Attachments_J8b-J18.pdf

Attachment J-8b Department of Defense

Oral Health and Readiness Classification System HA Policy: 02-011

TDRAW HT9402-17-R-0001 Attachment J-8b

The oral health status of uniformed personnel shall be classified as follows:

a. Class 1 (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

b. Class 2: Patients with a current dental examination, who require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental Class 2 may exhibit the following:

(1) Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.

(2) Interim restorations or prostheses that can be maintained for a 12-month period. This includes teeth that have been restored with permanent restorative material for which protective cuspal coverage is indicated.

(3) Edentulous areas requiring prostheses but not on an immediate basis.

(4) Periodontium that:

(a) Requires oral prophylaxis.

(b) Requires maintenance therapy.

(c) Requires treatment for slight to moderate periodontitis and stable cases of more advanced periodontitis.

(d) Requires removal of supragingival or mild to moderate subgingival calculus

(5) Unerupted, partially erupted or malposed teeth that are without historical, clinical, or radiographic signs or symptoms of pathosis, but which are recommended for prophylactic removal

(6) Active orthodontic treatment. The provider should consider placing the patient in passive appliances for deployments up to six months. For longer periods of deployment, the provider should consider removing active appliances and placing the patient in passive retention.

(7) Temporomandibular disorder patients in remission. The provider anticipates the patient can perform duties while deployed without ongoing care and any medications or appliances required for maintenance will not interfere with duties.

Attachment J-8b Department of Defense

Oral Health and Readiness Classification System HA Policy: 02-011

TDRAW HT9402-17-R-0001 Attachment J-8b

c. Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

(1) Treatment or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.

(2) Interim restorations or prosthesis that cannot be maintained for a 12-month period.

(3) Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.

(a) Acute gingivitis or pericoronitis.

(b) Active progressive moderate or advanced periodontitis.

(c) Periodontal abscess.

(d) Progressive mucogingival condition.

(e) Periodontal manifestations of systemic disease or hormonal disturbances.

(f) Heavy subgingival calculus.

(4) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication, or acceptable esthetics.

(5) Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal.

(6) Chronic oral infections or other pathologic lesions including:

(a) Pulpal, periapical, or resorptive pathology requiring treatment.

(b) Lesions requiring biopsy or awaiting biopsy report.

(7) Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections, or provide timely follow-up care (e.g., drain or suture removal) until resolved.

(8) Acute temporomandibular disorders requiring active treatment that may interfere with duties.

d. Class 4: Patients who require periodic dental examinations or patients with unknown dental classification. Class 4 patients normally are not considered to be worldwide deployable.

Attachment J-9 Dental Service Points of Contact (DSPOC) Review Codes

TDRAW HT9402-17-R-0001 Attachment J-9

The following codes are used to approve/deny authorization for payment of dental care for Active Duty Service Members (ADSMs). Private practice dentists should be informed that supplemental dental care benefits are intended to be an adjunct to dental care provided by military Dental Treatment Facilities (DTFs). All pre-treatment requests for dental care are reviewed by military dentists and/or their designated staff and treatment authorization is determined in accordance with military guidance for the dental readiness mission of the Services and to support world-wide deployability standards.

Note: This attachment will also apply to the Selected Reserve and Individual Ready Reserve members (mobilization asset only) if legislation is passed as stated in Section J, Attachment J-3d Program Operations for Selected Reserve and IRR Mobilization-Asset.

Upon implementation of MHS Genesis, these codes may not be renumbered or reused, as this would corrupt past data. This applies to the current contract and any future contracts.

AI00 ADDITIONAL INFORMATION REQUESTED

AI01 For further consideration for authorization of payment for the requested procedure, submit current diagnostic-quality bitewing radiographs.

AI02 For further consideration for authorization of payment for the requested procedure, submit current diagnostic-quality periapical and bitewing radiographs.

AI03 For further consideration for authorization of payment for the requested procedure, submit current diagnostic-quality Full Mouth Series (FMS) radiographs.

AI04 For further consideration for authorization of payment for the requested procedure, submit current diagnostic-quality FMS or panoramic radiograph documenting all missing and remaining teeth.

AI05 For further consideration for authorization of payment for the requested procedure, submit a post-Root Canal Therapy (RCT) periapical radiograph with a request for an appropriate core build up and full coverage restoration.

AI06 For further consideration for authorization of payment for the requested procedure, re-submit with narrative explanation and current diagnostic-quality radiographs (periapical and bitewings for single-unit crowns; FMS for bridges, partial dentures, and periodontal surgery).

AI07 For further consideration for authorization of payment for the requested procedure, please submit a revised treatment plan considering the previous DSPOC review comments and treatment recommendation(s); include appropriate current diagnostic-quality radiographs and narrative explanation (if applicable).

AI08 The information submitted does not provide sufficient information for authorization of payment for the requested procedure(s). For further consideration of authorization for payment, please provide a narrative explanation.

