• 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 office visits, and the construction of an occlusal splint, if necessary to relieve pain and discomfort
  • Treatment beyond four visits, or any repeat episodes of care within a period of six months, 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

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. 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. TRICARE beneficiaries may receive these dental services through military dental treatment facilities and through one of three TRICARE dental programs—the TRICARE Active Duty Dental Program, the TRICARE Dental Program or the TRICARE Retiree Dental Program—if enrolled. Refer to the TRICARE Program Options section of this handbook 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
• Emergency room visits for dental conditions, i.e., dental pain
• Extraction of teeth, including impacted wisdom teeth
• Provision of implants, crowns, dentures, and bridges

Care for accidental injury to the teeth alone is not considered adjunctive dental care and is not covered by the TRICARE health care benefit, whereas care for injury to the teeth resulting from the treatment of a medical condition, such as removing teeth fragments in order to treat facial trauma, is covered.

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 primary care manager [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 requires 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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