Department of Veterans Affairs VHA HANDBOOK 1130.01
Veterans Health Administration Transmittal Sheet
Washington, DC 20420 December 25, 2008
CRITERIA AND STANDARDS FOR DENTAL PROGRAM
1. REASON FOR ISSUE: This handbook establishes procedures for the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Dentistry Programs.
2. SUMMARY OF MAJOR CHANGES: This VHA Handbook is a revision of the VHA Handbook 1130.1, dated December 7, 1998.
3. RELATED DIRECTIVE: VHA Directive 1130.
4. RESPONSIBLE OFFICE: The Office of Dentistry (112D) is responsible for the contents in this VHA Handbook. Questions may be referred to 202-461-6947.
5. RECISSIONS: VHA Handbook 1130.1 dated December 7, 1998 is rescinded.
6. RECERTIFICATION: This VHA Handbook is scheduled for recertification on or before the last working day of December 2013.
Michael J. Kussman, MD, MS, MACP
Under Secretary for Health
DISTRIBUTION:
CO:
E-mailed 12/29/08
FLD:
VISN, MA, DO, OC, OCRO, and 200 – E-mailed 12/29/08
16. Custody and Disposition of Precious Metals..........................................................................
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17. Dental Prosthesis Lost and Found...........................................................................
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APPENDICES
APPENDIX A: SCOPE OF CARE QUICK REFERENCE GUIDE.........................................A-1
APPENDIX B: SCHEDULE OF RATINGS.........................................................................
.....B-1
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CRITERIA AND STANDARDS FOR DENTAL PROGRAM
1. PURPOSE
This Veterans Health Administration (VHA) handbook describes the mandatory procedures for implementation of oral and dental care programs at the Department of Veterans Affairs (VA) healthcare facilities throughout the country.
2. BACKGROUND
a. Under current statutes codified in Title 38 United States Code (U.S.C.), as amended, VA provides oral health services to eligible veterans therein specified. All VA medical centers and selected outpatient clinics provide oral and dental examinations and treatment. For the purposes of this handbook, the term Dental Program will refer to the dental and oral health care provided to beneficiaries by VHA. The Dental Program includes both on-site dental services and dental care provided by non-VA sources under VA supervision.
b. The Dental Program is operated in conjunction with other elements of the VHA and in accordance with the policies of the Secretary of Veterans Affairs and the Under Secretary for Health.
c. High quality, cost-effective dental care for eligible veterans will be provided. All VA dentists are expected to be knowledgeable concerning the role of dentistry in the mission of the VA and their responsibility in understanding and prescribing an extent of care consistent with VA eligibility.
3. SCOPE
The criteria and standards for the Dental Program are reviewed by VHA Central Office periodically, or at least every 3 years, and revised as necessary based upon further analyses and experience with their use.
4. RESPONSIBILITIES OF THE VHA OFFICE OF DENTISTRY
The VHA Office of Dentistry is responsible for:
a. Facilitating the continuous improvement of veteran dental care;
b. Providing dental operations and consultative services to Veterans Integrated Service Networks (VISNs), facilities and Dental Services;
c. Consulting on education and research issues related to provision of VA dental care;
e. Directing the management and enhancement of the Dental Encounter System databases and associated reporting and analysis services; and
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f. Advising VA healthcare facilities on eligibility for dental services.
5. RESPONSIBILITIES OF THE VETERANS INTEGRATED SERVICE NETWORK (VISN) DENTAL REPRESENTATIVE
The VISN Dental Representative is responsible for facilitating coordination and standardization of dental activities within the network. Their role is to serve as a dental liaison between VISN leadership, and the Office of Dentistry and the Dental Service Chiefs. The VISN Dental Representative is appointed by consensus of the Office of Dentistry and VISN leadership. The representative also serves as the first resource for guidance regarding interpretation of policies or procedures. If necessary, questions may be referred to the VHA Office of Dentistry.
6. RESPONSIBILITIES OF THE FACILITY DIRECTOR
The facility Director is responsible for ensuring appropriate staffing and infrastructure are provided to optimize the quality and cost effectiveness of dental care.