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AI09 For further consideration of authorization of payment for the requested procedure, please submit a narrative advising how long this tooth has been missing, what (if anything) is currently replacing this tooth and radiographic documentation of continued tooth movement over the past several years.

AI10 For further consideration of authorization of payment for dental care, the service member is requested to provide (via <insert contractor’s name>) the last 5 years of their military dental record.

AI11 For further consideration for authorization of payment for the requested procedure, submit a current diagnostic-quality periapical radiograph.

AI12 For further consideration for authorization of payment for the requested procedure, submit a current diagnostic-quality color photograph. Photographs are considered integral to the parent procedure.

AN00 ANESTHESIA / IV SEDATION / ANALGESIA COMMENTS

AN01 General anesthesia, IV sedation, conscious sedation, or analgesia IS authorized for payment in conjunction with surgical procedures.

AN02 General anesthesia, IV sedation, oral sedation and/or analgesia is NOT authorized for payment or reimbursement when provided in conjunction with a non-covered service.

AN03 The requested general anesthesia, sedation and/or analgesia is not authorized for payment for the requested procedure(s). If there is a special need for the sedation procedure, resubmit a narrative detailing the relevant circumstances for reconsideration.

AN04 General anesthesia, IV sedation, conscious sedation, or analgesia is not authorized for payment in conjunction with non-surgical procedures.

AN05 Nitrous oxide analgesia is not a covered service. Exceptions may be made in unusual circumstances but written authorization is required. If there is a special need for the sedation procedure, resubmit a narrative detailing the relevant circumstances for reconsideration.

AN06 Prescribed medications for dental procedures are covered by the service member’s TRICARE Medical coverage. The service member can have the prescription filled at a TRICARE network civilian pharmacy or a military treatment facility.

AP00 APPEAL COMMENTS

AP01 The following is a summary (not all inclusive) of requirements for pre-authorization of services: An Appointment Control Number (ACN) authorizes routine diagnostic and preventive services (frequency limitations apply) for the ADSM. Pre-authorization for all dental services is required for care over $750 per procedure or same day appointment or the total treatment plan exceeds $1,500 for routine and specialty care within a consecutive 12 month period. Procedures listed as specialty require authorization regardless of cost.

AP02 Claim payment for treatment without required authorization is a one-time exception.

DSPOC advises the provider and service member to follow the guidelines regarding required authorization for dental services. TRICARE Dental Readiness and Wellness (TDRAW) is not obligated to pay claims for procedure(s) that require authorization and for which none was obtained. Information regarding these requirements is available at <insert contractor’s website>.

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AP03 Service members who are located within 50 miles of a DTF are considered direct care and may only utilize benefits through TDRAW if they obtain a referral from the DTF. The referral lists all dental procedures that the provider should perform. The provider and service member are advised payment for this dental treatment is a one-time exception approved by the DSPOC. If future dental treatment is needed a referral from the DTF will be required or the service member may be financially responsible for the provider's charge(s).

AP04 The dental procedure has been denied for payment by the DSPOC. The provider and service member have previously been advised that direct care service members are not authorized to seek treatment through the TDRAW without a DTF referral. Network providers cannot bill the service member for this procedure.

AP05 Claim payment for treatment without required authorization is a one-time exception.

TDRAW requires service members to receive dental treatment from TDRAW network providers. DSPOC advises the provider and service member to follow TDRAW guidelines regarding authorization for dental services. TDRAW is not obligated to pay claims for procedure(s) that require authorization and for which none was obtained.

Information regarding TDRAW is available at <insert contractor’s website>.

AP06 The procedure has been denied for payment by the DSPOC. The provider and service member were previously advised that ADSMs are required to receive dental treatment from a TDRAW network provider. The service member is financially responsible for the dental treatment.

AP07 DSPOC is approving a one-time exception for payment for frequency limitation. The provider and service member is advised they must follow the TDRAW frequency limitations for dental procedures.

AP08 Under the TDRAW guidelines, all crowns require pre-authorization and are not considered emergency treatment. DSPOC advises provider and patient to follow TDRAW guidelines regarding required pre-authorization for dental services, and to note that TDRAW is not obligated to pay claims for the procedure(s) that require pre-authorization and for which none is received. For TDRAW information, access website: <insert contractor’s website>or phone: <insert contractor’s phone number>.

AP09 *Pre-operative periapical and bitewing radiographs are required.

AP10 *Post-operative periapical and bitewing radiographs, showing the seated crown are required for review.

AP11 The dental procedure has been denied for payment by the DSPOC. The provider and service member have previously been advised of the TDRAW authorization requirements. TDRAW network providers cannot bill the service member for this procedure.

AP12 An amalgam restoration was approved on a previous authorization request. Substitution of a procedure, other than the approved procedure, is not permitted under the TDRAW.

