DENTAL POLICY:
Adjunctive Dental Services
EFFECTIVE DATE:
December 1, 2012
LAST REVIEWED DATE:
June 12, 2024
LAST REVISED DATE:
June 12, 2024
PURPOSE:
The purpose of this dental policy is to ensure the policies and procedures of the New Jersey Medicaid program pertaining to the provision of, and reimbursement for, medically necessary dental services to eligible individuals are communicated. In addition to the private office, dental services may be provided in the home, hospital, approved independent clinic, nursing facility, intermediate care facility for the mentally challenged and residential treatment center.
SCOPE AND APPLICABILITY:
The policies and procedures of the New Jersey Medicaid program pertaining to the provision of, and reimbursement for, medically necessary dental services to eligible individuals. Adjunctive dental benefits are meant to be administered along with primary dental benefits.
Horizon BCBSNJ Government Programs provides specific Clinical Procedure Guidelines to appropriate practitioners/providers and healthcare professionals as a reference tool for identified acute and chronic medical conditions and for behavioral health conditions addressing both adult and child populations. These Clinical Procedure Guidelines identify the most current standards of care, based on evidence-based research. Providing these resources is intended to promote their use among practitioners and healthcare professionals in office practices in an effort to optimize clinical outcomes, improve health care quality and reduce unnecessary variation in care.
The Director of Dental Operations will provide oversight for this policy, including review of the NJ State Medicaid Contract, applicable NJ State and CMS Regulations, and national accreditation standards related to the above, revising procedures as necessary to reflect changes. The Utilization Management/ Care Management (UM/CM) Committee will implement this policy and applicable Clinical Procedure Guidelines as further defined below.
This policy was developed in accordance with applicable Centers for Medicare and Medicaid Services (CMS) guidelines, the NJ Medicaid Managed Care Contract, applicable NJ State and Federal Guidelines, and national accreditation standards. This policy will be reviewed annually, revising procedures as necessary to reflect changes to specific guidelines.
This policy applies to the Medicaid/NJ FamilyCare and Fully Integrated Dual Eligible Special Needs (“FIDE-SNP”) plans issued and/or administered by Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey and/or its affiliates, including Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health (collectively “Horizon”).
The Director of Dental Operations or his/her designee will conduct an annual review of this policy and procedure to ensure that it is still relevant and compliant with appropriate New Jersey State and Federal Medicaid, Medicare Advantage and Special Needs Program (SNP) regulatory and accrediting requirements, and accurately reflects current operations.
POLICY:
Below are the dental codes included under the scope of this policy. Please visit our Clinical Criteria Grid to review details about each code below, including age limits, frequency limits, benefit information and clinical criteria.
Unclassified Treatment
D9110: Palliative treatment of dental pain-per visit.
D9210: Local anesthesia not in conjunction with operative or surgical procedures
D9211: Regional block anesthesia
D9212: Trigeminal division block anesthesia5.
D9222: Deep sedation general anesthesia first 15 minutes
D9223: Deep sedation/general anesthesia- each 15 minutes increment
D9230: Inhalation of nitrous oxide/analgesia, anxiolysis
D9239: IV moderate sedation/analgesia- first 15 minutes
D9243: Intravenous moderate (conscious) sedation/analgesia- 15-minute increment
D9248: Non-intravenous conscious sedation
Professional Consultation
D9310: Consultation -diagnostic service provided by dentist or physician, other than requesting, dentist or physician
D9311: Treating dentist consults with a medical health care professional concerning medical issues that may affect member’s planned dental treatment.
Professional Visits
D9410: House/extended care facility call
D9420: Hospital or ambulatory surgical center call
D9430: Office visit for observation (during regularly scheduled hours) -no other services performed.
Drugs
D9610: Therapeutic parenteral drug, single administration.
D9612: Therapeutic parenteral drugs, two or more administrations, different medications
D9613: Infiltration of sustained release therapeutic drug, per quadrant
D9630: Other drugs and/or medicaments, by report
Miscellaneous Services
D99l0: Application of desensitizing medicament
D9911: Application of desensitizing resin for cervical and/or root surface, per tooth
D9920: Behavior management, by report
D9930: Treatment of complications, (post-surgical) -unusual circumstances, by report
D9941: Fabrication of athletic mouthguard
D9943: Occlusal guard adjustment
D9944: Occusal guard –hard appliance, full arch
D9945: Occlusal guard –soft appliance, full arch
D9947: Custom sleep apnea appliance fabrication and placement
D9948: Adjustment of custom sleep apnea appliance
D9949: Repair of custom sleep apnea appliance
D9951: Occlusal adjustment limited
D9952: Occlusal adjustment- complete
D9953: Reline Custom Sleep Apnea Device
D9971: Odontoplasty 1-2 teeth; includes removal of enamel projections
D9974: Internal bleaching -per tooth
D9999: Unspecified adjunctive procedure, by report
SANCTIONS:
Horizon may be subject to the Sanctions and/or Liquidated Damage Provisions of the NJ Medicaid Managed Care Contract. Specifically, Articles 7.15 and 7.16.
REFERENCES:
Regulatory References
NJ Medicaid Managed Care Contract, 31C Annual Review of Member Benefits, Policies
New Jersey Administrative Code 10:56, N.JAC 10:56 13:30
NCQA Current Standards and Guidelines for Accreditation of Health Plans
REVISION HISTORY:
06/07/2023: Removed the 2022 Dental Clinical Criteria Grid and replaced with the 2023 Dental Clinical Criteria Grid
06/12/2024: Reformatted policy content for posting within this new Dental Services subsection.
43C-010-06122024
