CurrentEmpire BluecrossPolicy Clinical Policy 01

Generally Accepted Standard of Dental Care

Defines criteria and documentation requirements used by the payer to determine whether proposed dental services meet generally accepted standards of dental care and are eligible for benefits; applies to treating dentists submitting requests for covered members.

Policy Summary

PayerEmpire Bluecross

PolicyGenerally Accepted Standard of Dental Care

Policy CodePolicy Clinical Policy 01

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionInclude recent, dated pretreatment radiographic images showing the radiographic apex and supporting clinical documentation when submitting requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

radiographs & notesdocumentation required

6-point chartperiodontal charting

several criteriaexclusion examples

12/06/2020last review

Coverage Criteria — Generally Accepted Standards

Policy Summary

PayerEmpire Bluecross

PolicyGenerally Accepted Standard of Dental Care

Policy CodePolicy Clinical Policy 01

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionInclude recent, dated pretreatment radiographic images showing the radiographic apex and supporting clinical documentation when submitting requests.

SourceLink

On This Page

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Structural and periodontal contraindications: Teeth with crown-to-root ratios poorer than 1:1; teeth exhibiting significant coronal structural loss that appears unrestorable; teeth with root fracture, root defects, or root perforation.

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

Periodontal disease: Uncontrolled or untreated periodontal disease evidenced by radiographic or periodontal charting, loss of supporting bone including furcation, or presence of tooth mobility.

Definitive periodontal therapy and periodontal maintenance must have been successfully performed or be included in the treatment plan; current dated 6‑point periodontal charting and history of periodontal therapy may be requested prior to benefit determination.

Endodontic considerations: Untreated or unresolved periapical or periradicular pathology; teeth with overfill/underfill root canal obturation or poor condensation; unresolved lesion in close proximity to the pulp chamber without planned endodontic therapy; teeth with internal or external resorption.

See Dental Policy 03-001 Endodontic Therapy for related coverage rules.

Sub-gingival caries: Treatment of teeth with sub‑gingival/sub‑osseous carious lesions that compromise the supracrestal tissues without addressing restorative and periodontal considerations is not appropriate.

Dental care directed at salvaging non-functional, non-restorable teeth may not be considered for benefits. Dental review will determine whether the proposed or rendered treatment meets the plan contract requirement that services adhere to generally accepted standards of dental care, including consideration of whether the service is effective, appropriately timed, not primarily cosmetic or for convenience, and not more costly than alternatives.

Examples of tooth conditions that may support a determination that treatment is not eligible for benefits include: unfavorable crown-to-root ratios (poorer than 1:1); uncontrolled or untreated periodontal disease with loss of supporting bone or furcation involvement unless definitive periodontal therapy and maintenance have been performed or are included in the treatment plan; untreated or unresolved endodontic pathology (including overfill/underfill of root canal obturation, poor condensation, or lesions near the pulp chamber without planned endodontic therapy); internal or external resorption; root fracture, root defects, or root perforation; and significant coronal structural loss that appears unrestorable.

Provider Actions, Documentation & Prior Authorization

Prior Authorization

Prior Authorization and Dental Review

Prior authorization is required for proposed restorative services when submitted by treating dentists. Dental review will determine whether the proposed treatment meets the plan contractual requirement that dental services conform to generally accepted standards of dental care and are the lowest cost option that properly addresses the patient's condition. Submission of a prior authorization request does not guarantee that a service is a covered benefit payable by the plan.

Prior authorization required for restorative treatment requests
Dental review assesses whether services meet generally accepted standards of dental care and contract requirements

Documentation Required

Documentation Specifics

Documentation must include recent, dated, properly identified pretreatment diagnostic radiographic image(s) that show the radiographic apex. Clinical chart notes, intra-oral photographs, a current dated 6‑point periodontal charting, and history of periodontal therapy may also be required to support benefit determination.

