Revised: July 2015 Approval: Dental Services, Appliances, Oral Surgery and T.M.J. Benefit Coverage Maxillofacial anatomic or functional reconstructive surgery and associated services performed due to missing or defective mandible, maxilla or associated structures, are covered benefits if medically indicated. Benefit Exclusion Dental services are not a covered benefit. Dental Services mean professional services performed or provided by dentists, including diagnosis and treatment of malposed teeth, disease or defects of the alveolar process, gums, jaws and associated structures; the use of specific medications, anesthetics and physical evaluations; consultations; home, office and institutional calls. The diagnosis and treatment of temporomandibular joint dysfunction (T.M.J.) is not a covered benefit for Medi-Cal Members. Examples of Covered Benefits 1. Inpatient hospital services furnished in connection with a surgical procedure if the patient has had an immediate accidental injury to natural teeth, jawbone or surrounding tissue. 2. Immediate emergency room services for trauma to the mouth. 3. Wiring of teeth when done in connection with the reduction of a jaw fracture. 4. Oral surgery for a patient with multiple traumas from an automobile accident, when medically stable. 5. Jaw reconstruction, when medically necessary due to removal of mandibular bone for cancer or tumor. 6. Outpatient or inpatient medical hospital services furnished in connection with the treatment of medically indicated dental procedures necessary to be performed in a hospital based setting. To include all hospital based medical services relating to such procedures, with prior authorization per Denti-Cal and IEHP. 7. General Anesthesia See General Anesthesia-Dental" IEHP Medi-Cal Benefit Manual 07/15 D-100.1
Dental Services, Appliances, Oral Surgery and T.M.J. (continued) Examples of Non-Covered Benefits 1. Routine Dental Screening. 2. Care and treatment of T.M.J. caused by any reason for Medi-Cal Members. 3. Any medical services of physicians done in connection with non-covered dental services (e.g., dentist, oral surgeon, or pathologist services when connected with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth), performed in an office or dental clinic setting. 4. Removal of teeth for the main purpose of fitting for dentures. 5. Reconstruction of jaw or supporting tissues to provide a better fit for dentures or following services which were purely dental in nature. 6. Extraction of an impacted tooth. 7. Orthodontic treatment. 8. Cosmetic dentistry such as whitening. 9. Dental veneers or prosthedontics. IEHP Medi-Cal Benefit Manual 07/15 D-100.2
Revised: July 2015 Approval: Detoxification (Substance Abuse) Benefit Coverage (Cal. Code Regs., tit. 22, 51328, 51341) (DHCS Contract 04-35765, Amend. 10, Exhibit E, 25G) Inpatient detoxification is covered only when the inpatient admission is primarily due to an underlying medical condition, which requires acute inpatient care. Detoxification alone as a reason for inpatient admission is not covered. Alcohol misuse screening services are covered for all Members ages 18 and older. These services for alcohol misuse cover one expanded screening for risky alcohol use per year and three (3) 15-minute brief intervention sessions to address risky alcohol use per year. The State established Voluntary Inpatient Detox (VID) services as a Fee For Service Medi-Cal benefit under Section 29 of Senate Bill 1 of the First Extraordinary Session of 2013 (Hernandez & Steinberg, Chapter 4, Statutes of 2013) and consistent with Section 1302(b) of the Affordable Care Act of 2010. Medical criteria for inpatient admission for voluntary inpatient detoxification must include one or more of the following: 1. Delirium tremens, with any combination of the following clinical manifestations with cessation or reduced intake of alcohol/sedative: Hallucinations; Disorientation; Tachycardia; Hypertension; Fever; Agitation; or Diaphoresis. 2. Clinical Institute Withdrawal Assessment Scale for Alcohol, revised (CIWA-Ar) form score greater than 15. 3. Alcohol/sedative withdrawal with CIWA score greater than 8 and one or more of the following high risk factors: Multiple substance abuse; History of delirium tremens; Unable to receive the necessary medical assessment, monitoring, and treatment in a setting with a lower level of care; Medical co-morbidities that make detoxification in an outpatient setting unsafe; History of failed outpatient treatment; IEHP Medi-Cal Benefit Manual 07/15 D-200.1
