National Standardized Dental Claim Utilization Review Criteria
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NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA Revised: 4/1/2017 The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines. CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE DIAGNOSTIC Clinical Oral Evaluations Documentation in member record that includes all services performed D0120–D0191 for the code submitted Pre-Diagnostic Services Documentation in member record that includes all services performed D0190 screening of a patient for the code submitted. D0191 assessment of a patient Diagnostic Imaging Documentation in the member record. Diagnostic, clear, readable Criteria for codes D0364–D0368, D0380–D0386, D0391–D0395: images, dated with member name. Image capture with interpretation Cone beam computed tomography (CBCT) is unproven and not medically D0210–D0371 necessary for routine dental applications. There is insufficient evidence that CBCT is beneficial for use in routine dental Image Capture only applications. CBCT should not replace traditional dental x-rays as a preliminary D0380–D0386 diagnostic tool, or for routine dental procedures such as restorations, but be Interpretation and Report only used as an adjunct when the level of detail CBCT is needed to safely render D0391–D0395 treatment for complex clinical conditions (e.g. oral surgery, implant placement and endodontics). These procedures may have a higher risk of complications CPT codes: 70486, 70487, 70488, without the level of detail CBCT imaging provides. CBCT imaging used for these 76376 and 76377 reasons should be read and interpreted by an appropriately trained professional. In addition, radiation exposure associated with CBCT needs to be weighed against possible benefits, which have not been supported in the published literature. Limited definitive conclusions regarding the clinical role of CBCT can be reached due to the lack of well-designed studies that systematically evaluate diagnostic accuracy and the impact of CBCT on clinical decision making and patient health outcomes. Additional studies are needed to verify that CBCT provides added diagnostic value beyond two-dimensional imaging such as panoramic radiography and conventional computed tomography and to 1 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Diagnostic Imaging determine whether CBCT improves treatment decision making and health (continued) outcomes. Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP002.02) Bacterial And Viral Testing Provider narrative including clinical reason/diagnosis for test and type of Criteria for codes D0414, D0415, D0416 D0414, D0415, D0416 test performed. Collection of Microorganisms for Culture and Sensitivity Collection of microorganisms for culture and sensitivity is indicated for the following: For odontogenic infections that do not respond to rational antibiotic empiric therapy and/or incision and drainage in a timely manner For odontogenic infections in patients with comorbidities including but not limited to impaired healing response, and compromised immune system Collection of microorganisms for culture and sensitivity is not indicated for the following: As a routine procedure for all infections (unless patient has multiple comorbidities or infection is resistant to conventional therapy) If infection is small and limited to localized area If infection is draining on its own with no evidence of spread of infection For fungal infections For viral culturing (this procedure has its own reporting code) Viral Culture Viral culturing is indicated for the presence of oral and perioral vesicles and ruptured vesicles resulting in lesions that may or may not be crusted over. Viral culturing is not indicated for suspected cytomegalovirus (CMV) oral lesions (an incisional biopsy and testing is indicated). Refer to coverage guideline: Bacterial And Viral Testing (DCG039.01) Salivary Testing Provider narrative including clinical reason/diagnosis for test and type of Criteria for codes D0417, D0418 D0417, D0418 test performed. Collection, Preparation and Analysis of Saliva Sample for Laboratory Diagnostic Testing Collection, preparation and analysis of saliva sample for laboratory diagnostic testing may be indicated as part of oral disease risk assessment and management, including but not limited to caries, periodontal disease and xerostomia. Refer to clinical policy: Salivary Testing (DCG037.01) 2 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Genetic Testing for Oral Disease Provider narrative including clinical reason/diagnosis for test and type of Criteria for codes D0422, D0423 D0422, D0423 test performed. Collection and Preparation of Genetic Sample Material for Laboratory Analysis and Report Genetic Test for Susceptibility to Diseases – Specimen Analysis The collection, preparation and testing of genetic samples are indicated for patients who have known human papilloma virus (HPV) infection, or have other related risk factors, to identify if the strain of HPV known to be related to oral and oropharyngeal cancers is present. The clinical utility of genetic testing for susceptibility to periodontal diseases has not been established. Additionally, there is a lack of objective, high quality clinical evidence to support these tests. Refer to clinical policy: Genetic Testing for Oral Disease (DCP036.01) Miscellaneous Diagnostic Criteria for codes D0425, D0460, D0470 Procedures Caries Susceptibility Tests D0425, D0460, D0470 There is a lack of objective, high quality clinical evidence to support or refute the efficacy or superiority of this specific testing method as a tool for caries risk assessment and management. Pulp Vitality Tests Pulp vitality tests are indicated for the following: For traumatic injuries to teeth Teeth with deep caries or defective restorations Pulp vitality tests are not indicated for the following: Sensitivity of exposed dentin without evidence of pulp pathosis Teeth with no evidence of caries, resorption, defective restorations, or otherwise asymptomatic As part of routine dental examinations Diagnostic Casts Combined with clinical and radiographic findings, diagnostic casts may be useful for select cases, as they can provide a further understanding of the overall dentition. They may be helpful in developing the treatment plan without the patient present, and can serve as an additional tool for educating the patient. They provide an opportunity for a more thorough evaluation of the following: Tooth interdigitation Functional occlusion, and any occlusal abnormalities Wear facets and defective restorations, coronal contours, proximal contacts and embrasure spaces between teeth Refer to coverage guideline: Miscellaneous Diagnostic Procedures (DCG040.01) 3 CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL PROCEDURE DOCUMENTATION COVERAGE GUIDELINE Non-Ionizing Diagnostic Provider narrative including clinical reason/diagnosis for test and type of Criteria for code D0600 Procedures test performed. There is inadequate evidence demonstrating the efficacy of these devices, D0600 limiting their use as a principal diagnostic tool. A non-ionizing diagnostic procedure refers to a device specifically designed to identify, quantify, monitor, and record changes in structure of enamel, dentin and cementum. These devices may be used as an adjunctive tool by the dental provider to identify high caries risk areas, and create non-invasive treatment plans for remineralization before caries begins. Visual and radiographic examinations remain the standard diagnostic methods for diagnosing active caries. Refer to clinical policy: Non-Ionizing Diagnostic Procedures (DCP041.01) Tests and Examinations Provider narrative including clinical reason/diagnosis for test and type of D0431 test performed. caries risk assessment D0601–D0603 Oral Pathology Laboratory D0472–D0502 Unspecified diagnostic procedure by report D0999 PREVENTIVE Dental Prophylaxis Services performed must be documented in the member record. D1110–D1120 Topical Fluoride Treatment Documentation Criteria for codes D1206, D1208 D1206, D1208 Age and medical necessity. An adult is generally defined as twelve years Topical Application of Fluoride – Excluding Varnish or older. CPT code: 99188 Topical fluoride treatments in the form of gel, foam and rinses applied as a caries preventive agent in the dental office are benefitted twice per consecutive twelve months for children up to age 15. Patients at low risk of developing caries may not need additional