Recent, dated, properly identified pretreatment radiograph(s) including the radiographic apex
Clinical chart notes and intra-oral photos
Current dated 6‑point periodontal charting and periodontal therapy history (if applicable)

Denial Risk

Services Directed at Salvaging Non‑Functional/Non‑Restorable Teeth

Dental services directed at salvaging non-functional or non-restorable teeth may not be considered for benefits. Examples of findings that commonly render teeth non-restorable or unlikely to meet benefit criteria include: crown-to-root ratios poorer than 1:1 (after consideration of full‑mouth condition, medical/dental history, periodontal history and maintenance, age, and occlusion); untreated or uncontrolled periodontal disease with radiographic bone loss or furcation involvement; teeth with root fracture, root defects, root perforation, internal or external resorption; teeth with significant coronal structural loss that appears unrestorable; and teeth with unresolved periapical or periradicular pathology.

Crown-to-root ratio poorer than 1:1 (requires full-mouth assessment)
Uncontrolled/untreated periodontal disease, loss of supporting bone, furcation involvement
Root fracture, root defects, root perforation, internal/external resorption
Significant coronal structural loss appearing unrestorable
Unresolved periapical or periradicular pathology

Documentation Required

If Periodontal or Endodontic Therapy Is Required

If periodontal or endodontic therapy is required to render a tooth restorable, include documentation of definitive therapy and maintenance or a clear timeline for completion. Teeth with untreated or unresolved endodontic pathology, overfill/underfill root canal obturations, poor condensation, or lesions near the pulp chamber in the absence of planned endodontic therapy will generally not be approved for indirect restorations until endodontic issues are addressed. Similarly, teeth with periodontal disease must demonstrate successful definitive periodontal therapy and ongoing maintenance or a treatment plan that anticipates evaluation of periodontal success prior to approval.

Provide documentation of definitive periodontal therapy and ongoing maintenance or a timeline for completion
Provide documentation of completed endodontic therapy or planned endodontic treatment prior to approval of indirect restorations
Teeth with overfill/underfill root canal obturation or poor condensation may be excluded until endodontic adequacy is demonstrated

Note

Provider Action Summary

Reiterated provider actions: submit complete prior authorization requests with the required diagnostic images and clinical documentation; document current periodontal status and history of therapy when periodontal concerns exist; document endodontic status and any definitive endodontic treatment when indicated. The plan may request additional information and will evaluate the full‑mouth and medical/dental context when determining benefit eligibility. Services primarily for patient or provider convenience, cosmetic procedures, or more costly alternatives without clinical justification may not meet the plan's standards.

Submit full prior authorization with radiographs, chart notes, photos, periodontal charting as applicable
Document definitive periodontal and/or endodontic therapy or timeline for completion when needed to render tooth restorable
Be prepared to provide full‑mouth assessment, medical/dental history, periodontal maintenance history, and occlusal considerations on request

Background

This policy describes how the plan applies the basis of generally accepted standards of dental care when making benefit determinations. Standards referenced include peer-reviewed dental literature, specialty society recommendations, and the views of recognized clinicians; determinations consider whether services meet accepted standards in type, frequency, and extent, are effective for the condition, are not primarily cosmetic or for convenience, and comply with plan contract requirements.

Definitions

Generally accepted standards of dental care — definition of services and clinical judgment basis

DefinitionDental services that a dental professional, exercising prudent clinical judgment, provides to evaluate, diagnose, or treat a dental injury or disease or its symptoms and that are: in accordance with generally accepted standards of dental care; effective for the patient’s condition in type, frequency, and extent; not primarily for convenience or cosmetic purposes; and not more costly than an appropriate alternative.

Basis for standardsStandards are based on credible scientific evidence published in peer‑reviewed dental literature, specialty society recommendations/criteria, and the views of recognized dentists practicing in the relevant clinical area (and other relevant factors).

Application to benefitsDental review will determine whether proposed or rendered treatment meets these generally accepted standards and plan contract requirements; meeting medical/dental necessity alone does not guarantee a covered benefit under the plan.

Non‑covered exampleDental care directed at salvaging non‑functional, non‑restorable teeth may not be considered for benefits.

Scope of judgmentAssessment is performed by a dental professional exercising prudent clinical judgment, considering type, frequency, extent, effectiveness, cosmetic/convenience intent, and cost relative to alternatives.