Clinical Criteria (Children)

For Utilization Review Decision Making

(Child and Adolescent Patients)

 

Benefit coverage of dental services and procedures is determined in accordance with the specific terms of a member's dental plan. It is Delta Dental’s policy to adopt objective and evidence-based written clinical criteria to be referenced as guidelines when the administration of member dental plans requires professional utilization review of the medical necessity or clinical appropriateness of dental services and procedures.

References subject to adoption by Delta Dental as clinical criteria for determining the medical necessity and clinical appropriateness of dental services and procedures for child and adolescent patients include clinical guidelines, parameters, positions, recommendations and statements published by the American Academy of Pediatric Dentistry, American Academy of Periodontology, American Academy of Oral Medicine, American Association of Endodontists, American Association of Oral and Maxillofacial Surgeons, American College of Prosthodontists, the Cochrane database of systematic reviews, the U.S. Centers for Disease Control and Prevention and the U.S. Centers for Medicare & Medicaid Services.

All clinical criteria adopted by Delta Dental must be reviewed on at least an annual basis and updated as necessary to ensure that they remain consistent with current clinical and scientific evidence.

Clinical criteria referenced by Delta Dental and associated benefit payment determinations do not qualify as dental or medical advice. Patients and their responsible persons must make all decisions about the desirability or necessity of dental procedures and services with their dentist.

The dental procedure codes referenced herein are from the current version of the American Dental Association’s Code on Dental Procedures and Nomenclature (the CDT® Code). CDT® is a registered trademark of the American Dental Association. The Association is the exclusive copyright owner of CDT, the Code on Dental Procedures and Nomenclature and the ADA Dental Claim Form. Inclusion of these codes is for informational purposes only and does not imply benefit coverage of a procedure by a member’s dental plan. To determine if a procedure is a covered benefit of an individual member’s dental plan, refer to the plan documents in effect on the date of service.

The following clinical criteria are not intended to cover every situation where a patient may require dental care. When evaluating dental services and procedures for medical necessity and clinical appropriateness, reviewers will take into consideration relevant individual patient characteristics, such as past and current dental condition, age, comorbidities, complications and progress of treatment. If appropriate, reviewers will also take into consideration available services in the local dental delivery system and the ability of those services to meet a member’s specific dental care needs when clinical criteria are applied. Statutes, rules and regulations of federal and state governments, dental plan contract provisions, local and national claim processing policies or other mandated requirements may take precedence over clinical criteria.

General Criteria

The following criteria generally apply to the planning and provision of dental services and procedures:

  • Appropriate informed consent must be obtained from responsible persons prior to providing dental services and procedures to child and adolescent patients.
  • The provision of dental treatment must be preceded by an appropriate clinical evaluation, the development of a diagnosis and the creation of a treatment plan. Treatment plans must be appropriate to individual patient needs, be consistent with documented diagnoses and have treatment appropriately sequenced.
  • If acceptable radiographs are reasonably available from another source, practitioners should use those images rather than exposing a patient to more radiation. When such images are not available, practitioners should obtain the appropriate radiographs required for the diagnosis and treatment of a patient in accordance with The Selection of Patients for Dental Radiographic Examinations published by the American Dental Association and the U.S. Food and Drug Administration and Optimizing radiation safety in dentistry published by the American Dental Association.
  • Clinicians must employ appropriate infection control procedures as described in the 2003 Guidelines for Infection Control in Dental Health-Care Settings and the 2016 Summary of Infection Prevention Practices in Dental Settings from the U.S. Centers for Disease Control and Prevention.
  • Patient dental records must legibly document appropriate information including, but not limited to:
    • Patient identification information including the patient’s full name, birth date, address, telephone number, emergency contact and authorized representative (if any)
    • Medical and dental history
    • Patient complaints
    • Thorough charting of the patient's existing oral health care status
    • The result of any diagnostic tests
    • A comprehensive diagnosis and treatment plan
    • All dental procedures performed upon the patient, including the date of service, identity of the treating clinician and thorough description of the procedure
    • Treatment progress notes
    • The date, dosage and amount of any medication or drug prescribed, dispensed or administered to the patient
    • Appropriate informed consent
    • Any other documentation required to completely document the quantity, quality, appropriateness and timeliness of dental services and procedures provided
  • Dental services and procedures must be covered by a member’s dental plan and be completed to be eligible for benefit payment. Non-covered services and incomplete procedures are not eligible for benefit payment. When dental care is interrupted or terminated due a change in a patient’s treating clinician or the death of a patient, any involved claim will be reviewed to determine what benefit coverage, if any, is available for services completed or in progress.
  • Dental services and procedures determined not to be medically necessary or clinically appropriate are not eligible for benefit payment.
  • When planing the provision of dental service and procedures, practitioners should consider the likely prognosis and whether a successful treatment outcome may reasonably be expected. Benefits for services and procedures determined to have a poor endodontic, periodontal, structural, restorative or prosthodontic prognosis may not be considered eligible for benefit payment.

