Government regulations, federal or state statutes or regulations, dental plan contract provisions, local or national claim-processing policies, CMS rules and requirements, and other mandated requirements may take precedence over or affect application of the criteria.

    • Apply the member's dental plan provisions and applicable government or statutory requirements when determining medical necessity, clinical appropriateness, and benefit coverage.
    • Follow applicable local or national claim-processing policies and other mandated requirements if they differ from or impose requirements beyond these criteria.

    Policy Background

    Appropriate dental care is evaluated based on whether the type, frequency, extent, site, and duration of treatment fit the patient’s dental condition. Review also considers whether the timing, sequencing, and documentation are consistent with generally accepted dental practice, together with the patient’s unique circumstances and mitigating factors, such as age, comorbidities, complications, treatment progress, psychosocial situation, home environment, and available local dental delivery-system resources.

    Key Definitions

    Appropriate care
    DefinitionDental care is appropriate when the type, frequency, extent, site, and duration of treatment apply to the individual patient’s dental condition.
    Treatment timingThe timing and sequencing of treatment must be consistent with generally accepted standards of dental practice.
    DocumentationDocumentation of treatment must be consistent with generally accepted standards of dental practice.
    EPSDT
    DefinitionEPSDT means Early and Periodic Screening, Diagnostic, and Treatment.
    Medicaid scopeEPSDT is a comprehensive healthcare benefit for children and youth under age 21 enrolled in Medicaid.
    Policy Summary
    PayerDelta Dental of Ohio
    PolicyClinical Criteria for Appropriateness of Care
    Policy CodePolicy 282.23.v2
    Change TypeNo material change
    Effective DateJun 21, 2025
    Next Review DateN/A
    Key ActionMaintain complete, organized, consistent clinical documentation and submit appropriate dental-record information when peer review is required.
    SourceLink
    On This Page
    Appropriateness-of-Care Review CriteriaDocumentation and Disapproval ConsiderationsPolicy BackgroundKey Definitions
  1. The tooth was extracted or missing as of the submitted service date.
  2. Information submitted with the claim is inconsistent with the patient's dental record.
  3. There is no documentation that the procedure was performed and completed.
    4. Included services
    The benefit includes regular vision, hearing, dental, and developmental screenings, diagnostic services, and treatment to correct or ameliorate health conditions.
    Dental coverageCovered dental services must include, at a minimum, care for relief of pain and infection, restoration of teeth, maintenance of dental health, and medically necessary orthodontic services.
    Medically necessary frequencyServices provided more frequently than the state periodicity schedule are covered when medically necessary for an individual child.