Dental Screening and Services

Health Net does not cover any charges for the dental procedure itself, including the professional fee of the dentist or any other dental provider.

However, medically necessary physician or certified registered nurse anesthetist administered IV moderate sedation and deep sedation/general anesthesia and associated facility charges for non-covered dental services rendered in a hospital (inpatient or outpatient) or ambulatory surgery center setting are covered if under one or more of the following circumstances:

1. member is developmentally disabled, regardless of age,
2. member's health is compromised and physician or certified registered nurse anesthetist administered anesthesia is medically necessary for dental services, regardless of member's age, or
3. dental services are medically necessary and behavior modification and local anesthesia have failed or are not possible.

Coverage Criteria¹

Behavior modification and local anesthesia must generally be attempted first, but may not be required in certain situations, depending on the medical needs of the member. Thereafter, minimal sedation must then be considered or determined not feasible based on the medical needs of the member, and is not always required depending on the medical needs of the member.

If the provider provides clear medical record documentation of both number 1 and number 2 below, then the member must be considered for IV moderate sedation or deep sedation/general anesthesia.

1. Use of local anesthesia to control pain failed or was not feasible based on the medical needs of the member.
2. Use of minimal sedation, either inhalation or oral, failed or was not feasible based on the medical needs of the member.

If the provider documents any one of numbers 3 through 6 below, then the member must be considered for IV moderate sedation or deep sedation/general anesthesia.

1. Use of effective communicative techniques and the inability for immobilization (member may be dangerous to self or staff) failed or was not feasible based on the medical needs of the member.
2. Member requires extensive dental restorative or surgical treatment that cannot be rendered under local anesthesia or minimal sedation.
3. Member has acute situational anxiety due to immature cognitive functioning.
4. Member is uncooperative due to certain physical or mental compromising conditions.

The procedures are ranked from low to high profundity as follows:

1. minimal sedation via inhalation or oral anesthetics
2. non-intravenous conscious sedation
3. IV moderate sedation
4. deep sedation/general anesthesia

Members with certain medical conditions such as, but not limited to: moderate to severe asthma, reactive airway disease, congestive heart failure, cardiac arrythmias and significant bleeding disorders, uncontrolled seizures and sleep disordered breathing, should be treated in a hospital setting or a licensed facility capable of responding to a serious medical crisis, as determined most appropriate by the provider.

In compliance with 42 CFR 455.410, all ordering or referring physicians or other professionals providing
Medi-Cal services must be enrolled as an original fee-for-service (FFS) Medi-Cal provider. All providers, such as the selected anesthesiologist must also meet standards for participation in the FFS Medi-Cal program at the time services are prescribed, ordered or rendered.

Prior Authorization Requirements¹

Requests for authorization (RA)/prior authorization (PA)/Treatment Authorization Requests (TAR) is required for physician-administered anesthesia services or IV sedation. Member selection for dental procedures under physician-administered deep sedation/general anesthesia or IV moderate sedation considers medical history, physical status, and indications for anesthesia management.

The dental provider in consultation with the anesthesiologist is responsible for determining whether a member meets the minimum criteria necessary for receiving deep sedation/general anesthesia and/or IV moderate sedation. In addition:

• The dental provider submits the RA/PA/TAR to the dental carrier for the dental procedure and works in collaboration with the anesthesiologist to determine whether the patient meets the minimum criteria for receiving IV moderate sedation, deep sedation/general anesthesia.
• The physician who renders the IV moderate sedation, deep sedation/general anesthesia is responsible to submit the RA for deep sedation/general anesthesia or IV moderate sedation to Health Net or to the member's delegated participating physician group (PPG). The RA must:
  • State the criteria indications, such as failed attempts of conscious sedation, local anesthesia and other mechanisms, or why prior attempts could not be attempted and include the planned location of the service.
  • The provider performing the IV moderate sedation, deep sedation/general anesthesia, must provide documentation and a copy of the approved RA/PA/TAR to request PA prior to delivering deep sedation/general anesthesia or IV moderate sedation.

• Prior to delivering anesthesia services being rendered, the provider must have a copy of a complete history and physical examination and the indication for IV moderate sedation or deep sedation/general anesthesia. Additionally, and not as a prerequisite to authorization, the provider and primary care physician must fulfill the requirements for chart documentation which, in addition to the above, includes diagnosis, treatment plan and documentation of perioperative care (preoperative, intraoperative and postoperative care) for the dental procedure.

¹Information taken or derived from APL 23-028 Attachment A, Policy for Intravenous Moderate Sedation and Deep Sedation/General Anesthesia.

Delegated PPG Response to Prior Authorization Requests

Delegated participating physician groups (PPGs) must respond to PA requests submitted for deep sedation/general anesthesia or IV moderate sedation as outlined above and render a utilization management decision in a timely manner in accordance with the PPG’s Provider Participation Agreement (PPA). If additional clinical information is required, the member and providers must be notified in writing within the applicable regulatory time frame. The PPG is also responsible for communicating the decision to the member and providers within the applicable regulatory time frame from the date of the original receipt of the request.

The member's PCP provides any necessary pre-operative history and physical examination and necessary laboratory or other medically necessary ancillary services. Both the dentist and anesthesiologist must have privileges at the selected place of service (such as the hospital (outpatient, inpatient or ambulatory surgery center), or a Letter of Agreement (LOA) needs to be initiated by the PPG in order to authorize and provide services at the designated facility site.

The primary care physician (PCP) must conduct a dental assessment for members under age 21 to check for normal growth and development and the absence of tooth and gum disease at the time of the initial health appointment (IHA) and at each Child Health and Disability Prevention (CHDP) program examination visit according to the periodic health examination schedules.

A dental screening for children under age three includes, but is not limited to, an examination of the mouth and gums; and anticipatory guidance on proper feeding practices and on cleaning the mouth to remove bacteria. For children over age three the screening includes, but is not limited to, an examination of the mouth, teeth and gums; prescription for fluoride supplementation if drinking water is not adequately fluoridated; and anticipatory guidance in the prevention of dental caries, orofacial injury and disease, proper oral hygiene practices, and consideration of dental sealants.

PCPs are also responsible for performing a dental screening exam on adult members as part of the initial health appointment and at scheduled periodic health assessments, and to encourage them to receive an annual dental exam. All screenings, referrals and the reason for the referral must be documented in the member's medical record.

Mandatory Referral

The PCP must make a mandatory dental referral following the member’s initial dental health screening starting at age three, or earlier, if dental problems are identified and continue to refer the member on subsequent, annual dental health screenings if warranted at the time by any new or ongoing dental issues identified. The PCP must provide a topical fluoride varnish to the member’s teeth during their exam. A referral to a dentist or orthodontist should be made if the member has severe malocclusion within six months of the first tooth erupting or no later than the member's first birthday. All screenings, referrals and the reason for the referral must be documented in the member's medical record.

Providers or members may call Denti-Cal for a list of three Denti-Cal providers in their ZIP Code (Los Angeles and Sacramento County members may also obtain services from a Health Net Dental provider, if applicable). Members who need interpreter assistance to locate a dentist may call Health Net's Medi-Cal Member Services Department, Community Health Plan of Imperial Valley Member Services Department or CalViva Health Medi-Cal Member Services Department (for Fresno, Kings and Madera counties).