Criteria for Diagnostic Services

Child and adolescent patients who have no contributing medical conditions and are developing normally should receive clinical oral evaluations and radiographic assessment on a periodicity that conforms to the American Academy of Pediatric Dentistry best practice guideline Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children. The Academy’s periodicity schedule can be accessed at http://www.aapd.org/assets/1/7/Periodicity-AAPDSchedule.pdf.

Comprehensive and periodic oral evaluation procedures must include, but are not limited to:

  • Review and documentation of a pediatric patient's medical and dental history
  • Examination and documentation of the condition of extra-oral and intra-oral tissues
  • Recording of periodontal status
  • Documentation of the condition of the teeth including restorations and caries
  • Caries risk assessment
  • Examination for oral pathology
  • Assessment of growth and development
  • Recording of appropriate diagnoses that are supported by evaluation findings
  • Documentation of a treatment plan that is consistent with diagnoses

As a guideline, to be considered acceptable for benefit payment and documentation of medical necessity and clinical appropriateness, radiographic images must be reasonably contemporaneous with treatment, include the appropriate number and type of images for the patient’s age and condition, be of diagnostic quality, include the identity of the patient and treating clinician, include the date of exposure and have acceptable brightness, contrast and clarity. Depending on the image type, radiographic images must be appropriately mounted, be labeled right and left, have no cone cutting, reveal contact areas and, as appropriate to the image, allow visualization of the crowns and roots of the teeth, periapical areas, alveolar bone in dentulous and edentulous regions and any vital structures that could be impacted by planned treatment.

 

References adopted by Delta Dental as clinical criteria for diagnostic services for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on the Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, available at

http://www.aapd.org/media/Policies_Guidelines/BP_Periodicity.pdf.

The American Academy of Pediatric Dentistry recommendations on Caries-risk Assessment and Management for Infants, Children, and Adolescents, available at

https://www.aapd.org/globalassets/media/policies_guidelines/bp_cariesriskassessment.pdf?v=new.

The American Academy of Pediatric Dentistry recommendations on Prescribing Dental Radiographs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs, available at

http://www.aapd.org/media/Policies_Guidelines/BP_Radiographs.pdf.

The Selection of Patients for Dental Radiographic Examinations published by the American Dental Association and the U.S. Food and Drug Administration, available at

https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/ada-fda-guide-patient-selection-dental-radiographs

The American Dental Association recommendations for Optimizing radiation safety in dentistry, available at https://jada.ada.org/action/showPdf?pii=S0002-8177%2823%2900734-1

The American Academy of Oral Medicine Clinical Practice Statement on Oral Cancer Screening, available at

https://www.aaom.com/clinical-practice-statement--oral-cancer-screening

Criteria for Preventive Services

Child Prophylaxis (D1120) and Adult Prophylaxis (D1110): Dental prophylaxis is intended for dentulous patients with a generally healthy periodontium where supragingival and subgingival deposits are removed to control irritational factors, as well as for patients with localized gingivitis to prevent further progression of the disease. The frequency of dental prophylaxis appointments should be determined based on the patient's oral condition, including the risk of caries, risk of periodontal disease and the need to control local irritational factors by the removal of plaque, calculus and stains from teeth. Dental benefit programs may establish program-specific criteria that define the age at which a person is considered an adult for the purpose of determining prophylaxis benefits. In the absence of program-specific criteria, generally patients age 14 or above are considered eligible for an adult prophylaxis.

Topical Fluoride Treatment (D1206-D1208): Professionally-applied topical fluoride is recommended as a preventive treatment for pediatric patients at risk of developing dental caries.

