Provider Handbook

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The TRICARE medical benefit covers adjunctive dental care. In most cases, adjunctive dental care is medically necessary in the treatment of an otherwise covered medical (not dental) condition; is an integral part of the treatment of such medical condition; or is required in preparation for, or as the result of, dental trauma that may be or is caused by medically necessary treatment of an injury or disease.

These are some examples of adjunctive dental procedures that TRICARE may cover:
   

• Removal of teeth and tooth fragments to treat and repair facial trauma resulting from an accidental injury
• Total or complete ankyloglossia (tongue-tie) to alleviate difficulty swallowing or speaking (Partial ankyloglossia is not covered.)
• Dental or orthodontic care that is directly related to the medical and surgical correction of a severe congenital anomaly
• Dental care in preparation for, or as a result of, in-line radiation therapy for oral or facial cancer
• Treatment of acute (not chronic) myofacial pain/TMJ pain; care of these patients is subject to some additional restrictive guidelines:
  •  Treatment of this syndrome may be considered a medical problem only when it involves immediate relief of pain.
  •  Emergency treatment may include initial radiographs, up to four (4) office visits, and the construction of an occlusal splint, if necessary to relieve pain and discomfort.
  •  Treatment beyond four (4) visits, or any repeat episodes of care within a six (6) month period, must receive individual consideration and be documented by the provider of services.
  •  Occlusal equilibration and restorative occlusal rehabilitation are specifically excluded for myofacial pain dysfunction syndrome.

TRICARE may, however, cover medically necessary institutional and general anesthesia services in conjunction with non-covered or non-adjunctive dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or under.  TRICARE beneficiaries may receive these dental services through military dental treatment facilities and through one of two TRICARE dental programs—the TRICARE Dental Program or the TRICARE Retiree Dental Program—if enrolled. (Refer to the TRICARE Program Options section for TRICARE dental program information).

These are some examples of dental care that the TRICARE health care benefit does not cover when the care is not related to, or caused by, an underlying medical condition or congenital abnormality:
 

• Treatment of dental caries and periodontal disease
• Extraction of teeth, including impacted wisdom teeth
• Provision of implants, crowns, dentures, and bridges

In some instances, hospital services and supplies may be covered for a patient who requires a hospital setting for non-covered, non-adjunctive dental care. For instance, a child with congenital heart disease and extensive dental disease necessitating care under anesthesia may require care in a hospital in order to ensure hemodynamic stability during the treatment.

There are several important considerations concerning this benefit. First, medical documentation must be submitted that establishes the severity of the patient’s underlying medical condition. (A PCM or specialty provider may need to submit this information.) Secondly, acute anxiety, behavioral issues, need for extensive treatment, or need for sedation/anesthesia do not, by themselves, qualify the patient for this coverage. The patient must still have a serious underlying medical condition, unless he or she is age 5 or younger, or has developmental, mental, or physical disabilities. Finally, when coverage is authorized, it is only for facility fees, medical supply coverage, anesthesiology services, and professional medical services related to the medical condition. Professional dental and anesthesiology services would not be covered.

All adjunctive dental care requires prior authorization. Prior authorization will determine if a beneficiary’s condition is adjunctive or non-adjunctive dental care. The prior authorization requirement is waived only when essential adjunctive dental care involves a medical emergency, such as facial injuries resulting from a car accident.

For a more detailed list of adjunctive dental procedures that TRICARE covers, access Chapter 8, section 13.1 of the TRICARE Policy manual.

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