7. RESPONSIBILITIES OF THE CHIEF, DENTAL SERVICE
The Chief, Dental Service has primary responsibility for operation of the local dental program and management of related professional and administrative activities such as ensuring appropriate processes are used for credentialing and privileging, and reviewing and making recommendations concerning sharing agreements, service agreements and inter-facility agreements. The Chief serves as the local subject matter expert on oral health. The term Chief, Dental Service refers to the individual charged with direct supervision of the Dental Program. NOTE: The title of this position may vary at different sites, but for purposes of this handbook the term Chief, Dental Service, will be used to represent this position. The Chief, Dental Service is also:
a. The local liaison to dental professional organizations, other government agencies, and non-VA service providers, as well as other departments within the facility. All professional communications regarding the Dental Program need to be conducted through the Chief, Dental Service, or designee.
b. Responsible for ensuring the appropriate documentation and accurate coding of completed dental procedures performed in the clinic are recorded. Current VHA Dental Coding Standards and Requirements may be found on the Dental Reporting and Analytics website VHA Dental Coding Standards and Requirements (This is an internal VA web site not available to the public.) or by contacting VHA Dental Coding Committee Outlook mail group.
c. Responsible for ensuring that the appropriate scope of care is provided for dental patients.
d. Responsible for ensuring compliance with submission requirements of the Central Dental Laboratories (CDL). Submission requirements can be found at http://vaww1.va.gov/ntxcdl. NOTE: This is an internal VA link not available to the public.
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8. RESPONSIBILITIES OF DENTAL SERVICE PERSONNEL
Dental service personnel must be knowledgeable of the provisions of this handbook as well as local policies and procedures, and conduct their activities in accordance with these provisions. All VA dentists are to ensure appropriate diagnostic findings, dental care plans and completed procedures are recorded accurately and completely through the CPRS adjunct application, Dental Record Manager Plus (DRM) for all patients under their care.
9. LOCAL DENTAL POLICIES AND PROCEDURES
a. The leadership of each facility must develop and publish local dental policies and procedures. A Dental Service Policy and Procedure Manual will relate to matters internal to the Dental Service. Policies will conform to the dictates of this handbook and will be published over the signature of the Chief, Dental Service.
b. Dependent upon local station requirements, there may be facility policies and procedures relating to matters that impact the operations of other individuals or services, or that require cooperation between services interacting with the Dental Program. Such policies are published as facility memoranda over the signature of the Director, or designee and must be available to all personnel.
c. These policies and procedures must be readily available either electronically or in hard copy to all dental personnel.
(2) It is not the established mission of VA to provide dental care to all veterans or even to all those who are hospitalized. The extent of treatment is determined through an understanding of the patient’s dental classification and the appropriate scope of dental care to be provided based on that classification.
b. Dental Classification. The laws and regulations mandate dental care as a benefit for defined veteran groups. Specific dental classifications have been established that further define patient groups and the appropriate scope of care based on that classification. The nuances of the
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classifications are addressed in the Inpatient, Outpatient and Long Term Care sections of this Handbook. Also see Appendix A for the Scope of Care Quick Reference Guide.
(1) The following patient groups are included in the defined dental classification scheme and are to be provided dental care in compliance with VHA regulations and Directives:
(a) Residents of VA Residential Rehabilitation Treatment Programs, including Domiciliaries.
(b) VA Community Living Center (formerly known as Nursing Home Care Unit) residents.
(d) Patients having a compelling medical need that requires completion of dental care initiated while an inpatient.
(e) Outpatient Dental Class I through VI beneficiaries.
(f) Outpatients with dental emergencies.
(2) The following patient groups are included in the defined dental classification scheme and may be provided dental care if clinic capacity is available.
(a) Hospitalized veterans whose dental conditions are not considered to be adjunct to their medical problems.
(b) Inpatients without other dental entitlement who are active duty military personnel or military retirees.
c. Professional Considerations. VA is obligated to fulfill the requirements of the statutes enacted by Congress and to follow their intent. Every Dental Service has the responsibility to provide care on the basis of the patient’s dental classification. A clearly defined and documented treatment plan, consistent with the appropriate scope of care for that patient’s classification, will be developed for each episode of care.
(1) There is no authority to expand the scope of care beyond the veteran’s level of entitlement in order to meet the demands of an educational program as a "teaching case." If a training program is dependent upon types of cases that are not available in sufficient numbers, the scope of that program should be reevaluated.
(2) The patient's ability to pay for the cost of private dental care should not be a factor in determining the extent or limitation of dental treatment that will be provided by VA.
