The Non-Insured Health Benefits (NIHB) Program

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Important notice regarding the Endodontic Trial Project

As of April 1 2011, the Non-Insured Health Benefits (NIHB) Program has initiated a nationwide two year endodontic trial project to assess the merits, feasibility, and the appropriateness of removing the predetermination requirement for standard root canal treatment (RCT) procedures on bicuspids and first molars (more information may be found on the 'Spring 2011 Dental Newsletter' available on the Express Scripts Canada Dental Provider website: http://www.provider.esicanada.ca/)

The general conditions of the Trial Project are as follows:

• The predetermination requirement has been removed for standard root canal treatment (RCT) procedures on permanent bicuspids and first molars including the following procedure codes:
  • 33111, 33121, 33131, 33141; and
  • Québec : 33100, 33200, 33300, 33400, 33475, 33111 EN, 33121 EN, 33131 EN, 33141 EN, 33150 PA, 33160 PA, 33170 PA, 33180 PA.
• A frequency limitation of three (3) standard RCT procedures in 36 months has been system implemented for all teeth. Once the frequency has been reached, subsequent standard RCT procedures require a predetermination.
• All claimed endodontic services must meet the restorability criteria of the current Endodontic Policy.
• NIHB Headquarters (HQ) will contact providers of randomly selected paid standard root canal cases to request all supporting documentation outlined in the endodontic policy. Failure to submit required documentation may result in recoveries.
• NIHB HQ will communicate directly with treating providers for cases that did not meet the endodontic policy.
• Health Canada Regional Offices also maintain the right to request supporting documentation for paid endodontic cases which will be reviewed against the NIHB endodontic policy.

Endodontic Policy July 2011

Updated November 2012

1.0 General Principles

• Predetermination is required for root canal treatment (RCT) on premolars and molars. For the duration of the trial project, bicuspids and first molars do not require predetermination. However, second and third molars continue to require predetermination as per the endodontic policy.
• Predetermination is not required for RCT on anterior teeth (13 - 23, and 33 - 43 inclusive); however the NIHB Program reserves the right to request preoperative records to ensure compliance with the endodontic policy.
• There is a frequency limitation of three (3) standard RCT procedures in 36 months for all teeth. Once the frequency has been reached, subsequent standard RCT procedures require a predetermination.
• The NIHB Program will consider coverage for a RCT when both the eligibility and restorability criteria have been met and the need of the requested treatment for the health of the client is evident and supported in the documentation submitted.
• The NIHB Program will not consider coverage for a RCT for high caries risk individuals or those with generalized moderate to severe periodontal disease when there is evidence of long-standing, uncontrolled and/or untreated rampant biological disease (either caries or periodontal disease).

2.0 Predetermination Documentation Requirements for Root Canal Treatment

The NIHB Program requires the following documentation for the review of a root canal treatment predetermination request:

• Predetermination request on one of the following forms: Complete Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29).
• Comprehensive treatment plan from the treating and/or referring dentist /specialist indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic and surgical services.
• Current conventional or digital radiographs (within last twelve months).
  1. Periapical and bitewing radiographs:
     • must be of good diagnostic quality (i.e., size, resolution, contrast); and
     • must be mounted and labelled with the date of service, client name and provider name.
  2. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs.

Please note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

• Notation of all missing teeth.
• Periodontal charting, and/or Periodontal Screening and Recording (PSR), and/or Periodontal assessment.
• Periodontal measurements (6 sites/tooth) for the tooth/teeth under review.
• All pertinent clinical findings/notes supporting the predetermination request.

3.0 Tooth Eligibility

The NIHB Program will consider coverage of an RCT on:

• incisors, canines, bicuspids and first molars; and
• second molars: may be considered for coverage where the first molar is missing and the second molar is in occlusion with a prosthetic or natural molar.

4.0 Tooth Restorability

The NIHB Program will consider coverage of an RCT when all of the following criteria are met:

• Adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs with absence of furcation involvement;
• Absence of active periodontal disease;
• Adequate remaining non-diseased tooth structure to ensure that biologic width can be maintained during restoration;
• A mesio-distal width equivalent to that of the natural tooth with no loss of space due to caries or crowding; and
• A tooth that does not require any additional dental treatment such as crown lengthening, root resectioning or orthodontic treatment.

Please note:

• Incomplete approved RCT requests will be paid to the equivalent of a pulpectomy.
• The final fee for a RCT includes the cost associated with a pulpectomy/pulpotomy and open and drain within the three month period prior to the completion of the RCT, when performed by the same provider/ same office.
• The final fee for a RCT or pulpectomy/pulpotomy includes the fee for the temporary restoration and its replacement if required.
• Coverage for pulpectomy/pulpotomy is once (1) per tooth/per lifetime.
• Pulpotomies and pulpectomies are not eligible on primary incisor teeth number 51, 52, 61, 62, 71, 72, 81, 82.