TDRAW network providers cannot bill the service member for this procedure. If the service member elected to receive a dental procedure other than the authorized procedure and the TDRAW network provider obtained the service members agreement to pay for the procedure, the service member is financially responsible for the provider's charge in full.

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AP13 The dental procedure has been denied for payment by the DSPOC. Substitution of a procedure, other than the approved procedure, is not permitted under the TDRAW.

TDRAW network providers cannot bill the service member for this procedure. If the service member elected to receive a dental procedure other than the authorized procedure and the TDRAW network provider obtained the service members agreement to pay for the procedure, the service member is financially responsible for the provider's charge in full.

AP14 The submitted radiograph(s) do not suggest the need for restorative treatment. TDRAW network providers cannot bill the service member for this procedure. If the service member elected to receive a dental procedure other than the authorized procedure and the TDRAW network provider obtained the service members agreement to pay for the procedure, the service member is financially responsible for the provider's charge in full.

AP15 TDRAW network providers cannot bill the service member for this procedure. If the service member elected to receive a dental procedure other than the authorized procedure and the TDRAW network provider obtained the service members agreement to pay for the procedure, the service member is financially responsible for the provider's charge in full.

BR00 BRIDGEWORK / FIXED PROSTHODONTICS COMMENTS

BR01 The requested abutment procedure is denied; a single unit crown procedure is authorized for payment. (specified below) BR02 Based on the information provided, there appears to be insufficient space for the requested pontic/restoration.

BR03 Based on the information provided, the requested procedure appears to have a poor long term prognosis due to inadequate abutment/retainer support.

BR04 Based on the information provided, the long-term prognosis for the requested procedure appears unfavorable due to the existing periodontal condition.

BR05 Based on the information provided, the requested retention wing will not significantly improve the long-term prognosis of the requested procedure.

BR06 Based on the information provided, the requested double abutment will not significantly improve the long-term prognosis of the restoration.

BR07 The radiograph(s) suggests the tooth has been missing for a considerable time and the occlusion is stable. Current Military guidelines for the TDRAW do not recommend authorization of payment for the procedure in this circumstance.

BR08 The radiograph(s) suggests the tooth has been missing for a considerable time and the occlusion is stable. Current Military guidelines for the TDRAW do not recommend authorization of payment for the procedure in this circumstance. For further consideration of authorization for payment of the procedure, provide documentation of continued tooth movement over the past several years.

BR09 The information submitted (radiographs and/or other information) suggests a high caries rate. Current Military guidelines for the TDRAW do not recommend authorization of payment for fixed prosthodontics in a high caries risk environment.

BR10 The radiographs suggest the abutment teeth have conservative or no existing restorations or defects. Consider evaluating for an implant if replacing the missing tooth is deemed necessary.

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BR11 Authorization for payment of the requested procedure is granted. Current Military guidelines require the service member be informed replacement of the missing tooth is elective and the need for reduction of sound natural tooth structure required in preparing the supporting teeth for the bridge can cause irreversible damage to the supporting teeth as well as adjacent teeth.

BR12 For further consideration for authorization of payment for the requested procedure, please submit a narrative that includes how long the tooth/teeth have been missing, what if anything is currently replacing the missing tooth/teeth and do you have radiographs documenting additional tooth movement of adjacent teeth during the past five years (if available)?

BR13 Authorization for payment of the requested procedure is denied by the DSPOC. Current Military guidelines require the service member be informed replacement of the missing tooth is elective and the need for reduction of sound natural tooth structure required in preparing the supporting teeth for the bridge can cause irreversible damage to the supporting teeth as well as adjacent teeth.

BR14 Current Military guidelines for the TDRAW do not recommend authorization of payment for cantilever bridges in this scenario.

BR15 All-ceramic fixed partial dentures involving and replacing molars will be Full-Contour zirconia (i.e., Bruxir, Lava Plus, Zirlux) only. Civilian dental providers are required to provide a copy of the lab bill, for non DTF-referred care, with the dental claim providing evidence of the materials used for fabricating the crown. If the dental office has their own milling machine so indicate.

BU00 BUILD-UPS / POSTS / CORES

BU01 The radiograph(s) do not suggest the need for a core build-up.

BU02 The radiograph(s) do not suggest a need for a core build-up. For further consideration of authorization for payment, please provide a narrative explanation.

BU03 The radiograph(s) suggest a need for a post and core build-up.

CR00 CROWNS / ONLAYS / INLAYS

CR01 The radiographs suggest the tooth can be restored more conservatively with a direct restorative material. Current Military guidelines for the TDRAW do not recommend authorization of payment for a full or partial coverage restoration in this circumstance.

CR02 The radiographs suggest the access opening can be restored more conservatively with a direct restorative material. Current Military guidelines for the TDRAW do not recommend authorization of payment for a full or partial coverage restoration in this circumstance.