Interim Caries Arresting Medicament Application (D1354): 38 percent silver diamine fluoride (SDF) has been approved by the FDA as a minimally invasive medicament to arrest caries in nonsymptomatic carious lesions without cutting of tooth structure. An FDA-approved SDF product for caries arrest must be used. After SDF application, the tooth must be monitored for caries arrest. Tooth restoration is generally required after SDF application and arrest of caries. Dental benefit programs may place limitations on the number of SDF applications per tooth that are eligible for benefits over a period of time, such as a maximum of five teeth treated per date of service and six application visits per lifetime. For more clinical information, please refer to the American Academy of Pediatric Dentistry recommendation on the Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs, available at http://www.aapd.org/media/Policies_Guidelines/G_SDF.pdf and Chairside Guide: Silver Diamine Fluoride in the Management of Dental Caries Lesions, available at http://www.aapd.org/media/Policies_Guidelines/R_ChairsideGuide.pdf.

Sealants (D1351): Sealants are indicated for application to the occlusal surfaces of permanent posterior teeth using resin-based sealants, resin-modified glass ionomer sealants, glass ionomer cements or polyacid-modified resin sealants. The use of sealants is intended to prevent dental caries on sound occlusal surfaces, but sealants may also be applied to non-cavitated occlusal carious lesions of permanent posterior teeth to mitigate caries progression. Dental benefit programs may place limitations on the teeth eligible for sealant benefits and when sealant repair (D1353) is eligible for benefits.

Space Maintainers (D1510-D1575): Space maintainers are considered necessary when required to hold space for permanent tooth eruption when a posterior primary tooth has been prematurely lost and the existing arch space must be maintained. The fixed, unilateral distal shoe space maintainer (D1575) is eligible for benefits only if it is used to guide the eruption of a first permanent molar. Dental benefit programs may place limitations on when re-cementing/re-bonding a space maintainer (D1551-D1553) is eligible for benefits.

References adopted by Delta Dental as clinical criteria for preventive services for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on the Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents, available at http://www.aapd.org/media/policies_guidelines/g_periodicity.pdf.

The American Academy of Pediatric Dentistry Policy on Early Childhood Caries available at http://www.aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf and http://www.aapd.org/media/Policies_Guidelines/P_ECCUniqueChallenges.pdf.

The American Academy of Pediatric Dentistry Policy on the Role of Dental Prophylaxis in Pediatric Dentistry, available at http://www.aapd.org/media/Policies_Guidelines/P_Prophylaxis.pdf.

The American Academy of Periodontology position paper on Periodontal Diseases of Children and Adolescents, available at https://onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2003.74.11.1696.

The American Academy of Periodontology Parameter on Plaque-Induced Gingivitis available at http://www.joponline.org/doi/pdf/10.1902/jop.2000.71.5-S.851.

The American Dental Association clinical practice guideline Professionally-Applied and Prescription-Strength, Home-Use Topical Fluoride Agents for Caries Prevention, available at

https://www.ada.org/en/resources/research/science-and-research-institute/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline.

The American Academy of Pediatric Dentistry Policy on Use of Fluoride, available at

https://www.aapd.org/globalassets/media/policies_guidelines/p_fluorideuse.pdf.

The American Dental Association Pit-and-Fissure Sealants Clinical Practice Guideline, available at https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research/sealants-clinical-practice-guideline

and the American Academy of Pediatric Dentistry recommendations on the Use of Pit-and-Fissure Sealants, available at http://www.aapd.org/media/Policies_Guidelines/G_Sealants.pdf.

The American Dental Association Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions (silver diamine fluoride), available at

https://jada.ada.org/action/showPdf?pii=S0002-8177%2818%2930469-0.

The American Academy of Pediatric Dentistry recommendations on the Management of the Developing Dentition and Occlusion in Pediatric Dentistry (space maintainers), available at

https://www.aapd.org/globalassets/media/policies_guidelines/bp_developdentition.pdf.

Criteria for Restorative Services

Direct and Indirect Restorations: Prior to beginning restorative treatment on child and adolescent patients, the condition of the involved teeth must be comprehensively evaluated and the necessity for treatment documented in the patient record. Teeth with unresolved periodontal disease or endodontic pathology should receive appropriate treatment that should ordinarily be completed prior to a course of restoration. Teeth with an unrestorable structural, endodontic or periodontal condition and primary teeth where exfoliation is imminent do not qualify for restorative benefits.

