Dental Bulletin - December 2002

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Dental Bulletin
Non-Insured Health Benefits Program

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This bulletin outlines important modifications to benefits under Non-Insured Health Benefits Program (NIHB).

Post Approval of Dental Treatment Reminder

Please note that those procedures with a "P" and procedures that are exceptions to the program continue to require predetermination prior to commencing treatment and are ineligible for post approval consideration under the NIHB Program. The following is a sample of procedures that require predetermination "P": Root Canal treatment, Crowns, and Dentures.

Endodontic Funding Policy

The policy will be used by adjudicators for funding requests for endodontic treatment.

1. DOCUMENTATION:
   A proposed treatment plan must include,
   1. A completed DENT29 form with a current and correct Part 3B "missing tooth notation."
   2. current radiographs (including periapical films of all teeth for which endodontic therapy is indicated, in addition to bitewings and/or pantographic films).
   3. complete treatment plan for the mouth, including eriodontal therapy, restoration of all carious lesions and replacement of missing teeth.
2. ESTABLISHED ORAL HEALTH STATUS:
   Endodontic treatment will be considered only for patients that display a commitment to improving their oral health as evidenced by,
   1. current status of oral disease*. * A mouth that presents with rampant biological disease (either caries or periodontal disease) will not be considered a suitable candidate for endodontic therapy.
   2. patient motivation and participation in achieving health. This would be evidenced by,
      i) a statement from the dentist as to the patient's level of motivation.
      ii) a past history of regular dental care and a commitment to ongoing care.
3. ESTABLISHED NEED FOR TREATMENT:
   A tooth that has been treatment planned for endodontics must be shown to be:
   
   1. functional, periodontally sound tooth within the arch, opposing/occluding with a periodontally sound tooth.
   2. an essential component in maintaining arch integrity. To that end, NIHB supports the concept of a "shortened dental arch"*.
      * for the purpose of the NIHB dental program, the shortened dental arch is defined as being teeth numbers 16 to 26 and 36 to 46, inclusive. To that end, second and third molars may not be considered essential components of the arch, where the remaining teeth which comprise a stable occlusion include the first molars.
   3. a tooth that cannot be included in any planned removable prosthodontics, or would not be considered a critical abutment for any planned prosthodontics.
4. ESTABLISHED ABILITY TO RESTORE:
   Restorability will be determined by evidence of,
   1. A favorable crown-root ratio (at least 1:1).
   2. adequate periodontal support, based on alveolar bone levels visible on submitted radiographs, in addition to further supporting documentation indicating amount of mobility, loss of attachment, and accessibility of the tooth to standard home care procedures.
   3. adequate remaining non-diseased tooth structure to ensure that biological width is maintained during restoration of the tooth by either direct restoration with amalgam or composite, or indirect restoration with full gold or porcelain crowns including, if necessary, the additional use of posts and cores such that an adequate ferrule can be achieved.
   4. no need for any further complex dental treatment such as crown lengthening, root re-sectioning or orthodontic movement.

National Removal of Prescription Drug Codes from the NIHB Program

Effective January 1, 2003, prescription drug codes 96101 and 96102 (in Quebec 96100, 96101) are no longer a funded benefit under the NIHB program. Any claims with a service date on or after January 1, 2003 will not be considered for funding.

Space Maintainers

Effective December 1, 2002, space maintainers and procedures associated with space maintainers will no longer be a funded benefit under the NIHB program, except when associated with a comprehensive orthodontic treatment plan. Submissions should be sent to the following address:

Orthodontic Review Centre
First Nations and Inuit Health Branch
Graham Spry Building
250 Lanark Avenue, 6th Floor
Address Locator 2006C
Ottawa, Ontario K1A 0K9

Dental Procedures Associated With Existing Dental Implants

Implants and associated dental procedures are not a funded benefit under the NIHB program. However, in complete overdenture situations where dental implants already exist within an arch, the NIHB Program may provide funding equivalent to the costs associated with complete over dentures (tissue borne, supported by natural teeth with no attachments) as an alternate benefit. In these situations the following applies:

Complete Overdenture As An Alternate Benefit:

Where a client has one or more implants and requires a complete overdenture (tissue borne, supported by implants with no attachments), the NIHB Program may fund the implant supported dentures 51721 (in Quebec 51931) (maxillary), 51722 (in Quebec 51932) (mandibular) and 51723 (combined) at the rate for the standard overdentures (tissue borne, supported by natural teeth with no attachments); procedure codes, 51711 and 51712 and 51713 respectively.

NIHB will provide an alternate benefit at a maximum dollar value equivalent to the cost of a standard removable prosthesis including estimated laboratory costs. The maximum dollar value is determined using regional reimbursement rates. In all cases, predetermination is required before treatment begins.

Radiograph Interpretation

NIHB will fund radiograph interpretation at the cost of a half unit for radiograph interpretation from another source.

NEW Benefits Added to the NIHB Program

1. Pit and Fissure Sealants and Preventive Resins:
   Procedures identifying additional tooth in same quadrant, code 13409(Pit and Fissure Sealant) and code 13419 (Preventive Resin) have been added to the NIHB Program as eligible benefits. In addition, the lingual surface of the maxillary anterior teeth will also qualify for pit and fissure sealants.
2. Examination and Diagnosis, Stomatognathis, Dysfunctional:
   01301 Complete exam
   01302 Limited exam
3. Posts, Fabricated with bonded amalgam core for crown restoration are funded at the non bonded equivalent. Procedure codes 25761, 25762 and 25763 will be funded at the level of procedure codes 25751, 25752 and 25753 respectively.
4. Posts, Fabricated with composite bonded core for crown restorations; codes 25764, 25765 and 25766 have also been added to the list of eligible benefits.