Clinical Criteria (Adults)

For Utilization Review Decision Making (Adult 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 adult patients include clinical guidelines, parameters, positions, recommendations and statements published by the 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 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 patients or authorized representatives prior to providing dental services and procedures.
  • 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

Comprehensive and periodic oral evaluation procedures must include, but are not limited to, review and documentation of a patient's medical and dental history, examination and documentation of the condition of extra-oral and intra-oral tissues, recording of periodontal status including periodontal charting, documentation of the condition of the teeth including restorations and caries, examination for oral cancer, recording of appropriate diagnoses that are supported by evaluation findings and documentation of a treatment plan that is consistent with diagnoses. The interval for periodic oral evaluations must be determined based on an individual patient’s overall oral condition, risk status and prognosis.

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, 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, show the crowns and roots of the teeth, display periapical areas and show alveolar bone including edentulous areas.

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

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-radiograph

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

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

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 tooth structures

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

The American Academy of Periodontology Parameter on Plaque-Induced Gingivitis, available at https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.85

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

Giannobile WV, Braun TM, et al. Patient stratification for preventive care in dentistry. J Dent Res. 2013 Aug;92(8):694-701. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711568/

Criteria for Restorative Services

Direct and Indirect Restorations: Prior to beginning restorative treatment, 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 the course of restoration. 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 extensive loss of tooth structure or untreated pathology 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 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-third 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 a large area of original coronal tooth structure 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 include:

The American Dental Association 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 Direct materials for restoring caries lesions, available at https://jada.ada.org/action/showPdf?pii=S0002-8177%2822%2900576-1

The American Dental Association 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. Cochrane Database of Systematic Reviews 2021, Issue 8. Art. No.: CD005620. 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 the treating clinician has established and documented an appropriate endodontic diagnosis prior to initiating endodontic treatment and the tooth to be treated is in a reasonably restorable condition and has an acceptable periodontal prognosis.

References adopted by Delta Dental as clinical criteria for endodontic diagnosis and treatment planning 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 Colleagues 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 may not be eligible for benefit payment.

References adopted by Delta Dental as clinical criteria for endodontic services 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 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 Surgical Services (D4210-D4285): For periodontal surgical services to be eligible for benefit payment, a comprehensive periodontal evaluation and periodontal diagnosis must be documented in the patient record. The record must establish that the patient has periodontal disease or a periodontal condition that requires surgery to resolve the disease process or correct the 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 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 include:

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 position paper on 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 review Bone Augmentation Techniques, available at https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2007.060048

The American Academy of Periodontology review 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 Scaling and Root Planing (D4341-D4342): 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. 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 include:

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 Maintenance (D4910): Periodontal maintenance is eligible for postservice benefit payment only if it is instituted following surgical or nonsurgical periodontal treatment. 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 include:

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. Patients must receive appropriate education on the use and maintenance of dentures. Removable prosthodontic treatment that does not meet these requirements may not be eligible for benefit payment.

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

The American College of Prosthodontics Parameters of Care, available at https://www.prosthodontics.org/acp-publications/parameters-of-care/

Criteria for Implant Services

Prior to planning and performing implant treatment, the treating clinician must carry out and fully document a comprehensive evaluation that includes appropriate diagnostic imaging and a thorough assessment of the patient’s endodontic and periodontal status, structural integrity of existing teeth and restorations, occlusion, edentulous ridge anatomy, location of vital structures, bone quantity and quality, soft tissue quality and any risk factors for implant failure due to the patient’s medical or dental health status.

The treatment plan for implant placement should address the number and location of missing teeth, the number, type and location of implants to be placed, the interarch space, the crown-to-implant ratio, the occlusal scheme, significant risk factors and the post-surgery considerations for implant supported prosthetics and implant maintenance. Teeth with unresolved periodontal disease or endodontic pathology should receive appropriate treatment that should ordinarily be completed prior to implant placement.

Implant placement must conform to generally accepted dental standards for implant surgical services with respect to selection of appropriate candidates for implant placement, location of suitable implant placement sites, acceptable proximity to other implants or natural tooth roots, need for a surgical guide template, adequate quantity and quality of bone and appropriate implant size, shape, material and angulation. The placement of mini implants is not eligible for benefit payment when installed to support a fixed denture, crown or fixed partial denture.

The fabrication and installation of implant supported prosthetics should not be initiated until adequate implant osseointegration is evident. The size, position and angulation of an implant must be suitable for the fabrication and installation of a functional and esthetically acceptable prosthetic restoration. Stresses placed on an implant supported prosthetic unit must be properly distributed to prevent implant osseointegration being compromised and increasing the risk of implant failure.

References adopted by Delta Dental as clinical criteria for implant services include:

The American Academy of Periodontology Parameter on Placement and Management of the Dental Implant, available at https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2000.71.5-S.870

The American Academy of Periodontology report Peri-Implant Mucositis and Peri-Implantitis, available at https://aap.onlinelibrary.wiley.com/doi/epdf/10.1902/jop.2013.134001

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

American Association of Oral and Maxillofacial Surgery. Introduction to Implant Dentistry: A Student Guide. Journal of Oral and Maxillofacial Surgery, Volume 75, Issue 2, 1-100. Available at https://www.joms.org/pb/assets/raw/Health%20Advance/journals/yjoms/YJOMS752S.pdf

The American College of Prosthodontics Parameters of Care, available at https://www.prosthodontics.org/acp-publications/parameters-of-care/

The American College of Prosthodontists position statement Diagnostic Imaging in the Treatment Planning, Surgical, and Prosthodontic Aspects of Implant Dentistry, available here.

Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography, available here.

Hämmerle CHF, Cordaro L. et al. Biomechanical aspects: Summary and consensus statements of group 4. The 5th EAO Consensus Conference 2018. Clin Oral Implants Res. 2018 Oct:29 Suppl 18:326-331. Available at https://onlinelibrary.wiley.com/doi/epdf/10.1111/clr.13284

Morton D, Gallucci G, et al. Group 2 ITI Consensus Report: Prosthodontics and implant dentistry. Clin Oral Implants Res. 2018 Oct:29 Suppl 16:215-223. Available at https://onlinelibrary.wiley.com/doi/epdf/10.1111/clr.13298

Criteria for Fixed Prosthodontics Services

Prior to planning and performing fixed prosthodontic treatment, the treating clinician must carry out and fully document a comprehensive evaluation of the condition of existing teeth and edentulous areas. Abutment teeth upon which a fixed partial denture retainer will be supported must have an acceptable endodontic and periodontal prognosis, be free of untreated caries and have adequate structural integrity. Any untreated caries, periodontal disease, endodontic pathology or structural weakness involving abutment teeth should ordinarily be resolved before the teeth are utilized in fixed partial denture treatment.

Fixed partial denture retainers must meet the applicable standards of dental practice for restorative material selection, restoration design and preparation, marginal integrity, interproximal contacts and retention. Fixed partial denture pontics must have appropriate adaptation to edentulous ridges. Fixed partial denture units must have appropriate occlusion. Patients must receive appropriate education on the use and maintenance of fixed partial dentures. Fixed prosthodontic treatment that does not meet these requirements may not be eligible for benefit payment.

References adopted by Delta Dental as clinical criteria for fixed prosthodontic services 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

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

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.

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

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 Adjunctive General Services

Anesthesia and Intravenous Sedation: 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.

Non-intravenous Conscious Sedation, Hospital or Ambulatory Surgical Center Call or Behavior Management: 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 anesthesia and sedation services include:

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 here.

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