 

Completed restorations must meet the applicable standards of dental practice for restorative material selection, restoration design and preparation, marginal integrity, interproximal contacts, retention and occlusion. Restorations performed on teeth with a condition that significantly compromises the restorative prognosis will generally not be eligible for benefit payment. Documentation in the patient record must clearly describe the restoration and restorative material(s) provided, the reason for the restoration, per-visit details of multi-stage procedures, the tooth number(s) and the tooth surface(s) involved.

 

Single Crown Restorations: For a tooth to be eligible for single crown benefit payment, the tooth must have either (1) extensive loss of coronal structure (50% or more of coronal tooth structure is missing) due to caries or fracture where a more conservative restoration is not the appropriate treatment or (2) a failing crown restoration that requires replacement. Examples of extensive loss of coronal structure include:

  • An anterior tooth with loss of coronal tooth structure due to initial caries, recurrent caries, restoration failure or fracture involving four or more surfaces and one-half or more of the incisal edge lost
  • A posterior tooth with loss of coronal tooth structure due to initial caries, recurrent caries, restoration failure or fracture involving three or more surfaces and one or more cusps lost
  • A tooth with successful prior endodontic treatment and an endodontic access opening that has removed an extensive amount of tooth structure such that a crown is required to support the remaining tooth structure

 

Core Buildup: For a tooth to be eligible for core buildup benefit payment, there must be preoperative evidence of extensive loss of original coronal tooth structure (50% or more of coronal tooth structure is missing) due to caries, fracture or appropriate endodontic therapy, such that without placement of the core material there would be insufficient vertical height in the prepared tooth to provide adequate resistance to displacement and retention of an extra-coronally retained crown.

 

Post and Core: For a tooth to be eligible for post and core benefit payment, a preoperative assessment must document that the tooth (1) has had successful completion of endodontic therapy, (2) needs a crown to protect the remaining tooth structure or to support a fixed partial denture, (3) requires a core buildup to replace missing tooth structure needed to retain the crown, (4) needs a post to retain the core material and (5) has sufficient root length to accommodate the post.

 

References adopted by Delta Dental as clinical criteria for restorative services for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on Caries-Risk Assessment and Management for Infants, Children, and Adolescents, available at http://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf and the American Dental Association Caries Risk Assessment and Management clinical information available at https://www.ada.org/en/member-center/oral-health-topics/caries-risk-assessment-and-management.

The American Academy of Pediatric Dentistry recommendations on Pediatric Restorative Dentistry, available at http://www.aapd.org/media/Policies_Guidelines/BP_RestorativeDent.pdf.

The American Dental Association report on Evidence-based clinical practice guideline on restorative treatments for caries lesions, available at

https://jada.ada.org/action/showPdf?pii=S0002-8177%2823%2900258-1

The American Dental Association report on Direct materials for restoring caries lesions, available at

https://jada.ada.org/action/showPdf?pii=S0002-8177%2822%2900576-1

The American Dental Association report on Direct and indirect restorative materials, available at

https://jada.ada.org/article/S0002-8177(14)64119-2/pdf

The American College of Prosthodontics Parameters of Care, available at

https://www.prosthodontics.org/acp-publications/parameters-of-care/

Worthington HV, Khangura S, et al. Direct composite resin fillings versus amalgam fillings for permanent posterior teeth, available at

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005620.pub3/epdf/full

Criteria for Endodontic Services

 

Endodontic Diagnosis and Treatment Planning: A tooth qualifies for endodontic therapy benefit payment only if (1) the treating clinician has established and documented an appropriate endodontic diagnosis prior to initiating endodontic treatment, (2) the tooth to be treated is in a reasonably restorable structural condition and (3) the tooth has an acceptable endodontic and periodontal prognosis.

 

References adopted by Delta Dental as clinical criteria for endodontic diagnosis and treatment planning for pediatric patients include:

The American Association of Endodontics Guide to Clinical Endodontics, available at

https://www.aae.org/specialty/clinical-resources/guide-clinical-endodontics/

The American Association of Endodontists Endodontic Competency whitepaper, available at

https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/09/endo-competency-whitepaper.pdf

The American Association of Endodontists Colleges for Excellence publication on Endodontic Diagnosis, available at https://www.aae.org/specialty/newsletter/endodontic-diagnosis/

The American Association of Endodontists guide to Treatment Options for the Compromised Tooth, available at

https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/2014treatmentoptionsguidefinalweb.pdf

 

Endodontic Therapy: Endodontic therapy with resultant adverse treatment outcomes such as inadequate root canal preparation, incomplete or overfilled root canal obturation, root perforations or non-treatment of a patent root canal is not eligible for benefit payment.