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(3) Dental care provided for reasons of medical necessity should not exceed the scope necessary to resolve the condition that is complicating a medical problem. For example, a patient's medical problem may require only the removal of foci of infection. Even though VA may edentulate a patient to resolve the dental condition's impact on a medical problem, VA is not obligated to provide prostheses for this patient.
(4) Appropriate dental authorization for outpatient dental care for veterans that have other rated, compensable service connected conditions of the head and neck area is sometimes confusing. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even though there may be no physical trauma to the dental structures, per se. These non-dental conditions are not rated in the 9900 series of the Schedule for Rating Disabilities (See Appendix B) and are considered medical conditions. The decision as to whether or not dental care will be authorized as adjunctive care (either as Class III or Class VI) will be determined by the Chief, Dental Service, or designee and based on the same criteria as for other medical conditions.
d. Scope of Dental Care. Once a patient's dental classification has been properly established, the appropriate scope of care for that patient must be determined. The scope of dental care to be provided can be categorized as Comprehensive, Focused or Emergent/Urgent. The intent of these categories is to facilitate a consistent standard of care throughout all VA dental facilities.
(1) Comprehensive Dental Care. Patients eligible for Comprehensive Dental Care receive any dental treatment that is reasonably necessary and clinically determined by the treating dentist to meet the patient’s dental needs. A recall program should be established for those patients who are eligible for comprehensive and repeat dental care. The goal of care is to attain and sustain oral health and function including prosthetic rehabilitation as indicated.
(2) Focused Dental Care. Focused dental care is intended to resolve a specific dental condition dependent upon, and consistent with the patient’s classification. Treatment may include relief of pain, elimination of infection, or improvement of speech or esthetics. It also includes treatment of adjudicated non-compensable service connected teeth (i.e. Class II and Class IIa.) The goal of care is to provide a specific improvement of the oral conditions that directly impact the medical condition (Class III and VI), assist in vocational rehabilitation (Class V), or to provide dental care professionally determined to be medically and functionally appropriate to their status for those in a VA Community Living Center or extended care facility.
(a) Consultation requests, when applicable, from non-dental providers must identify the medical condition being aggravated or the management of which is compromised by the dental problem. The Dental Service Chief, or designee, will review the consult and make a final determination based on dental eligibility and scope of care.
(b) Dental treatment is generally limited and may include supportive periodontal therapy, endodontic therapy, restorative dentistry, and oral surgical procedures.
(3) Emergent/Urgent Dental Care. Outpatient emergency dental care is provided as a humanitarian service to individuals who do not have established dental eligibility. Dental treatment is limited to that necessary to address acute pain, significant infection, uncontrolled bleeding, or any dental condition that is determined to be a serious threat to health or endangering life. The goal of treatment is to eliminate symptoms and/or remove foci of infection. Dental care is generally limited to one time palliative procedures and appropriate pharmacological therapy.
(a) The provision of emergency dental treatment does not entitle the patient to subsequent or follow-up care unless the individual is eligible under some other provision.
(b) Individuals who are not eligible for VA dental care, but who are provided outpatient emergency dental treatment will be processed in accordance with VA policy and procedures as follows:
1. Veterans presenting at VA medical facilities requesting treatment for acute pain, significant infection or uncontrolled bleeding of oral origin should initially be seen for administrative processing and triage. Triage will include, if applicable, verification of any medical condition for which there is a potential for adjunct (Class III or VI) dental care.
2. If the patient is not eligible or has limited eligibility for outpatient dental care, the patient must be informed of this fact and advised that if emergency treatment is provided for which there is no eligibility, the patient will be billed for treatment. The eligibility clerk or designee will complete and sign the statement of ineligibility on VA Form 10-2570g, Dental Outpatient Emergency Referral and Treatment Record. The applicant will sign the statement of understanding related to the emergency dental care and billing prior to referral to the Dental Service.
3. Dental Service personnel will examine the patient to determine the appropriate course of treatment based on the following options:
a. If the condition requires hospitalization, the patient will be returned to the admitting area with the necessary documents for admission.
b. If the dental condition can be treated on an outpatient basis and does not require immediate attention, the patient will be referred to community resources at their expense.
c. If the dental condition is considered emergent, appropriate care will be provided and documented.
4. Upon treatment completion, a brief description of the emergency treatment provided will be recorded, signed by the treating dentist and returned to the VA office responsible for billing.