CR03 The endodontic access opening appears to be very conservative. Current Military guidelines for the TDRAW recommend authorization of payment for restoration of the access opening with direct restorative material such as amalgam or composite resin. No further treatment is recommended.

CR04 The submitted radiograph(s) do not suggest the need for crown replacement. For further consideration of authorization for payment, please provide a narrative explanation and diagnostic-quality radiographs.

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CR05 Based on the information provided, there is insufficient justification for authorization for payment of the requested procedure. Current Military guidelines for the TDRAW recommend authorization of payment for a full-cuspal coverage crown when the tooth is extensively decayed and/or has a cusp fracture (not craze lines), and cannot be restored by an amalgam or a composite resin restoration. Authorization of payment for a crown is not routinely granted based upon a potential for future restoration failure or tooth fracture.

CR06 Current Military guidelines for the TDRAW recommend use of high noble metal in contact with opposing natural dentition.

CR07 The request for an anterior gold crown is denied for payment, a Porcelain Fused Metal (PFM) crown (D2750) is recommended and authorized. The service member must be informed in writing that gold crowns on anterior teeth may not be in compliance with Military policies and directives concerning military dress and appearance. If current or future local command or Military policies prohibit gold crowns on anterior teeth, it will be the financial responsibility of the service member to replace the gold crown to become compliant with local command or Military service policies or regulations.

CR08 Current Military guidelines for the TDRAW do not recommend authorization of payment for an all-porcelain/ceramic crown in this circumstance.

CR09 Current Military guidelines for the TDRAW recommend that base metal crowns/restorations only be used in extremely rare circumstances.

CR10 Current military guidance for the TDRAW recommends authorization of payment for a full coverage crown with a high-noble metal occlusal/lingual surface to allow future endodontic access without the need for replacement of the existing crown.

CR11 The information submitted (radiographs and/or other information) suggests a high caries rate. Current military guidelines for the TDRAW do not recommend authorization of payment for crowns in a high caries risk environment. Military guidelines define high caries risk as three or more new incipient or cavitated carious lesions within the last 12 months.

CR12 Crown lengthening is authorized for payment if provided as a separate procedure from restorative procedures and sufficient time (at least 8 weeks) from date of crown lengthening to initiation of restorative procedures to allow tissue healing and maturation of attachment. Under the TDRAW, crown lengthening provided at the same time as restorative procedures is considered integral to the restorative procedure.

CR13 In this scenario, the DSPOC recommends that the provider offer the service member the option of a full metal crown due to the lower complication rate and lower long term maintenance costs.

CR14 Military guidelines do not recommend placement of fixed prosthodontics in a high caries risk environment. DSPOC recommends an extended period of time to allow the service member to demonstrate the ability to maintain low caries risk. The provider may submit an interim caries control treatment plan for the active lesions. Following interim treatment, a request for full coverage crowns can be resubmitted.

CR15 The radiographs indicate the tooth has minimal, if any, opposing occlusion. Current military guidelines for the TDRAW do not recommend authorization of payment for the requested procedure in this scenario.

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CR16 Based on Military Specialty Consultants' recommendation, all ceramic crowns D2740 are required to be either Lithium Disilicate (IPS E.Max CAD or Ivoclar Vivadent) or Full Contour Zirconia (i.e., Bruxir, Lava Plus, Zirlux) whether they are placed in DTFs or via private sector care. Civilian dental providers are required to provide a copy of the lab bill with the dental claim providing evidence of the materials used for fabricating the crown.

If the dental office has their own milling machine (Cerec, ProCad, Vitablocs, Paradigm) the dentist shall indicate this and also confirm what brand and material type of block was used.

EL00 ELIGIBILITY STATEMENTS

EL01 Defense Enrollment Eligibility Reporting System (DEERS) (the military database for dental benefits eligibility) indicates the member's eligibility for the TDRAW will end shortly. In accordance with federal fiscal law, only procedures that are completed in their entirety while the member is in an eligible status can be authorized for payment under the

TDRAW.

EL02 DEERS (the military database for eligibility) indicates the member's eligibility for the TDRAW benefits ends before the requested treatment can be completed. In accordance with federal fiscal law, only procedures that are totally completed while the member is in an eligible status can be authorized for payment under the TDRAW.

EL03 Per DEERS (the military database for eligibility), the service member was not in an TDRAW eligible status at the time of the dental treatment and is therefore not eligible for authorization for payment of care. If the DEERS information is inaccurate, the Service Member must work with his/her unit to correct the information in DEERS.

EL04 There is no documentation the dental condition incurred during, or was aggravated by, the active duty service. Therefore, the member is not eligible for authorization of payment for dental care related to active duty service under the provisions of the

TDRAW.

EL05 Per DEERS (the military database for eligibility), the service member is/was not in an TDRAW eligible status and is therefore not eligible for authorization for payment of care. If the DEERS information is inaccurate, the Service Member must work with his/her unit to correct the information in DEERS.