 

References adopted by Delta Dental as clinical criteria for endodontic therapy for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on Pulp Therapy for Primary and Immature Permanent Teeth, available at http://www.aapd.org/media/Policies_Guidelines/BP_PulpTherapy.pdf.

The American Association of Endodontics Guide to Clinical Endodontics, available at

https://www.aae.org/specialty/clinical-resources/guide-clinical-endodontics/

The American Association of Endodontists Treatment Standards whitepaper, available at

https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/04/TreatmentStandards_Whitepaper.pdf

The American Association of Endodontists Colleagues for Excellence publication on Access Opening and Canal Location, available at

https://www.aae.org/specialty/newsletter/access-opening-canal-location/

The American Association of Endodontists Colleagues for Excellence publication on Canal Preparation and Obturation, available at

https://www.aae.org/specialty/newsletter/canal-preparation-obturation-updated-view-two-pillars-nonsurgical-endodontics/

Criteria for Periodontal Services

 

Periodontal Evaluation and Diagnosis: For periodontal services to be eligible for benefit payment, a comprehensive periodontal evaluation, risk assessment and periodontal diagnosis must be documented in the patient record. Clinicians must distinguish between periodontal disease in child and adolescent patients and normal physiological changes from growth and development. The record must establish that the patient has periodontal disease or a periodontal condition that requires nonsurgical or surgical periodontal treatment to resolve the disease process or correct the condition.

 

Full Mouth Debridement (D4355): Full mouth debridement is eligible for benefit payment when the buildup of plaque and calculus is so extensive that it interferes with the ability of the dentist to perform a comprehensive oral evaluation and must be removed to allow gingival inflammation to subside, so that the dentist can perform an accurate evaluation at a later date.

 

Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation - Full Mouth, After Oral Evaluation (D4346): The D4346 full mouth scaling procedure is indicated after an oral evaluation has been performed and a patient is found to be free of periodontitis, but needs treatment for inflammation of a moderate to severe nature occurring throughout the gingiva. Clinical criteria for D4346 scaling includes swollen, inflamed gingiva, generalized suprabony periodontal pockets and moderate to severe bleeding on gingival probing, with no evidence of attachment or bone loss. Where a patient has a generally healthy periodontium with only localized gingival inflammation, the indicated procedure for controlling local irritational factors Is usually the child or adult prophylaxis. For patients with attachment and bone loss from periodontitis, non-surgical and/or surgical periodontal treatment is generally indicated.

 

Periodontal Scaling and Root Planing (D4341-D4342): Scaling and root planing is a nonsurgical periodontal therapy intended to control the clinical factors that result in the inflammation of periodontal tissues. For scaling and root planing to be eligible for benefit payment, the patient record of the treating clinician must document the presence of periodontitis with radiographic evidence of alveolar bone loss around the involved teeth. The scaling and root planing procedure necessitates meticulous instrumentation of the crown and root surfaces of the involved teeth to thoroughly remove plaque and calculus, as well as to remove cementum and dentin that is rough and/or permeated by calculus and/or toxins or microorganisms. If required, the clinician must be able to show that sufficient treatment time was allowed for the number of teeth treated. When scaling and root planing is completed, and if more advanced periodontal treatment is not required, the treating clinician should determine and initiate an appropriate interval for periodontal maintenance.

 

References adopted by Delta Dental as clinical criteria for periodontal scaling and root planing for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on Periodontal Conditions in Pediatric Dental Patients, available at

https://www.aapd.org/globalassets/media/policies_guidelines/bp_periodontal.pdf.