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e. Refusal to Accept Dental Services. In those instances when patients refuse to accept Dental Service’s recommendations or do not cooperate in receiving treatment, a statement of the facts will be entered into a progress note for consideration and appropriate disposition by the Chief, Dental Service, or designee.
f. Treatment Continuation for Patients Who Relocate to Another Geographic Area. A key objective of VA Dentistry is to provide a consistent standard of dental care throughout VA dental facilities. If, however, a patient has a plan of treatment for a scope of care inconsistent with their dental classification, the receiving facility is not obligated to provide care beyond that which is justified. The Dental Service at the new facility will perform an evaluation, update the treatment plan and communicate any changes to the patient.
g. Patient Responsibility in Making and Keeping Dental Appointments. Any veteran eligible for dental treatment on a one-time completion basis only and who has not received such treatment within 3 years after filing the application shall be presumed to have abandoned the claim for dental treatment. (38 CFR 17.164)
11. OUTPATIENT DENTAL PROGRAM
a. Overview. The goal of VA Dental Services is to provide high quality, cost-effective dental treatment to eligible veterans. All VA dentists will be knowledgeable regarding the scope of care to be provided that is consistent with the patient’s dental classification.
b. Persons Eligible for Outpatient Dental Care. Statutory eligibility for outpatient dental care is granted to veteran beneficiaries and is provided in accordance with existing law and regulations. Classes of eligible dental outpatients are as follows:
(1) Class I.
(a) Veterans having a compensable (10% or greater), service connected dental disability or condition (combat or non-combat related) rated under the 9900 series of the Schedule for Rating Disabilities (See Appendix B) are eligible for any necessary dental care to maintain or restore oral health and masticatory function, including repeat care.
(b) Appropriate dental authorization for outpatient dental care for veterans that have other rated, compensable service connected conditions of the head and neck area is sometimes confusing. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even though there may be no physical trauma to the dental structures, per se. These non-dental conditions are not rated under the 9900 series, are considered medical conditions and are not eligible under Class I. The decision as to whether or not dental care will be authorized as adjunctive care (either as Class III or Class VI) will be determined by the Chief, Dental Service, or designee and based on the same criteria as for other medical conditions.
(2) Class II. Veterans having a noncompensable, service connected dental disability shown to have been in existence at the time of discharge or release from active duty may be provided
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any treatment as reasonably necessary for the one-time correction of the noncompensable, service connected dental disability if all of the following criteria are met:
(a) They are discharged or released from active duty under conditions other than dishonorable, from a period of active military service of not less than 180 days. In the case of Gulf War Era, Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, they are discharged or released from active duty under conditions other than dishonorable from a period of active military service of not less than 90 days.
(b) Application for dental treatment is made within 180 days of discharge or release from active duty.
1. One Episode of Class II Care. When Class II eligibility for a one-time episode of dental care has been exhausted by satisfactory completion of the authorized treatment, no further care will be provided. Class II dental beneficiaries who (through no fault of the VA) have not completed authorized treatment within 3 years after filing the application shall be presumed to have abandoned the claim for dental treatment.
2. Dental Prostheses and Implants Provided by VA. Class II dental beneficiaries are not entitled to long term maintenance of fixed or removable dental prostheses or dental implants. Once adjustments are satisfactory, the episode of prosthetic care is considered to be complete and subsequent treatment is the responsibility of the patient.
3. Periodontal Conditions. Specific treatment authorized for periodontal conditions of Class II beneficiaries is expected to provide maximum benefit by the time that episode of care is completed. When that treatment is satisfactorily completed as authorized, VA will not furnish any further treatment or follow-up for the periodontal condition.
4. Impacted Teeth. Impacted teeth are a developmental condition. Consideration for surgical extraction should be based on sound professional judgment to resolve existing disease or symptoms.
5. Malposed Teeth. Malposed teeth are considered a developmental abnormality and a pre-existing condition. VA will not provide orthodontic care in this circumstance. For cases in which trauma incurred in the line of duty resulted in malalignment of the teeth or when restorative procedures for which the patient is eligible require orthodontic intervention, orthodontic care may be provided.
