CurrentEmblemHealthPolicy MG.MM.ME.73aC

Dental Care or Treatment Necessary Due to Congenital Disease

Governs medical (non-dental-benefit) coverage for dental care or treatment when necessitated by congenital disease; affects providers requesting prior authorization from EmblemHealth for such services.

Policy Summary

PayerEmblemHealth

PolicyDental Care or Treatment Necessary Due to Congenital Disease

Policy CodePolicy MG.MM.ME.73aC

Change TypeTitle/terminology update (non-material)

Effective Date

Next Review Date

Key ActionSubmit prior authorization with clinical evidence (genetics verification, x‑rays, photos, and comprehensive treatment plan) showing the patient meets all policy criteria.

SourceLink

POLICY UPDATE CHANGES

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

3coverage criteria items required (I-III)

~30examples of qualifying congenital conditions listed

severaldocument types a reviewer may require

listedexplicit implant exclusions

Coverage Criteria for Dental Care Related to Congenital Disease

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Medical necessity criteria

Covered when ALL of the following are met:

Overall coverage rule

I. Underlying congenital disease: The patient must have an underlying congenital disease (examples listed in policy).
Examples of qualifying congenital diseases provided (non-inclusive list).
II. Necessity: Dental care is necessary when the 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.
Orthodontic cases will be considered necessary if they result from congenital disease and meet NYS Medicaid criteria for severe physically handicapping malocclusion.
III. Appropriateness: Dental care is appropriate for the condition; EmblemHealth reserves the right to evaluate treatment options on a case-by-case basis and to substitute least costly clinically acceptable alternatives.
Common isolated dental anomalies (e.g., missing lateral incisors or bicuspids) generally do not meet the substantial long-term deficit requirement and will not be covered.

I. Underlying congenital disease — supporting detail: Congenital disease: a disease present at birth; may be due to hereditary factors, prenatal infection, injury, or effects of a drug taken during pregnancy.

II. Necessity — supporting detail: Orthodontic care: considered necessary when resulting from congenital disease and meeting requirements of a severe physically handicapping malocclusion per New York State Medicaid policy.

III. Appropriateness — supporting detail: EmblemHealth may substitute least costly alternatives and will generally not cover isolated dental anomalies that do not cause substantial long-term deficits in eating or speaking.

Temporary restorations are included in the fee for the final restoration and should not be billed separately. Dental implants are excluded in several scenarios: when abutment teeth already have crowns or, in the opinion of a consultant, require crowns; when implants are not part of a clinically acceptable treatment plan; when replacing third molars; and when replacing primary (deciduous) teeth. Additionally, implants are not covered in age-inappropriate cases or clinical circumstances where there is not a reasonable chance of success because implants are not indicated until appropriate alveolar growth has occurred.

Dental anomalies such as congenitally missing lateral incisors or bicuspid teeth are reviewed on a case-by-case basis but generally do not meet the policy criteria and therefore will not be covered.

Isolated dental anomalies (for example, a single missing lateral incisor or bicuspid) that do not reasonably cause substantial and long-term deficits in the individual’s ability to eat or speak are not considered medically necessary under this policy and will not meet coverage criteria.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. The treating physician or primary care provider must submit clinical evidence demonstrating the patient meets ALL policy criteria. Without sufficient documentation, EmblemHealth will not be able to properly review the request for prior authorization and the request may be deferred or denied.

Submit clinical evidence that the patient has an underlying congenital disease
Demonstrate that dental care is necessary because the patient experiences or is reasonably expected to experience substantial, long-term deficits in eating or speaking due to multiple missing or malformed teeth
Show the proposed dental care is appropriate for the condition

Note

Least Costly Alternative Consideration

EmblemHealth may evaluate proposed treatments on a case-by-case basis and reserve the right to substitute the least costly acceptable alternative. Treatment options that do not meet the policy threshold for substantial and long-term functional deficits (for example, isolated missing lateral incisors or bicuspids) will generally not meet coverage criteria.

EmblemHealth may substitute least costly alternatives when clinically acceptable
Case-by-case review will consider functional impact on eating and speaking

Documentation Required

Required Supporting Documentation

A reviewer may request specific supporting documentation to verify the diagnosis and medical necessity. Failure to provide requested supporting documentation may prevent review or result in denial.

Geneticist verification of the underlying congenital condition when applicable
X-rays demonstrating teeth are congenitally missing (not missing due to extraction)
Clinical photographs as needed to document oral findings
A comprehensive treatment plan describing proposed procedures and rationale

Denial Risk

Documentation Required for Review

EmblemHealth requires complete documentation for review. If documentation is missing, incomplete, or does not demonstrate the member meets all policy criteria, EmblemHealth may be unable to complete a medical necessity review and may deny the request.

Provide all requested records, imaging, verification letters, and treatment plans at time of prior authorization submission
Clearly document functional deficits in eating or speaking and link proposed treatment to expected functional improvement
Note any exclusions or limitations that may apply (see Limitations/Exclusions)

Definitions

Congenital Disease — definition

DefinitionA disease that is present at birth; may be due to hereditary factors, prenatal infection, injury, or the effect of a drug the mother took during pregnancy.

Timing of onsetPresent at birth (congenital).

Possible causesHereditary factors, prenatal infection, injury, or maternal drug exposure during pregnancy.

Relevance to coveragePolicy applies to dental care necessitated by congenital disease—coverage requires documentation that condition is present at birth and meets clinical criteria.

Documentation noteGeneticist verification or clinical evidence may be required to substantiate the congenital diagnosis for prior authorization review.

OpenPayer

Dental Care or Treatment Necessary Due to Congenital Disease

Coverage Criteria for Dental Care Related to Congenital Disease

Provider Requirements, Prior Authorization, and Documentation

Definitions

Background