The American Dental Association Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts, available at

https://jada.ada.org/action/showPdf?pii=S0002-8177%2815%2900334-7

The American Academy of Periodontology Parameter on Chronic Periodontitis With Slight to Moderate Loss of Periodontal Support, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.853

The American Academy of Periodontology Parameter on Chronic Periodontitis With Advanced Loss of Periodontal Support, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.856

 

Periodontal Surgical Services (D4210-D4285): Surgcial treatment of periodontal diseases and conditions is indicated when nonsurgical periodontal therapy cannot stabilize a patient's periodontal condition. Periodontal surgical procedures must be appropriate for the periodontal diagnosis and be provided in accordance with generally accepted standards of periodontal practice. Resolution of concurrent endodontic pathology must be addressed as part of treatment. In the case where periodontal surgery is performed in more than two sites in the same quadrant on the same date of service, there must be clear evidence of medical necessity for same-day treatment or the treatment may not be eligible for benefit payment. After completion of periodontal surgery, the treating clinician should determine and initiate an appropriate interval for periodontal maintenance.

 

References adopted by Delta Dental as clinical criteria for periodontal surgical services for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on Periodontal Conditions in Pediatric Dental Patients, available at

https://www.aapd.org/globalassets/media/policies_guidelines/bp_periodontal.pdf.

The American Academy of Periodontology Classification of Periodontal and Peri-Implant Diseases and Conditions, available at

https://www.perio.org/research-science/2017-classification-of-periodontal-and-peri-implant-diseases-and-conditions/

The American Academy of Periodontology Parameter on Comprehensive Periodontal Examination, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.847

The American Academy of Periodontology Diagnosis of Periodontal Diseases, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2003.74.8.1237

The American Academy of Periodontology Parameter on Chronic Periodontitis With Slight to Moderate Loss of Periodontal Support, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.853

The American Academy of Periodontology Parameter on Chronic Periodontitis With Advanced Loss of Periodontal Support, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.856

The American Academy of Periodontology Parameter on Mucogingival Conditions, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.861

The American Academy of Periodontology Bone Augmentation Techniques, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2007.060048

The American Academy of Periodontology American Academy of Periodontology best evidence consensus statement on the efficacy of laser therapy used alone or as an adjunct to non-surgical and surgical treatment of periodontitis and peri-implant diseases, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1002/JPER.17-0356

 

Periodontal Maintenance (D4910): Periodontal maintenance is eligible for benefit payment only if it is instituted following surgical or nonsurgical periodontal treatment, i.e., there must be a history of therapeutic treatment of active periodontal disease documented in the patient record. The interval for periodontal maintenance must be determined based on an individual patient’s periodontal condition, risk status and prognosis. The periodontal maintenance procedure includes assessment of the patient’s periodontal status, removal of bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated and polishing of the teeth. Additional periodontal therapy may be recommended if indicated due to the recurrence or progression of periodontal disease.

 

References adopted by Delta Dental as clinical criteria for periodontal maintenance for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on Periodontal Conditions in Pediatric Dental Patients, available at

https://www.aapd.org/globalassets/media/policies_guidelines/bp_periodontal.pdf.

The American Academy of Periodontology Parameter on Periodontal Maintenance, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.849

The American Academy of Periodontology position paper on Periodontal Maintenance, available at

https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2003.74.9.1395

Criteria for Removable Prosthodontics Services

 

Prior to planning and performing removable prosthodontic treatment, the treating clinician must carry out and fully document a comprehensive evaluation of the condition of existing teeth and/or edentulous areas. If denture fabrication involves abutment teeth or retained teeth, any untreated caries, periodontal disease, endodontic pathology or structural weakness should be resolved before the teeth are utilized in denture treatment. Existing partial or complete dentures being replaced must not be reasonably serviceable.

 

Partial and complete dentures must be made of a nonporous, color-stable, heat-cured acrylic material that has adequate impact strength, flexural strength and fracture resistance under normal functioning. Dentures must also have an appropriate fit to abutment or retained teeth, good adaptation to edentulous ridges and appropriate occlusion. The provision of denture adjustments as part of the denture service for six months after delivery is considered to be a generally accepted practice. Patients must also receive appropriate education on the use and maintenance of dentures as part of the comprehensive service.

 

References adopted by Delta Dental as clinical criteria for removable prosthodontic services for pediatric patients include:

The American College of Prosthodontics Parameters of Care, available at

https://www.prosthodontics.org/acp-publications/parameters-of-care/

Criteria for Oral and Maxillofacial Surgery Services

 

Prior to performing extractions on pediatric patients, a thorough preoperative medical and dental evaluation should be performed including age-appropriate clinical and radiographic examination to assess the condition of individual crown and root development and ensure the avoidance of damage to the developing dentition. The relationship of primary tooth roots to developing permanent successors should be considered, as well as the potential impact of tooth extraction on the positioning of adjacent teeth and future occlusion. Any concerns that arise from the evaluation should be communicated with the parent or legal guardian as part of the process of obtaining informed consent.