EL06 Follow-up treatment may be available through Veterans Administration (VA) benefits if the service member meets appropriate eligibility criteria. The service member should contact the nearest VA facility as soon as possible for further benefit information or use on-line services to help access VA care at www.va.gov.

EN00 ENDODONTIC COMMENTS

EN01 Direct and indirect pulp caps are considered integral to the restorative procedure and are not payable as a separate charge.

EN02 The information provided suggests periapical pathology exists on the tooth to be restored.

EN03 The information provided suggests that periapical pathology exists. This potential emergency condition has priority for care over the requested procedure.

EN04 Based on the information provided, the root canal obturation material appears to be inadequately condensed.

EN05 Based on the information provided, the root canal obturation appears to be short of the apex.

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EN06 Based on the information provided, the root canal filling material appears to extend beyond the apex.

EN07 Based on the information provided, the long-term prognosis for the requested procedure is marginal to poor because the tooth appears to have a broken instrument in the canal.

EN08 Based on the information provided, Military guidelines recommend that because of the complexity of this particular case, it is recommended that RCT be evaluated by an endodontic specialist if one is available. Consideration of payment for non-surgical RCT treatment/retreatment can be reviewed if an authorization request is submitted by a TDRAW network endodontic specialist.

EN09 Based on the information provided, a periapical radiolucency exists. The patient should receive non-surgical RCT treatment/retreatment. Following RCT treatment/retreatment, the restorative dentist should submit a post-RCT radiograph and a treatment plan requesting a post/core (as appropriate) and crown.

EN10 The information provided indicates elective RCT will reduce the remaining sound natural tooth structure that is required to support the post/core/crown complex, increasing the potential for tooth fracture and/or restoration failure.

EN11 If the tooth is discolored and/or esthetically compromised as a result of the RCT or associated trauma, please resubmit for authorization and include a narrative and quality color photograph for the non-vital bleaching procedure.

EN12 Based on the information provided, the tooth may be non-restorable or require non-surgical RCT due to the extent of the decay. Please determine restorability and the need for RCT by excavating all caries. If the tooth is restorable after the removal of the decay and a RCT is not necessary, please submit diagnostic quality radiographs, including a narrative of the pulpal health and vitality for authorization of a definitive restorative treatment plan. If a RCT is necessary due to the proximity to the pulp or symptoms consistent with irreversible pulpitis, please submit an authorization request for completion of RCT.

EN13 For endodontically treated anterior teeth, it is the remaining sound natural tooth structure, not a crown that provides resistance to fracture. If a crown is needed to replace significantly missing coronal tooth structure, a post is recommended to minimize potential of catastrophic tooth fracture following reduction of remaining sound natural tooth structure for the crown. This guideline is consistent with the restorative guidelines recommended by the American Association of Endodontists and the American College of Prosthodontists.

EN14 The periapical radiograph indicates encroachment on the pulp chamber and/or periapical radiolucency's may exist. The service member should be referred to an endodontist for evaluation and non-surgical RCT if indicated. The provider and/or the service member will be contacted to receive an appointment control number for the endodontic evaluation by the endodontist. If RCT is not indicated, include a copy of the endodontist's report with the request for a core build-up and crown. If RCT is indicated, the endodontist should submit a treatment plan for DSPOC review. The authorization request may be resubmitted with a diagnostic quality radiograph of the completed RCT for consideration of the build-up and crown following completed endodontic treatment.

G00 GENERAL COMMENTS

G01 The information provided does not indicate the need for the requested procedure.

G02 The tooth number requested does not appear to be present on the radiograph submitted.

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G03 The requested procedure is not authorized for payment under the current Military guidelines for the TDRAW.

G04 Based on the information provided, the requested procedure does not appear to meet the American Dental Association's (ADA) Current Dental Terminology (CDT) procedure code definition under which it was submitted. Therefore, no authorization for payment can be made.

G05 The tooth number and/or ADA procedure code number and/or description do not match.

Please correct the discrepancy and resubmit request. If resubmitted for review, include current diagnostic-quality periapical and bitewing radiographs.

G06 Per contract guidelines for the TDRAW, the requested procedure is considered integral to the parent procedure and is not authorized for payment as a separate charge.

G07 Oral hygiene instructions, Over-the-Counter (OTC) products and other products available without a prescription are not authorized for payment or reimbursement under the Service guidelines for the TDRAW Program.

G08 The radiograph(s) suggest a low caries rate. Current Military guidelines indicate a fluoride treatment will not provide a significant benefit and is therefore not authorized for payment under the TDRAW.

G09 The information submitted does not provide sufficient documentation/justification for authorization for payment of the requested procedure.

G10 The requested procedure is not a covered benefit. Before initiating any non-covered service, the provider has a responsibility to obtain written consent and advise the member they will be financially responsible for payment of any non- covered service.

