CurrentEmblemHealthPolicy MG.MM.ME.73C5a

Dental Care or Treatment Necessary Due to Congenital Disease

This guideline governs when medical (not dental) coverage may be provided for dental care or treatment that is necessary due to a congenital disease, and applies to EmblemHealth members and treating providers requesting prior authorization.

Policy Summary

PayerEmblemHealth

PolicyDental Care or Treatment Necessary Due to Congenital Disease

Policy CodePolicy MG.MM.ME.73C5a

Change TypeTitle/content wording revision

Effective Date

Next Review Date

Key ActionPrior authorization is required with submission of clinical evidence that the patient meets all policy criteria for coverage.

SourceLink

POLICY UPDATE CHANGES

Removed 'Anomaly' from title, definition, and content of policy

25+examples of qualifying congenital conditions listed

3core coverage criteria items required for eligibility

4documented reviewer verification items that may be required

4explicit implant exclusions/conditions listed

Coverage Criteria for Dental Care Related to Congenital Disease

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Eligibility criteria

Covered when ALL of the following are met

Core criteria

I. Underlying condition: The patient must have an underlying congenital disease.
II. Necessity: The dental care is necessary when an individual experiences or is reasonably expected to experience substantial and long-term deficits in the ability to eat or speak due to multiple missing or malformed teeth.
III. Appropriateness: The dental care is appropriate for the condition; EmblemHealth may evaluate treatment options case-by-case and substitute least costly clinically acceptable alternatives.

Orthodontic cases are considered necessary if they result from a congenital disease and meet the New York State Medicaid definition of severe physically handicapping malocclusion.

Dental anomalies such as isolated missing lateral incisors or bicuspid teeth generally do not meet the policy requirement that a congenital defect cause a substantial and long-term functional deficit in the ability to eat or speak. EmblemHealth reviews such anomalies on a case-by-case basis, but absent clear evidence that the anomaly produces the requisite persistent impairment, these findings alone will not support coverage.

Examples of situations that typically do not reasonably cause substantial and long-term deficits include isolated missing lateral incisors or single missing bicuspids. Coverage is likewise unlikely when the proposed intervention is a temporary restoration (which is inclusive in the fee for final restorations) or when the procedure falls into specific implant exclusions such as replacement of third molars or primary teeth. EmblemHealth may consider exceptions only when documentation demonstrates the anomaly results in ongoing, significant impairment of eating or speaking and the proposed treatment is part of an appropriate, clinically acceptable plan.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. The treating physician or primary care provider must submit clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization.

Prior authorization and clinical evidence required for review

Note

EmblemHealth May Substitute Least-Cost Options

EmblemHealth reserves the right to evaluate treatment options on a case-by-case basis and to substitute the least costly clinically acceptable alternatives.

EmblemHealth may substitute least costly clinically acceptable options

Documentation Required

Documentation That May Be Required

The provider must submit clinical evidence demonstrating the congenital condition and that the proposed dental care meets the policy criteria. A reviewer may require:

Geneticist verification of underlying congenital condition
X-rays demonstrating teeth are congenitally missing (not due to extraction)
Additional supporting documentation including photos as needed
A comprehensive treatment plan

Denial Risk

Failure to Submit Required Clinical Evidence

Failure to submit the required clinical evidence will prevent EmblemHealth from properly reviewing the prior authorization request and may result in denial of the request.

Incomplete or missing documentation risks denial or inability to complete review

Denial Risk

Procedures Not Meeting Medical Necessity / Not Covered

Procedures that do not meet the policy's medical necessity criteria will be denied or are not covered. Examples include minor dental anomalies that do not generally cause substantial, long-term deficits in eating or speaking (e.g., missing lateral incisors or bicuspid teeth). Dental implants are excluded in specific situations (see Limitations/Exclusions) such as replacing third molars, replacing primary teeth, age-inappropriate cases prior to adequate alveolar growth, when abutment teeth have or require crowns per consultant opinion, or when not part of a clinically acceptable treatment plan.

Minor anomalies (missing lateral incisors or bicuspids) generally not covered
Dental implants not covered when: replacing third molars; replacing primary teeth; age-inappropriate or without reasonable chance of success; abutment teeth have or require crowns; not part of a clinically acceptable treatment plan

OpenPayer

Dental Care or Treatment Necessary Due to Congenital Disease

Coverage Criteria for Dental Care Related to Congenital Disease

Provider Requirements and Prior Authorization

Background and Clinical Context

Key Definitions