NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA Revised: 4/1/2016 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. PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DIAGNOSTIC Clinical Oral Evaluations Documentation in member record that includes all services performed for the code submitted D0120-D0191 Pre-Diagnostic Services Documentation in member record that includes all services performed for the code submitted. D0190-screening of a patient 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 used as an adjunct when the level of detail CBCT is needed to safely render Interpretation and Report only- treatment for complex clinical conditions (e.g. oral surgery, implant placement D0391-D0395 and endodontics). These procedures may have a higher risk of complications without the level of detail CBCT imaging provides. CBCT imaging used for these 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 1 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE 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 determine whether CBCT improves treatment decision making and health outcomes. Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP.002.01) Tests and Examinations Provider narrative including clinical reason/diagnosis for test and type of D0415-D0470 test performed. D0601-D0603-caries risk assessment Oral Pathology Laboratory D0472-D0502 D0999-Unspecified diagnostic procedure by report PREVENTIVE Dental Prophylaxis Services performed must be documented in the member record. D1110-D1120 Topical Fluoride Treatment Age and medical necessity. An adult is generally defined as twelve years For hypersensitivity and to prevent root caries and recurrent decay around D1206-D1208 or older. existing restorations. Often for patients who have undergone head/neck radiation therapy. Other Preventive Services Documentation/narrative in member record that service was performed D1310-D1330 and materials supplied to member. Sealants Sealant: Tooth numbers. Provider responsible for three years for repair or Preventive Resin Restoration: D1351-D1352 replacement. No decay or restorations- the occlusal surface must be intact. Sealant cannot be done on the same tooth as a preventive resin. Space Maintenance Radiographs of the involved arch. 2 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE D1510-D1555 For primary dentition only. Should be submitted for primary tooth that has been extracted. All adjustments for 6 months are included. No benefit if permanent tooth is ready to erupt. If bilateral teeth are missing, benefit given for bilateral space maintainer, even if two unilateral space maintainers are requested. RESTORATIVE Direct Restorations: Documentation Inclusive components: Tooth number and surface. Local anesthesia; tooth prep; liners/bases; restorative material; Amalgam Restorations Caries removal documented in member record. polishing/sealing; adjustments; tooth etching. D2140-D2161 Criteria: Resin-Based Composite Primary teeth should not be ready to exfoliate and requests are subject to Restorations-Direct review based on the age of the patient and the tooth number. D2330-D2394 Gold Foil Restorations D2410-D2340 3 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Indirect Restorations: Documentation Criteria for codes D2510-D2664, D2710-D2799 Pre-operative x-rays. If endodontic therapy has been performed, a Inlay/Onlay Restorations periapical radiographic image clearly showing the apex of the completed Indications for Coverage D2510-D2664 (Inlay/onlays) treatment is required; otherwise, bitewing x-rays may be sufficient at Five-year longevity should be evident, periodontium must be healthy or have the discretion of the reviewer. documentation the member has periodontal disease under control for a period Crowns-Single Restorations Only of at least 6 months, and no evidence of endodontic pathology or potential D2710-D2799 A narrative or photograph may provide additional information, endodontic issues on the radiographic image. Coverage includes local especially for replacement of existing crowns. anesthetic, impressions, tooth preparation, temporary restoration, fitting, cementation, adjustment and any liners or bases. “Cracked tooth syndrome” requires adequate documentation of extent of fracture, location and how it was diagnosed. Tooth must be Crowns symptomatic. Crowns are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Restorations for members under age 15 require statement of medical Large, >50% of the tooth, defective restoration that can be seen on the necessity. radiographic image Fracture of cusps Inclusive Endodontically treated teeth, unless minimal access opening on anterior Local anesthesia; tooth preparation; temporary crown; fitting; tooth cementation; post-op adjustments, impressions; bases. Documentation that a direct restoration is not possible Crown/root ratio must be favorable Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image 50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and one or more cusps involved Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and one or more cusps involved Symptomatic “cracked tooth syndrome” (not enamel “craze lines”) Full coverage restoration of a primary tooth without a permanent successor Crowns are not indicated for the following: If a lesser means of restoration is acceptable If root resorption is present Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration) For alteration of vertical dimension For purposes of preventing future fracture, or to eliminate enamel craze lines (Cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative. Tooth must be symptomatic). To treat non-pathologic wear/abrasion, or abfraction lesions in the absence 4 of decay For molars exhibiting bone loss with a class III furcation involvement Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable Fracture of porcelain not involving the margin or a functional ridge is not PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Other Restorative Services Documentation Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934 (D2910-D2999) Tooth number Prefabricated Crowns are indicated for the following: For the restoration of teeth with more than two surfaces affected with Porcelain/Ceramic Crown carious lesions, or where extensive one or two surface lesions are present. D2929 For one and two surface carious lesions in documented high caries risk children. Risk factors must be thoroughly documented by the provider in Stainless Steel Crown the dental record, and include: D2930, D2931, D2932, D2933, o Mother or primary caregiver has active caries; D2934 o White spot lesions or enamel