G11 Based upon the information provided and Service guidelines for the TDRAW, this service does not meet the requirement of dental care that is necessary to meet military dental readiness guidelines and/or provide adequate dental function for world- wide deployability.

G12 The purpose of the TDRAW is to provide eligible service members a uniform dental benefit to meet Military requirements for dental health and world-wide deployability.

G13 Veneers, bleaching and other cosmetic procedures are elective and do not meet current Military guidance for authorization for funding under the TDRAW.

G14 The requested procedure has been denied. An alternate procedure code has been authorized. Substitution of a procedure other than the authorized procedure is not allowed for payment under the guidelines for the TDRAW.

G15 An ADA procedure code/description has been entered by the DSPOC to clarify the procedure authorized for payment to meet Military requirements. Substitution of a procedure other than the authorized procedure code is not allowed for payment under the guidelines for the TDRAW.

G16 The request for authorization for payment of this procedure has been forwarded to the appropriate Department of Defense (DoD) Service Dental Consultant for review. The TDRAW Dental Service Point of Contact (DSPOC) will relay the Consultant's decision as soon as it is received.

G17 Payment for this procedure has been authorized by the appropriate DoD Service Dental Consultant. Authorization of payment for this procedure does not grant coverage or authorization of payment for any follow-up care. Any future care should be requested following appropriate TDRAW guidelines for pre-determination of benefits.

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G18 Authorization of payment for this procedure has been denied by the appropriate DoD Service Dental Consultant. Any future care should be requested following appropriate TDRAW guidelines for pre-determination of benefits.

G19 This procedure has been authorized for payment. Authorization of payment for this procedure does not grant coverage or authorization for any follow-up care. Any future care should be requested following appropriate TDRAW guidelines for pre-determination of benefits.

G20 Authorization of payment for this procedure is granted with the understanding that all costs associated with this treatment (including follow-up care) are included in this fee.

If not, a new pre-treatment estimate should be submitted for review prior to initiating any care. Authorization of payment for this procedure does not grant authorization of payment for any follow-up care.

G21 This procedure was authorized on a previous TDRAW DSPOC review. It is not a new authorization for this procedure.

G22 The TDRAW is intended to be an adjunct, not a replacement for, active duty DTF dental care. Current military guidance for the TDRAW recommends treatment and services not immediately required to establish or maintain dental health to meet dental readiness or world-wide deployability standards be delayed until this treatment can be provided at an active duty military DTF.

G23 Current Military guidelines for the TDRAW recommend the procedure, and/or evaluation for the procedure, be deferred until the service member is collocated with an active duty military DTF.

G24 The requested procedure has been denied as a duplicate (data) entry.

G25 The requested procedure has been denied as an incorrect code (data) entry. A correct

CDT code is authorized for payment. Substitution of a procedure other than the authorized procedure is not allowed for payment under current military guidelines for the TDRAW Program.

G26 The TDRAW pre-treatment review provided by the active duty military dentist DSPOCs does not dictate treatment recommendations; however, it does indicate what procedures are authorized for payment under the TDRAW. Authorization of payment is based on US Government fiscal regulations and Military dental treatment guidelines to ensure ADSMs meet dental readiness requirements for world-wide deployability. Specific dental services to be provided and financial responsibility is ultimately for the service member and provider to discuss and determine. However, the US Government financial responsibility will be limited to procedures appropriately authorized for payment under the provisions of the TDRAW contract.

G27 To be considered a covered service a procedure or treatment must meet the requirement of being appropriate and necessary to establish and maintain dental health to meet military worldwide readiness/deployment status. Based upon the information provided, this service does not meet that requirement. If the service member authorizes the dental provider to provide care without pre-authorization payment approval, the service member is responsible for payment of any care deemed elective or non-covered.

G28 Please refer to additional TDRAW guidance in "Note(s)" section.

G29 ADSMs are required to use TDRAW network providers for dental treatment. Further use of non-network provider may result in claims being denied and the service member held personally responsible for payment of non-DSPOC approved treatment.

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G30 The provider and service member are informed this procedure requires pre-authorization prior to initiation of treatment. Further initiation of treatment prior to receiving pre-authorization may result in claims being denied.

G31 The provider and service member are informed the procedure has been denied for payment by the active duty military DSPOC reviewer. Furthermore, this procedure is not billable to the service member under the "Hold Harmless" clause of the contractor's TDRAW-network dentist contract.

G32 Per TDRAW guidance, treatment plans over $1500 are to be submitted comprehensively for pre-authorization and are not to be divided into separate submissions within a 12 month period. Procedures listed as specialty require authorization regardless of cost.

G33 The service member's claims history indicates the procedure(s) have been completed.

Please submit an appeal request for consideration of payment.

G34 Emergency care is care that is required to treat or control hemorrhage, infection, swelling and pain and does not require an authorization, referral or appointment control number.

