Processing Policy Changes Starting 1/1/2020

October 01, 2019
Mandatory Pre-Determination Removal:

Implementation: January 1, 2020

Groups affected: All Risk groups; all Individual policies.

Effective January 1, 2020 for Individual policies and all Risk groups, Pre-Determinations will no longer be mandatory for any code.

Scaling and Root Planing (Code D4341):

Implementation: January 1, 2020

Groups affected: All groups.

Effective January 1, 2020 for all groups, when scaling and root planing (SRP) is performed in 3 or more quadrants on the same day, the claim will be referred to dental consultants for review.

Review Criteria:

  • There must be 4 or more teeth in a quadrant.

  • Exposure of cemental surfaces of the root is necessary for root planing, therefore radiographs must show the crest of the alveolar bone more than 1.5 - 2.0 mm apical to the CEJ.

  • Submit periapical or bitewing radiographs and periodontal chart documenting probing depths, amount of attached gingiva and clinical attachment levels.

Please Note: Panoramic radiograph (D0330) will no longer be accepted for SRP claims documentation and determination. According to the American Academy of Periodontology, panoramic X-rays have limited value in the diagnosis of periodontal disease (Delta Dental Dentist Handbook, Pg. 67).

General Anesthesia and IV Sedation (Codes D9222, D9223, D9239, & D9243):

Implementation: January 1, 2020

Groups affected: All groups.

Effective January 1, 2020 for all groups, if general anesthesia and IV sedation are performed in excess of one hour, the claim will be referred to dental consultants for review.

Review Criteria:

  • Submit anesthesia record showing start/stop times, vitals checked, anesthesia used, etc.

  • Submit chart notes which should include procedure(s) performed and, if necessary, the reason/necessity for additional anesthesia.

Fabrication of Athletic Mouthguard (D9941):

Implementation: January 1, 2020

Groups affected: All Risk groups; all Individual policies

Effective January 1, 2020 for Risk groups and Individual policies, D9941 will be a covered Major service under the group's plan, excluding plans that do not have coverage for Major services. The underlying contract, age limitations and frequency limitations apply.

 

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