The Non-Insured Health Benefits (NIHB) Program

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Removable Prosthodontic Policy July 2011

Updated November 2012

1.0 General Principles

• Predetermination is required for complete and partial dentures.
• Complete and partial dentures supported by implants along with all implant related procedures are not a covered benefit under the Non-Insured Health Benefits (NIHB) Program (exclusions).

2.0 Removable Partial Dentures

2.1 General Principles

Removable partial dentures are covered once in any eight (8) year period (96 months) per arch. Within this period, replacement with any type of removable denture (including complete dentures) may not be considered for coverage; however, they may be considered for modifications as per the needs of the client.

2.2 Predetermination Documentation Requirements for Partial Dentures

The NIHB Program requires the following documentation for the review of a partial denture 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 radiographs of abutment teeth and bitewing radiographs:
     • must be of good diagnostic quality (i.e., size, resolution, contrast);
     • 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 all of the abutment teeth.
• All pertinent clinical findings/notes supporting the predetermination request.

Please note: At Health Canada's request, diagnostic models or other documentation may be required.

2.3 Eligibility

The NIHB Program will consider coverage for a partial denture for teeth numbered 16 to 26 and 36 to 46 inclusive, under the following conditions:

• General conditions:
  • All basic treatment must be completed including:
    • control of caries and of periodontal and periapical disease for all teeth; and
    • restoration of major structural defects in the abutment teeth;
  • The space to be replaced is greater than or equal to the corresponding natural teeth;
  • All abutment teeth must have:
    • adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs; and
    • absence of active periodontal disease; and
  • If there is an existing partial denture, it must be at least eight (8) years old.
• Please note:  If there is evidence of periodontal disease, the NIHB Program may cover up to the cost of a removable acrylic partial denture.
• Specific conditions:
  • There must be one or more missing teeth in the anterior sextant; or
  • There must be two or more missing posterior teeth in a quadrant excluding second and third molars.

3.0 Complete Dentures

3.1 General Principles

• Complete dentures are covered once in any eight (8) year period per arch.
• For replacement of a standard complete denture that is at least eight (8) years old, dental providers have the option to fax their request directly to their respective dental predetermination office. Dental providers must confirm clients' eligibility with Express Scripts Canada before faxing the request. All requests must comply with current supporting documentation requirements.
• The fee for complete dentures includes three months post-insertion care including adjustments and modifications.
• The fee for immediate complete dentures includes the tissue conditioner, but not the processed reline/rebase.

3.2 Predetermination Documentation Requirements for Complete Dentures

The NIHB Program requires the following documentation for the review of a complete denture 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).
• Notation of all missing teeth or planned extractions.
• Panoramic X-ray (if available).
• All pertinent clinical findings/notes supporting the predetermination request.

Please note: At Health Canada's request, diagnostic models or other documentation may be required.

3.3 Eligibility

The NIHB Program will consider coverage for a complete denture:

• For an initial placement; or
• For replacement of an existing complete denture that is at least eight (8) years old.

4.0 Non-Inserted Removable Prosthodontic Policy

4.1 Standard Partial Dentures and Complete Dentures

The NIHB Program may consider paying up to 20% of the current NIHB professional fee and 100% of the laboratory fee, if applicable, for non-inserted dentures under the following conditions:

• The denture has been completed but not inserted due to circumstances beyond the control of the dental provider;
• The provider has made substantial efforts to contact the client to schedule an insertion appointment; and
• The provider has communicated the details of the situation in writing to their respective dental predetermination office.

4.2 Immediate Dentures

The NIHB Program may consider paying up to 100% of the current NIHB professional fee and 100% of the laboratory fee, if applicable, for non-inserted immediate dentures under the following conditions:

• The provider who fabricated the immediate denture is different from the provider who was scheduled to do the extraction(s) and insertion;
• Substantial efforts have been made by both providers to contact the client to reschedule the missed extraction/insertion appointment; and
• The provider who fabricated the immediate denture has communicated the details of the situation in writing to their respective dental predetermination office.

Please note: A non-inserted denture (any type) that has been claimed and paid in full, without complying with the above noted conditions, will result in recovery.