Just when we thought all of the rules for 2018 have been implemented, bam, we find out that Guardian Dental has changed their guidelines for coverage of removal of impacted wisdom teeth and for anesthesia coverage.  United Healthcare implemented a similar policy last year.  It is so important to continue to review carriers’ websites for updates, read and review the newsletters that are sent to offices via email or via snail mail.  This is a major shift for Guardian and will have an impact on all oral surgery offices, whether you are a participating provider or not.  Clear communication to your patients prior to surgery is key.  

Here are some of the highlights from the new Guardian clinical guidelines: 

Conditions NOT qualifying for benefit coverage:

• Asymptomatic impacted teeth and tooth buds

• Impacted teeth with no apparent pathology

• Removal of teeth to “prevent crowding” or future periodontal disease

• Removal for non-specific symptoms such as “headaches,” “jaw pain,” or TMJ discomfort.

One or more of the following conditions must be present for the tooth to qualify for benefit coverage:

• The presence of caries, clinically visible fracture, or pulpal involvement

• Pathological cyst formation of 2 mm or greater

• Bone loss or caries on the adjacent second molar that cannot be treated adequately without removal of the third molar

• More than one documented episode of pericoronitis as evidenced in the clinical notes

• Ectopic position of tooth preventing the eruption of an adjacent tooth

• Periodontal disease involving the second molar caused by the position of the third molar and of greater severity than the periodontal condition which will follow removal of the third molar.

• Osteomyelitis or cellulitis

• Internal/external resorption of the tooth or adjacent tooth

• Tooth/teeth impeding orthognathic surgery, reconstructive surgery, or trauma surgery.

• Overlying removable prosthesis

• Impaction preventing the eruption of the second molar

Guardian’s general anesthesia coverage guidelines have changed as well.  Surgery in 3 quadrants is now the standard for coverage with most patients.  You can no longer assume that anesthesia services will be covered.  I strongly recommend you log into the website and review the new guidelines today! 

Also according to their guidelines, appeals must be submitted with radiographs along with office notes/surgical notes.  Post procedure narratives will not suffice with appeals.   Documentation will be key. 

This is a good time for you to review the policies and plans of the patients you treat in the office.  Are you up to date on the current guidelines?  When was the last time you read the policy manual or guidelines on the carrier’s website?   Now it the time, before you assume what may no longer be true!  A quick log in and review should do the trick!