This includes treatment necessary to relieve pain, treat infection, or control hemorrhage to include: temporary or permanent fillings, root canal treatment, single tooth extractions, incision and drainage or other immediate required treatment. Crowns, bridges and dentures are not considered emergency care and require authorization.

HY00 HYGIENE COMMENTS

HY01 The TDRAW allows payment for two dental cleanings per year. Current Military guidance for the TDRAW recommends authorization of payment for two professional dental prophylaxis per year combined with thorough daily oral hygiene to be adequate and appropriate treatment.

HY02 The diagnostic materials submitted suggest a high caries rate. The DSPOCs recommend the TDRAW network provider write a prescription for fluoride toothpaste to be filled by the service member's TRICARE pharmacy benefit.

HY03 The diagnostic materials submitted suggest a high caries rate. Current Military guidelines for the TDRAW do not recommend authorization of payment for this requested procedure in a high caries risk environment.

HY04 The TDRAW program allows two topical fluoride applications in a consecutive 12-month period when performed as an independent procedure. The DSPOC has denied the additional fluoride treatment in this scenario.

HY05 The TDRAW program allows up to four periodontal maintenance procedures or any combination of routine prophylaxes and periodontal maintenance procedures totaling four may be paid within a consecutive 12-month period.

IM00 IMPLANT COMMENTS

IM01 Based on the information provided, the proposed implant/restoration does not meet current Military's dental function requirements to justify authorization of payment.

IM02 Current Military guidelines for dental implants do not authorize immediate implant loading following fixture placement. Therefore the phasing will need to allow sufficient time for adequate bone graft healing and replacement with natural bone prior to implant fixture placement and sufficient time for osseointegration prior to the prosthetic phase.

Military guidelines require that the service member have a minimum of 12 months active duty time remaining. Authorization of payment for implant services by civilian dentists will not be granted if these conditions are not followed.

TDRAW HT9402-17-R-0001 Attachment J-9

IM03 In order to standardize the implant process from initial placement through long-term follow-up care, current Military guidance requires that all dental implants, purchased via private sector care, must be compatible with one of the five authorized implant abutment connection systems: Noble Biocare conical connection, Nobel Biocare external hex, Nobel Biocare tri-lobe, 3i/Biomet external hex, or 3i/Biomet Certain. TDRAW guidelines require 100% compatibility of the proposed implant system with these abutment configuration & screw thread designs, regardless of the manufacturer. No other restorative connections are authorized. Members electing to use an implant system that is not compatible with these requirements must sign a Written Consent Form prior to initiating treatment, in which they agree to pay all expenses incurred for the placement, restoration, follow-up and maintenance of the implant. Civilian dental providers are requested to provide a letter or a copy of their dental record that documents the implant fixture specifications and abutment connection systems utilized. Additionally a post-treatment panorex shall be taken and a copy provided to the member for inclusion into their military dental record.

IM04 Current military funding and dental restorative guidance for the TDRAW does not allow for replacement of second molars in an otherwise intact, stable and functional occlusion.

IM05 Military guidelines recommend that the military member be a non-smoker and a non-user of smokeless tobacco products before implant surgery may be initiated. Please provide a narrative on member's use/non-use of these items.

IM06 If significant grafting and other procedures are required, an implant may not meet the requirements for being the most conservative and cost effective replacement option.

TDRAW also requires that the dentist inform the service member that dental implant as well as bridge maintenance can be expensive and the service member accepts full responsibility for all future maintenance costs after eligibility ends. The provider should discuss all available treatment options with the service member, including the option of a bridge, the risks and benefits associated with all treatment options, the prognosis for success of all treatment options as well as the short and long term maintenance costs associated with all treatment options.

OR00 ORTHODONTIC COMMENTS

OR01 Current Military guidance for the Active Duty Dental Program limits authorization for payment of civilian orthodontic treatment to correct recent trauma and/or in support of required oral maxillofacial surgery provided by active duty military oral surgeons or prosthodontic procedures. Based on the information provided, the requested service does not meet these requirements.

OR02 Repair of damaged orthodontic appliances is not covered as a separate charge.

OR03 The replacement of a lost or missing appliance is not a covered benefit.

OR04 The request for orthodontic treatment does not meet current Military guidelines and policies for authorization of payment under the TDRAW.

OS00 ORAL SURGERY / THIRD MOLAR COMMENTS

OS01 The tooth appears to be non-restorable; consider extraction for authorization of payment as TDRAW covered dental treatment.

OS02 If third molars are causing an occlusal interference, consider extraction for authorization for payment of dental treatment.

TDRAW HT9402-17-R-0001 Attachment J-9

OS03 Restoration of third molars is authorized for payment only when the third molar is in an ideal occlusal relationship with an opposing tooth and oral hygiene is adequate to prevent caries on the third molar as well as adjacent teeth.

