Policy on Medically-Necessary Care

Policy statement

Dental care is medically necessary to prevent and eliminate orofacial disease, infection, and pain, to restore the form and function of the dentition, and to correct facial disfiguration or dysfunction. MNC is based upon current preventive and therapeutic practice guidelines or recommendations formulated by professional organizations with recognized clinical expertise. Benefits of MNC outweigh potential risks of treatment or no treatment. Early detection and management of oral conditions can improve a child’s oral health, general health and well-being, academic performance, and self-esteem. Early recognition, prevention, and intervention could result in savings of health care dollars for individuals, community health care programs, and third-party payors. Because a child’s risk for developing dental disease can change over time, continual professional reevaluation and preventive maintenance are essential for optimal oral health. The value of services is an important consideration, and all stakeholders should recognize that cost-effective care is not necessarily the least expensive treatment.

The AAPD encourages:

1. oral health care to be included in the design and provision of individual and community-based health care programs to achieve comprehensive health care.
2. establishment of a dental home for all children by 12 months of age in order to institute an individualized preventive oral health program based upon each patient’s unique caries risk and periodontal disease assessments.
3. healthcare providers who diagnose oral disease to either provide therapy or refer the patient to a dentist or dental/medical specialist as dictated by the nature and complexity of the condition. Immediate intervention is necessary to prevent further dental destruction, as well as more widespread health problems.
4. evaluation and care provided for an infant, child, or adolescent by a cleft lip/palate, orofacial, or craniofacial team as the optimal way to coordinate and deliver such complex services.
5. the dentist providing oral health care for a patient to determine the medical indication and justification for treatment. The dental care provider must assess the patient’s developmental level and comprehension skills, as well as the extent of the disease process, to determine the need for advanced behavior guidance techniques such as sedation or general anesthesia.

Furthermore, the AAPD encourages third-party payors to:

1. recognize malformed and missing teeth are resultant anomalies of facial development seen in orofacial anomalies and may be from congenital defects. Just as the congenital absence of other body parts requires care over the lifetime of the patient, so will these.
2. include oral health care services related to these facial and dental anomalies as benefits of health insurance without discrimination between the medical and dental nature of the congenital defect. These services, optimally provided by the craniofacial team, include, but are not limited to, initial appliance construction, periodic examinations, and replacement of appliances.
3. end arbitrary and unfair refusal of compensation for oral health care services related to orofacial and dental anomalies.
4. recognize the need for preventative, restorative, and surgical oral health care services to be regarded as a medically necessary benefit.
5. ensure that all children have access to the full range of oral health delivery systems. If sedation or general anesthesia and related facility fees are payable benefits of a health care plan, these same benefits shall apply for the delivery of oral health services.
6. regularly consult the AAPD with respect to the development of benefit plans that best serve the oral health interests of infants, children, adolescents, and individuals with SHCN, especially those with craniofacial or acquired orofacial anomalies.