Adjunctive dental care is dental care which is medically necessary:
- in the treatment of an otherwise covered medical (not dental) condition,
- is an integral part of the treatment of such medical condition, or
- is required in preparation for, or as the result of, dental trauma which may be or is caused by medically necessary treatment of an injury or disease.
Regular dental benefits are available under the separate TRICARE dental programs.
Adjunctive dental procedures covered may include:
- Removal of teeth and tooth fragments to treat and repair facial trauma, or for example, treatment of a fractured jaw. Tooth restoration may be covered if the trauma was directly related to the treatment of an otherwise covered medical condition.
- Total or complete ankyloglossia (tongue-tie) to alleviate difficulty swallowing or speaking. (Partial ankyloglossia is not covered.)
- Dental or orthodontic care directly related to the medical and surgical correction of a severe congenital anomaly.
- Dental care in preparation for, or as a result of, inline radiation therapy for oral or facial cancer.
- Dental procedures when required to treat or rectify the dental trauma/damage resulting from the treatment of an underlying medical condition.
- Anesthesia and facility fees for non-covered dental when specific criteria is met. See below.
Dental Anesthesia and Facility Benefits
Facility services and supplies required to safeguard the life of the patient, if the patient has a medical condition that could become life-threatening during a routine dental procedure, are covered benefits. For example, a tooth extraction for a patient with hemophilia. Note: The professional dental services or anesthesiology would not be covered in this situation.
Facility services, supplies and anesthesiology services for children age five or younger or beneficiaries with severe disabilities undergoing a routine dental procedure, are covered benefits. Note: TRICARE does not cover the professional dental services and anesthesiology services rendered by the attending dentist. However, TRICARE will cover anesthesiology services rendered by a separate anesthesiologist.
- If an eligible TRICARE beneficiary in this category requires general anesthesia for dental care, it must be provided by a TRICARE-authorized anesthesiologist.
- Except in an emergency, the dentist or oral surgeon must request prior authorization for general anesthesia and facility benefits from Health Net Federal Services, LLC before the dental procedure is performed. Health Net Federal Services does not require a separate referral from the beneficiary's primary care manager.
Prior authorization is required for all beneficiaries (excluding those with other health insurance) before receiving any adjunctive dental treatment to ensure the services will be covered. The prior authorization requirement is waived only when essential adjunctive dental care involves a medical emergency, such as facial injuries resulting from a car accident.
If covered, the type of location where the services are provided will determine cost information: outpatient office setting, ambulatory surgery center or inpatient hospital setting.
It is important to remember the TRICARE medical benefit does not cover routine, preventive, restorative, emergency, prosthodontic, or periodontic dental care that is not related to a medical condition. Some examples of dental care that is not covered include:
- Treatment of dental caries and periodontal disease
- Emergency room visits for dental conditions, for example, dental pain
- Tooth extraction, including impacted wisdom teeth
- Provision of implants, crowns, dentures, and bridges
For example, the removal of broken teeth to treat a fractured jaw due to a car accident is a covered adjunctive dental care service because the care is related to a medical condition (the fractured jaw). However, care for accidental injury to the teeth alone or emergency room visits for dental pain are considered non-adjunctive dental care and are not covered by the TRICARE medical benefit.