Adjunctive Dental Care
      

The TRICARE medical benefit covers adjunctive dental care. Adjunctive dental care is medically necessary to treat a 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. All nonemergency adjunctive dental care requires prior authorization. Prior authorization determines if adjunctive or non-adjunctive dental care is required. However, emergency adjunctive care (e.g., to treat facial injuries resulting from a car accident) does not require prior authorization.

TRICARE may cost-share certain medically-necessary care for the following medical conditions:

TRICARE may cover certain hospital services and supplies for a patient who requires a hospital setting for non-covered, non-adjunctive dental care. For example, if a child with congenital heart disease and extensive dental disease requires care under anesthesia, TRICARE covers hospitalization to ensure hemodynamic stability during treatment.

There are several important considerations concerning the adjunctive dental care benefit. First, medical documentation must be submitted to Humana Military to establish the severity of the patient’s underlying medical condition. The primary care manager (PCM) or specialty provider may need to submit this documentation.  Secondly, acute anxiety, behavioral issues, need for extensive treatment, or need for sedation/anesthesia does not alone qualify a patient for adjunctive dental care coverage. The patient must also have a serious underlying medical condition, unless he or she is age 5 or younger, or has a qualifying developmental, mental, or physical disability. Finally, Humana Military only authorizes facility fees, medical-supply coverage, anesthesiology services, and professional medical services related to the medical condition.

Note: The attending dentist cannot provide general anesthesia; a separate anesthesiology provider must administer anesthesia, regardless of the setting. TRICARE does not cover professional fees for non-adjunctive dental care.

The TRICARE health care benefit does not cover non-adjunctive dental care, which refers to any routine, preventive, restorative, prosthodontic, periodontic, or emergency dental care that is not related to a medical condition. The following are examples of non-adjunctive dental services that the TRICARE medical benefit does not cover unless related to or caused by an underlying medical condition or congenital abnormality:

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 younger. Eligible TRICARE beneficiaries may receive non-adjunctive dental services at military dental treatment facilities or if enrolled in one of three TRICARE dental programs—the TRICARE Active Duty Dental Program, the TRICARE Dental Program, or the TRICARE Retiree Dental Program. Refer to the TRICARE Program Options section of this handbook for more information.

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