 

For a surgical extraction (D7210-D7241) to be eligible for benefit payment, there must be a complicating condition where a nonsurgical extraction would be clinically inadvisable or contraindicated. The patient record should document any complicating condition that justifies surgical extraction. Examples of such conditions include, but are not limited to:

  • Large restorations or existing root canal therapy with a high risk of fracture if a nonsurgical extraction was attempted
  • Structural breakdown from caries or fracture with a lack of access for a nonsurgical extraction
  • Anatomical variations that would make a nonsurgical extraction difficult or contraindicated, such as bulbous root development, dilacerated roots or close proximity to a nerve requiring dissection
  • Ankylosed roots
  • Mesial or distal angulation that would make nonsurgical extraction difficult or contraindicated
  • Adjacent vital structures such as sinus cavities or neurovascular tissues

 

As appropriate to the surgery, treating clinicians should document the tooth number, flap reflection, removal of bone, sectioning of the tooth, complete or partial removal of the tooth, closure of the surgical site and any complications encountered. When submitting claims for benefit coverage, the procedure codes selected for surgical extractions should be based on the anatomical position of the tooth, not the degree of extraction difficulty or the amount of time required. Dental benefit programs may establish program-specific criteria that define when tooth extraction is considered medically necessary and eligible for benefit coverage. These proprietary criteria may include an exclusion of coverage for prophylactic removal of asymptomatic impacted teeth or impacted teeth that are not associated with a defined pathological condition or teeth being removed to facilitate orthodontic treatment.

 

References adopted by Delta Dental as clinical criteria for oral and maxillofacial surgery services for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on Management Considerations for Pediatric Oral Surgery and Oral Pathology, available at http://www.aapd.org/media/Policies_Guidelines/BP_OralSurgery.pdf.

The American Association of Oral and Maxillofacial Surgery Parameters of Care: AAOMS Clinical Practice Guidelines for Oral and Maxillofacial Surgery, available at

https://members.aaoms.org/PersonifyEbusiness/AAOMSStore/Product-Details/productId/77216029

The American Association of Oral and Maxillofacial Surgeons statement The Management of Impacted Third Molar Teeth, available at

https://www.aaoms.org/docs/practice_resources/clinical_resources/impacted_third_molars.pdf

Criteria for Orthodontic Services

Orthodontic treatment is generally considered to be medically necessary for patients diagnosed with significant deformities of craniofacial structures and the dentition that result in functional impairment of speech, respiration, nutrition and/or oral hygiene. In the absence of program-specific criteria that define when orthodontic treatment is considered medically necessary and eligible for benefit coverage, the following indications for treatment generally align with the American Association of Orthodontists qualifying criteria for establishing a basis for medically necessary orthodontic care:

  • A congenital or developmental disorder (craniofacial anomaly), traumatic injury to craniofacial structures or craniofacial pathology  
  • Congenitally missing teeth in multiple quadrants
  • Excessive overjet of 9 millimeters or more
  • Excessive reverse overjet of 3.5 millimeters or more
  • Anterior and/or posterior crossbite involving 3 or more teeth per arch
  • Lateral or anterior open bite of 2 millimeters or more involving 4 or more teeth per arch
  • Impinging overbite with evidence of occlusal contact causing damage to the opposing palatal soft tissue
  • Permanent tooth impactions where eruption is impeded but extraction is not indicated and impacted teeth have a good prognosis of being brought into the arch
  • Severe crowding or excessive spacing of 10 millimeters or more in either the maxillary or mandibular arch

 

Factors that must be taken into consideration when planning orthodontic treatment for pediatric patients include the patient's developmental and chronological age, craniofacial development, tooth eruption patterns, oral habits, condition of teeth and periodontal tissues, temporomandibular dysfunction, airway obstruction, speech disorders, medical or dental disorders where a patient’s medical or dental condition could compromise or be compromised by orthodontic treatment and the patient’s ability to cooperate with treatment. The complexity of craniofacial disorder cases may require a multidisciplinary approach involving collaboration among orthodontists and other health care professionals.

