Dental Services (POC 4)

Purpose

This policy provides direction on the provision of dental services for eligible individuals. Coverage of dental services is determined on an individual basis taking into consideration criteria such as the individual's oral health needs.

Policy

1. Dental services provide coverage for basic dental care and some pre-authorized non-basic and major dental services subject to the specifications outlined in this policy and the Benefit Grids and in the fee schedule for the associated provincial / territorial Dental Association. 
2. Basic dental services are common or accepted forms of treatment such as dental cleaning, exams, fillings, simple extractions, and standard dentures
3. Non-basic services include treatment such as crownwork or bridgework, and require pre-authorization by Veterans Affairs Canada.
   1. Individual dental providers must provide treatment plans to Veterans Affairs Canada for approval of non-basic dental services.
   2. The provision of non-basic dental services must meet the following criteria:
      1. the treatment is required in order to address health needs; and
      2. oral or general health would be placed at risk in the absence of these treatments.
4. Major dental services include treatment such as implant treatment and equilibrated dentures. Dental services that are considered to be major dental services (also referred to as excluded procedures) require pre-authorization by Veterans Affairs Canada.
   1. Individual dental providers must provide treatment plans to Veterans Affairs Canada for approval of major dental services.
   2. The provision of major dental services is only approved when there is no other clinically acceptable treatment available, and one of the following criteria apply:
      1. the procedures or services are clinically necessary to maintain oral health; or
      2. the individual’s oral and/or general health would be negatively affected in the absence of this particular treatment; or
      3. the oral health is such that the individual is a good candidate for the procedure  being proposed and the individual’s health will not be negatively impacted by what is being proposed; or
      4. other significant factors exist (where the treatment is required in order to maintain overall health and nutrition).
5. Removable, custom-fit, titratable oral appliances, referred to as Mandibular Advancement splints, may be an approved equipment for the treatment of Obstructive Sleep Apnea (OSA) for patients who are intolerant of CPAP when:
   1. prescribed for diagnosed obstructive sleep apnea by a specialist;
   2. supported, at a minimum, by a Level III type home study diagnostic of obstructive sleep apnea; and
   3. the oral appliance be considered, rather than no treatment for patients with obstructive sleep apnea.
6. When oral appliances are prescribed by a physician with specialty training in sleep medicine for a patient with obstructive sleep apnea, the qualified dentist may use a removable, custom-fit, titratable oral appliance.
7. Dental orthotics, full-mouth rehabilitation or reconstructive dentistry will not be approved for obstructive sleep apnea or other conditions.

Eligibility

8. The following individuals may be eligible for dental services:
   1. Individuals who have a disability benefits entitled condition requiring dental services, for example: individuals deemed eligible for A-line coverage;
   2. Individuals who have eligibility other than for a disability benefits entitled condition and require dental services, for example: individuals deemed eligible for B-line coverage. These individuals must first access provincial / territorial programs or private plans for provision of dental services. Veterans Affairs Canada will provide coverage for dental services neither available to them as residents of that jurisdiction nor recoverable from a third party.

Dental Providers

9. Dental services are available for eligible individuals from Veterans Affairs Canada approved dental providers. Dental providers who may be approved to provide dental services are: dentists, dental specialists, denturists and dental hygienists. See policy on Health Professionals.

Dental Specialists

10. Where the services of a dental specialist (for example: Oral and Maxillofacial Surgeon, Prosthodontist, Endodontist, Periodontist) are required, the dental specialist must be licensed, authorized, and in good standing with the regulatory body of the province / territory in which they practice.
11. For dental services required by a dental specialist,
    1. individuals must have written referral, with rationale, by a dentist;
    2. the dental service is a service not routinely performed by a dentist; and,
    3. the dental service must be authorized by Veterans Affairs Canada.
12. Where a dental specialist provides dental services that are not pre-authorized by Veterans Affairs Canada and are routinely performed by a dentist, payment for these dental services will not exceed the rate for a dentist rendering the same services in that jurisdiction

Emergency Dental Services

13. Emergency dental services include treatment for trauma, pain or infection that must be rendered immediately. For emergency dental services only, pre-authorization is not required by Veterans Affairs Canada.

Payment of Fees

14. Dental service fees are payable according to Section 5 (1)(b) of the Veterans Health Care Regulations. Where dental services are not fully insured health services of a province, Veterans Affairs Canada will only pay the rate set out in the fee schedule for the associated provincial / territorial Dental Association.

References

Veterans Health Care Regulations

Eligibility for Health Care Programs – Eligible Client Groups

Health Professionals policy

Treatment for a Disability Benefits Entitled Condition policy

Benefit Grids

Prostheses (POC 11) policy