The Non-Insured Health Benefits (NIHB) Program

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Preventive and Periodontal Policy September 2012

Updated November 2012

1.0 General Principles

• Predetermination (PD) is not required for scaling and root planing services up to the annual maximum allowable units; for any additional units, predetermination is required. Please refer to Table 1.1.1.
• Predetermination requests must be supported with all items listed in the Predetermination Documentation Requirements for Preventive and Periodontal Services (Section 1.2.3).
• All preventive and periodontal procedures claimed must be supported with proper, clear, and detailed documentation for verification against the Non-Insured Health Benefits (NIHB) Program's terms and conditions. A procedure code or procedure name is not sufficient in a client record to support payment.

1.1 Preventive Services

1.1.1 Polishing, Fluoride Treatment, Scaling and Root Planing

Age	0-11 years	12-16 years	17+ years
Table 1 footnotes Table 1 footnote 1 Please refer to the 'NIHB Dental Benefits Guide', Diagnostic Services section for frequency guidelines.
Recall Exam Annual Maximum	1 in any 6 month period	1 in any 6 month period	1 in any 12 month period
Polishing Annual Maximum	1 time in any 6 month period	1 time in any 6 month period	1 time in any 12 month period
Fluoride Annual Maximum	1 treatment  in any 6 month period	1 treatment in any 6 month period	Not covered
Scaling in combination with Root Planing Annual Maximum (no PD)	0.5 unit in any 6 month period	1 unit in any 6 month period	4 units in any 12 month period

1.1.2 Sealants and Preventive Resin Restorations

• Clients under the age of fourteen (14) are covered for sealants and preventive resin restorations on the occlusal surface of permanent molar teeth (16, 26, 36, 46, 17, 27, 37, 47) and on the lingual surface of permanent maxillary incisor teeth (11, 12, 21, 22) where surfaces are unrestored.

1.2 Periodontal Services

1.2.1 Scaling and Root Planing (additional units)

• A predetermination is required for the NIHB Program to consider coverage for additional units of scaling and root planing in any 12 month period over the maximum allowable units covered without a predetermination. Please refer to Table 1.1.1.
• Eligibility for additional units of scaling and root planing will be based on several factors including, but not limited to:
  • The severity of periodontal disease based on current (within the last 12 months) clinical notes, diagnosis and prognosis, complete periodontal charting, and radiographs;
  • Comprehensive treatment plan addressing all client oral health needs;
  • The date of the last visit for periodontal and preventive services;
  • The regularity and compliance of periodontal maintenance; and
  • Medical condition relative to periodontal diseases including any prescribed medication.

1.2.2 Surgical Services

• Periodontal surgeries are not eligible services under the NIHB Program, however certain surgeries may be considered for coverage on an exception basis (PD required):
• Gingivoplasties/gingivectomies for the treatment of drug-induced gingival hyperplasia that is unresponsive to non-surgical periodontal therapy; and
• Gingival grafts for the treatment of gingival recession leading to minimally attached/keratinized gingiva on a tooth that is a critical abutment for a removable prosthesis.
  Note: Coverage for gingival grafts on teeth that show chronic periodontal disease or to improve esthetics will not be considered.

1.2.3 Predetermination Documentation Requirements for Preventive and Periodontal Services

The NIHB Program requires the following documentation for the review of a preventive/periodontal service 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 the last twelve months).
  1. Periapical and bitewing radiographs:
     • must be of good diagnostic quality (e.g., size, resolution, contrast); and
     • must be mounted and labeled 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.

• Periodontal chartingwith information regarding:
  • Missing teeth;
  • Probing depths (6 sites/tooth);
  • Recession;
  • Area of minimal attached gingiva;
  • Mobility;
  • Bleeding on probing, suppuration;
  • Plaque (generalized/localized, minimal/moderate/abundant);
  • Calculus (generalized/localized, minimal/moderate/abundant);
  • Furcation; and
  • Abscess/fistula.
• Periodontal diagnosis and prognosis.
• All pertinent clinical findings/notes supporting the predetermination request.