 

References adopted by Delta Dental as clinical criteria for orthodontic services for pediatric patients include:

The American Academy of Pediatric Dentistry recommendations on the Management of the Developing Dentition and Occlusion in Pediatric Dentistry (space maintainers), available at https://www.aapd.org/globalassets/media/policies_guidelines/bp_developdentition.pdf.

American Association of Orthodontists Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics, available at https://www2.aaoinfo.org/practice-management/cpg/.

American Association of Orthodontists definition of Medically Necessary Orthodontic Care, available at https://www2.aaoinfo.org/practice-management/patient-management/medically-necessary-orthodontic-care/.

 

Criteria for Adjunctive General Services

 

Anesthesia and Intravenous Sedation (D9222-D9223, D9239-D9243): For general anesthesia and intravenous sedation to be eligible for benefit payment, the patient’s record must document the physical, medical, behavioral or other condition which necessitates the use of anesthesia or sedation. Conditions where general anesthesia and intravenous sedation may be considered to be medically necessary include, but are not limited to:

  • Physical compromising conditions such as inability to obtain adequate analgesia with local anesthesia, allergy to local anesthetics or other known contraindications to local anesthesia
  • Medical compromising conditions such as diseases and conditions with severe spasticity, closed head trauma or stroke causing inability to cooperate with directions
  • Behavioral, intellectual or psychological compromising conditions such as developmental disability disorders characterized by significant limitations in intellectual functioning, adaptive behavior or physical functioning
  • Long, extensive or complex dental procedures necessary to treat a patient's dental condition such as surgical removal of teeth involving multiple quadrants or treatment where unexpected patient movement may compromise treatment results

 

The administration of general anesthesia and intravenous sedation must conform to applicable professional standards and requirements of government agencies for clinician training and experience, equipment condition and safety, patient evaluation, patient supervision, drugs and dosing, patient monitoring, emergency protocols, recovery and discharge and record keeping. There must be adequate documentation of anesthesia and intravenous sedation procedures and monitoring in the patient record. With respect to reporting anesthesia/sedation services, treatment time begins when the clinician administering the anesthetic/sedative agent initiates the appropriate anesthesia/sedation and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia/sedation services are considered completed when the patient may be safely left under the observation of trained personnel and the administering clinician may safely leave the room to attend to other patients or duties.

 

If applicable standards are not followed or appropriate documentation is not provided, anesthesia and intravenous sedation procedures are not eligible for benefit payment. Failure to follow requirements for anesthesia and sedation safety may result in referral to the appropriate regulatory agency.

 

References adopted by Delta Dental as clinical criteria for anesthesia and sedation services for pediatric patients include:

The American Academy of Pediatric Dentistry Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures, available at http://www.aapd.org/media/Policies_Guidelines/BP_MonitoringSedation.pdf.

The American Dental Association Guidelines for the Use of Sedation and General Anesthesia by Dentists, available at

https://www.ada.org/resources/ada-library/oral-health-topics/anesthesia-and-sedation/

The American Association of Oral and Maxillofacial Surgeons white paper Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon, available at

https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/office_based_anesthesia_whitepaper_1.pdf

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018, a report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists and Society of Interventional Radiology, available at

https://pubs.asahq.org/anesthesiology/article/128/3/437/18818/Practice-Guidelines-for-Moderate-Procedural

 

Non-intravenous Conscious Sedation (D9248), Hospital or Ambulatory Surgical Center Call (D9240) or Behavior Management (D9920): For these procedures to be eligible for benefit payment, the patient’s record must document the physical, medical, behavioral or other condition that necessitates the procedure. Claims for these procedures must be accompanied by a report clarifying the service, e.g., documentation of the sedative, facility or specific behavior management techniques used.

 

References adopted by Delta Dental as clinical criteria for behavior management services for pediatric patients include:

The American Academy of Pediatric Dentistry recommendation on Nonpharmacological Behavior Guidance for the Pediatric Dental Patient, available at https://www.aapd.org/globalassets/media/policies_guidelines/g_behaviorguidance.pdf.

The American Academy of Pediatric Dentistry recommendation on Behavior Guidance for the Pediatric Dental Patient, available at https://www.aapd.org/globalassets/media/policies_guidelines/bp_behavguide.pdf.