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HealthPartners

Coverage criteria policies

Dental services – medically necessary outpatient

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for requests for coverage of dental services under your medical plan.

Coverage

Dental services are generally not covered under your medical plan except for the indications listed below and per your plan documents.

Indications that are covered

Medical coverage is limited to dental services that are required for treatment of an underlying covered medical condition such as removal of teeth to complete radiation treatment for cancer of the jaw, or extraction of teeth prior to organ transplant.

Indications that are not covered

The following list, though not all inclusive, details dental services not eligible for coverage.

  1. Treatment which is necessary due to a diagnosed dental condition
  2. Pre-prosthetic surgery, including jaw augmentation, subperiosteal, endosseous or osseointegrated implants or surgical preparation of the mouth for dentures.
  3. Tooth extraction for dental, periodontal or occlusal disorder.
  4. Dentures and other dental procedures not related to medical therapy are specific exclusions and are not eligible for coverage
  5. Services that do not treat the underlying medical condition.

Definitions

Medically necessary outpatient dental services - Dental services required for the treatment of a medical condition such as removal of the teeth to complete radiation treatment for cancer of the jaw, cysts and lesions.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 01/01/1994 - Date of origin
  • 02/01/2017 - Effective date
Review date
  • 02/2018

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