Psychiatric co-morbidities; Pregnancy; or History of seizure disorder or withdrawal seizures. 4. Complications of opioid withdrawal that cannot be adequately managed in the outpatient setting due to the following factors: Persistent vomiting and diarrhea from opioid withdrawal; and Dehydration and electrolyte imbalance that cannot be managed in a setting with a lower level of care. To receive these services, the Member must be referred to a VID provider in a general acute care hospital. The VID provider facility must not be a Chemical Dependency Treatment Facility or Institution for Mental Disease. The VID provider must submit a Treatment Authorization Request (TAR) to local field offices for approval. IEHP must provide care coordination with the VID provider as needed. Additional documents submitted with the TAR should verify that the beneficiary s condition satisfies admissions criteria and demonstrates the medical necessity for the inpatient stay. Benefit Exclusion Services for the treatment of chronic, medically uncomplicated drug dependence or alcoholism are not covered benefits. Patients requiring outpatient detoxification services will be referred to the Short-Doyle Medi-Cal (SD/MC) or Medi-Cal Fee-For-Service (FFS) program. Examples of Covered Benefits 1. Inpatient treatment of alcoholism or drug dependence is not covered unless there is an underlying medical condition requiring acute, 24-hour monitoring (e.g., Myocardial Infarction, CVA, etc.). 2. Inpatient detoxification will be covered in conjunction with an admission as outlined above. Examples of Non-Covered Benefits 1. All drug and/or alcohol detoxification where there are no medical complications. 2. Inpatient detoxification after the patient s medical condition has stabilized. 3. Outpatient detoxification services. 4. Voluntary Inpatient Detox services available through Fee For Service Medi- Cal. IEHP Medi-Cal Benefit Manual 07/15 D-200.2
Revised: March 2001 Approval: Durable Medical Equipment (DME) Definition DME is equipment which: - can withstand repeated use; can normally be rented and used by successive patients. - is primarily used to serve a medical purpose. - is not useful to a person in the absence of illness or injury. - is appropriate for use in a patient s home when applicable. Benefit Coverage (Cal. Code Regs., tit. 22, 51321) DME means equipment, which meets the medical equipment needs of the patient. DME is covered in accordance with the standards in the California Code of Regulations, Title 22, Section 51303(a) and when prior authorization is obtained through the contracted IPA. DME may be authorized for skilled nursing facility or intermediate care facility inpatients as follows: 1. The equipment is necessary for the continuous care of the patient to meet the medical needs of the patient. 2. Cane, crutches, wheelchairs, and walkers may be authorized only when the item must be custom made or modified to meet the unusual medical needs of the patient and the need is expected to be permanent. 3. Suction and positive pressure apparatus may be authorized for one month or more only when the item will be continuously used by the patient or must be immediately available to the patient. 4. Durable medical equipment may be authorized to assist a disabled Member in caring for a child for whom the Member is a parent, stepparent, foster parent, or legal guardian. (Welf. & Inst. Code, 14132) Benefit Exclusion Medical equipment will not be authorized when a household item will adequately serve the patient s medical needs and authorization for DME shall be limited to the lowest cost item that meets the patient s medical needs. IEHP Medi-Cal Benefit Manual 07/15 D-300.1
Durable Medical Equipment (continued) Examples of Covered Benefits Refer to Appendix A - DME, Corrective Appliances, Medical Supplies and Surgical Implantables Grid. Examples of Non-Covered Benefits 1. Alterations or improvements of real property are not covered. 2. Modification of automobiles. 3. Books. 4. Air conditioners or air filters. 5. Food blenders. 6. Reading lamps. 7. Bicycles or tricycles. 8. Orthopedic mattresses. 9. Waterbeds. 10. Household items. See: Appendix A DME, Corrective Appliances, Medical Supplies and Surgical Implantables Grid IEHP Medi-Cal Benefit Manual 07/15 D-300.2