Coverage Policy Manual
Policy #: 2011029
Category: PPACA Preventive
Initiated: September 2010
Last Review: August 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: DENTAL CARIES PREVENTION IN PRESCHOOL CHILDREN

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
 

Policy/
Coverage:
Effective August 2017
 
ORAL FLUORIDE
 
Counseling for treatment with oral fluoride supplementation is covered for children whose primary water source is deficient in fluoride for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) as part of a normal wellness office visit at 6mos, 9 mos, 12 mos, 18 mos, 24 months, 30 mos, and yearly from 3 years to 16 years.
 
The appropriate ICD-10 codes to report these services are Z00.121, Z00.129 and Z41.8.
 
The codes that used to report this service are those associated with a preventive medicine office visit, 99381-99383 or 99391-99393. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
FLUORIDE VARNISH
 
The application of flouride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption is covered for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-10 codes to report these services are Z00.121, Z00.129 and Z41.8.
 
The codes that used to report this service is CPT 99188. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
Effective June 2015 – July 2017
 
ORAL FLUORIDE
 
Counseling for treatment with oral fluoride supplementation is covered for preschool children older than 6 months of age whose primary water source is deficient in fluoride for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) as part of a normal wellness office visit.
 
The appropriate ICD-10 codes to report these services are Z00.121, Z00.129 and Z41.8.
 
 
The codes that used to report this service are those associated with a preventive medicine office visit, 99381-99383 or 99391-99393. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
FLUORIDE VARNISH
 
The application of flouride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption is covered for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-10 codes to report these services are Z00.121, Z00.129 and Z41.8.
 
The codes that used to report this service is CPT 99188. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
Effective prior to June 2015
Counseling for treatment with oral fluoride supplementation is covered for preschool children older than 6 months of age whose primary water source is deficient in fluoride for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) as part of a normal wellness office visit.
 
The appropriate ICD-9 code to report these services is V20.2 or V07.31.
 
The codes that used to report this service are those associated with a preventive medicine office visit, 99381-99383 or 99391-99393. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
Counseling for treatment with oral fluoride supplementation is covered for preschool children older than 6 months of age whose primary water source is deficient in fluoride of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) as part of a normal wellness office visit.
 
The appropriate ICD-9 code to report these services is V20.2 or V07.31.
 
The codes that used to report this service are those associated with a preventive medicine office visit, 99381-99383 or 99391-99393.  When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 

Rationale:
USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride (Grade B recommendation).
 
The USPSTF recommendations include the following information:
      • Dental disease is prevalent among young children, particularly those from lower socioeconomic populations; however, few preschool-aged children ever visit a dentist. Primary care clinicians are often the first and only health professionals whom children visit. Therefore, they are in a unique position to address dental disease in these children.
      • Fluoride varnishes, professionally applied topical fluorides approved to prevent dental caries in young children, are adjuncts to oral supplementation. Their advantages over other topical fluoride agents (mouth-rinse and gel) include ease of use, patient acceptance, and reduced potential for toxicity.
      • Dental fluorosis (rather than skeletal fluorosis) is the most common harm of either oral fluoride or fluoride toothpaste use in children younger than 2 years in the United States. Dental fluorosis is typically very mild and only of aesthetic importance. The recommended dosage of fluoride supplementation was reduced by the American Dental Association in 1994, which is likely to decrease the prevalence and severity of dental fluorosis. The current dosage recommendations are based on the fluoride level of the local community's water supply and are available online at http://www.ada.org. The primary care clinician's knowledge of the fluoride level of his or her patients' primary water supply ensures appropriate fluoride supplementation and minimizes risk for fluorosis.
 
2015 Update
In 2014, the USPSTF published updated recommendations on screening for dental carries in children.  
 
The USPSTF gives a Grade B  recommendation that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. Additionally, a Grade B recommendation is given for primary care clinicians to apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
 
The USPSTF found adequate evidence that oral fluoride supplementation, also known as dietary fluoride supplementation, in children who have low levels of fluoride in their water and application of fluoride varnish to the primary teeth of all children can each provide moderate benefit in preventing dental caries.
 
The USPSTF contains the following information (USPSTF, 2014)
    • This recommendation applies to children age 5 years and younger.
    • The USPSTF limited its consideration of caries screening and prevention by primary care clinicians to infants and preschool-aged children. The rationale for this decision was that, at the present time, nondental primary care clinicians are more likely than dentists to have contact with children ages 5 years and younger in the United States; this situation changes as children reach school age and beyond. In addition, as children grow older, dental professionals use sealants rather than fluoride varnish. As such, the USPSTF limited its review of the evidence of preventive interventions for dental caries to this age group. This recommendation should not be construed to imply that preventive interventions for dental caries should cease after 5 years of age.
    • No study directly assessed the appropriate ages at which to start and stop the application of fluoride varnish. Available trials of fluoride varnish enrolled children ages 3 to 5 years; however, given the mechanism of action of this intervention, benefits are very likely to accrue starting at the time of primary tooth eruption. Limited evidence found no clear effect on caries increment between performing a single fluoride varnish once every 6 months versus once a year or between a single application every 6 months versus multiple applications once a year or every 6 months.
2017 Update
 
Bright Futures recommends that pediatricians perform oral health risk assessments on all children beginning at 6 months of age (Clark, 2014). Assessments are recommended as part of the wellness office visits at 6 mos, 9 mos, 12 mos, 18 mos, 24 months, 30 mos, and yearly from 3 years to 16 years. Fluoride supplementation is recommended for consideration if the primary water source is fluoride deficient. The coverage statement has been updated to include these recommendations.   

CPT/HCPCS:
99188Application of topical fluoride varnish by a physician or other qualified health care professional
99381Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)
99382Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years)
99383Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years)
99391Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)
99392Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years)
99393Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years)

References: Clark MB and Slayton RL.(2014) Fluoride use in caries prevention in the primary care setting. Pediatrics 2014;134:626–633

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Prevention of Dental Caries in Preschool Children, Topic Page. April 2004. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm

USPSTF.(2014) Final Recommendation Statement. Dental Caries in Children from Birth Through Age 5 Years: screening, May 2014. Accessed at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/dental-caries-in-children-from-birth-through-age-5-years-screening . Last accessed June 12, 2015.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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