OS04 Current Military guidelines for the TDRAW do not recommend authorization of payment for placement of graft material during extraction of third molars in this scenario.

OS05 Biopsy procedures authorized for payment under current Military guidelines for the TDRAW do not include brush biopsy or light-assisted diagnostic biopsy adjunctive procedures. Biopsy procedures authorized for payment include incisional or excisional surgical biopsy that has been indicated following appropriate clinical evaluation and differential diagnosis to support a surgical biopsy procedure.

OS06 The x-rays indicate a retained/impacted third molar. A retained or impacted third molar has the potential to cause a significant infection in a deployed environment.

This situation is a military dental readiness issue and evaluation for possible extraction of the tooth is indicated.

OS07 The x-rays indicate a retained/impacted tooth. If an impacted tooth space is in communication with the oral cavity, a potential for significant infection exists. This situation is a military dental readiness issue and evaluation and possible extraction of the tooth is indicated.

OS08 Based on the information provided, current Military guidelines recommend that because of the complexity of this particular case, the service member should be evaluated by an oral and maxillofacial surgeon. The service member should contact the TDRAW to obtain an appointment control number and assistance with locating a TDRAW network oral and maxillofacial surgeon.

OS09 The service member should be referred to an oral surgeon for evaluation and extraction of retained third molars. From a military readiness perspective, the retained third molars present a significant risk for the service member's health and compromise for worldwide deployability.

PE00 PERIODONTAL TREATMENT COMMENTS

PE01 Current Military guidance for the TDRAW considers local antibiotic treatment and/or irrigation to be adjuncts to primary periodontal therapy. Scaling and root planing is the recommended primary therapy.

PE02 The radiographs indicate significant periodontal disease exists.

Untreated/uncontrolled periodontal disease is a military world-wide deployability readiness concern. The member should be referred to a periodontist for full mouth series radiographs and a periodontal evaluation.

PE03 The information provided does not indicate guided tissue regeneration would result in a significantly improved healing outcome.

PE04 Based on the information provided, the outcome of the requested procedure has a questionable prognosis due to the existing periodontal condition. Military guidelines for the TDRAW do not recommend authorization for payment of the procedure under these circumstances.

PE05 Based on the information provided, the existing periodontal condition is not severe enough to justify authorization for payment of the requested procedure. Military guidelines for the TDRAW do not recommend the procedure be provided under these circumstances.

TDRAW HT9402-17-R-0001 Attachment J-9

PE06 Based on the information provided, current Military guidelines recommend that because of the complexity of this particular case, the service member should be evaluated by a periodontist, if one is available.

PE07 Based on the information provided, the requested gingivectomy/gingivoplasty performed in conjunction with prosthodontic treatment is not justified to be chargeable as a separate procedure.

PE08 Based on the information provided, appropriate periodontal therapy should include periodontal scaling and root planing. For further consideration for authorization of payment, please provide a narrative explanation and/or diagnostic radiographs documenting initial mouth preparation.

PE09 The procedure is authorized to allow open flap debridement of root surfaces and periodontal tissues. The need for osseous recontouring is not evident on the radiographs and/or information provided.

PE10 The requested procedure is authorized for payment. However, the service member shall be informed of alternate therapies including those that may be less invasive. This will ensure the service member has been informed of all risks and benefits of the proposed treatment and other realistic alternatives and that informed consent has been fully obtained.

PE11 Color photographs, in addition to current diagnostic quality radiographs, would be helpful in documenting justification for authorization of payment for subepithelial and other soft tissue graft procedures.

PE12 The photographs indicate the recession has existed for a considerable time and there is no indication the recession will continue or be a compromise to the service member’s dental health in the future.

PE13 Current military guidance for the TDRAW limits authorization for periodontal scaling and root planing to once every two years as clinically indicated and supported by periodontal charting, Full Mouth X-ray (FMX), Bite Wing X-ray (BWX), or Periapical X-ray (PAX) of treatment area. If patient requires periodontal scaling and root planing within two years, the service member should be evaluated and treated, as indicated, by a periodontist.

PE14 Military guidelines recommend that the military member be a non-smoker and a non-user of smokeless tobacco products before periodontal surgery may be initiated. Please provide a narrative on member's use/non-use of these items.

PE15 The chief complaint appears to be temperature sensitivity. There is no guarantee grafting will be effective or provide a long- term stable root coverage in this scenario. There are non-surgical/non-restoration treatment options that may address the chief complaint without the need for surgery or restorations. Current military guidelines for the TDRAW recommend use of non-surgical and non-restorative options for treatment of sensitive exposed root surfaces in this scenario.

PE16 The information submitted does not provide sufficient information for authorization of payment for the requested procedure(s). For further consideration of authorization for payment, please provide the periodontal charting.

PR00 PROSTHODONTIC COMMENTS

PR01 Special procedures used in constructing dental prosthetics are not authorized for payment as a separate charge…