6. Veterans with Orthodontic Appliances. When veterans arrive at VA facilities with orthodontic appliances for the purpose of correcting developmental malocclusion and have not
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had their treatment completed by the military prior to discharge, they need to be instructed to contact the dental clinic at their last active duty military assignment to arrange for completion of the care. If the military does not complete the orthodontic treatment, VA is not obligated to assume the responsibility of any phase of the orthodontic care unless directly related to rehabilitation of combat trauma to the maxillofacial region.
7. Service Connection of Dental Conditions for Treatment Purposes. Veterans Benefits Administration (VBA) may, upon request, provide documentation to the Dental Service defining service connection of specific teeth for dental treatment purposes. (38 CFR 3.381). The regulation provides for identification of teeth treated during military service, and applies only to Class II beneficiaries who have met the criteria as specified in Para. 11 b.(2)(a-c). The Chief or designee can use the document to assist in development of appropriate treatment recommendations.
(3) Class IIA. Those veterans having a noncompensable, service connected dental disability adjudicated as resulting from combat wounds or service trauma are eligible for repeat care and maintenance or replacement of the involved tooth/teeth. A Dental Trauma Rating (VA Form 10-564-D) or VA Regional Office Rating Decision letter (VA Form 10-7131) identifies the tooth/teeth eligible for care. Public Law 83, 84th Congress, Chapter 52, H.R. 5100, Approved June 16, 1955 invalidates old dental ratings and eligibility letters dated before 1955. Prior to 1955, teeth that received routine dental care while the veteran was on active duty were listed as “service connected”. Patients with these dental ratings are not eligible for repeat care for the listed “service connected” teeth.
(4) Class IIC. Veterans who were Prisoners of War (POWs) are eligible for any needed dental care, including repeat care.
(5) Class III. Veterans with a dental condition professionally determined by VA to be aggravating or complicating the management of a service connected medical condition under active treatment are eligible for care to treat the dental condition. The goal is to provide focused care to treat only the oral conditions that directly impact the management of the service-connected medical condition. Eligibility for each episode of dental care must be predicated on referral (consult), followed by a new dental evaluation.
(6) Class IV. Veterans whose service connected disabilities have been rated at 100 percent (total) or who are receiving the 100 percent rate by reason of individual unemployability are eligible for any needed dental care, including repeat care, with the following exception: a veteran awarded a temporary total disability rating by the Veterans Benefits Administration is not eligible for comprehensive outpatient dental services based on an opinion by VA General Counsel (023) to the Under Secretary for Health (16), February 24, 2006, VAOPGCADV 2-2006. Determination of temporary status is the responsibility of the eligibility section of the Business Office.
(7) Class V
(a) A veteran who is actively engaged in a Chapter 31 vocational rehabilitation program is entitled to dental care to the extent needed to meet any of the following goals listed:
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1. make possible his or her entrance into a rehabilitation program,
2. achieve the goals of the veteran's vocational rehabilitation program,
3. prevent interruption of a rehabilitation program,
4. hasten the return to a rehabilitation program of a veteran in interrupted or leave status,
5. hasten the return to a rehabilitation program of a veteran placed in discontinued status because of a dental condition,
6. secure and adjust to employment during the period of employment assistance, or
7. enable the veteran to achieve maximum independence in daily living.
(b) Requests for dental care will be forwarded to the Dental Service by the Chapter 31 Vocational Rehabilitation Program on VA Form 28-8861. This form needs to be provided for each episode of care requested. Dental care should not be provided beyond the anticipated rehabilitation date as specified on the form.
(8) Class VI
(a) Any veteran scheduled for admission or who is receiving outpatient care under 38 U.S.C. may receive dental care if the dental condition is clinically determined to be complicating the non-service connected medical condition currently under VA treatment. Eligibility for each episode of dental care will be predicated on referral and consultation, followed by a decision based upon clinical judgment. The goal is to provide focused care to treat only the oral conditions that directly impact the management of the non-service connected medical condition.
(b) Certain homeless and other enrolled veterans also are eligible for a one-time course of dental care per VHA policy, Public Law 107-95 and Title 38 United States Code (U.S.C.) § 2062. Dental workload for veterans participating in this program is recorded under the Class VI dental outpatient classification.
(9) Other Beneficiaries. Other beneficiaries who may be eligible for dental care in VA dental clinics on an outpatient basis, subject to and consistent with the provision of existing laws, VA regulations, and the availability of VA resources are:
(a) Armed Forces Personnel on Active Duty. Authority from the Commanding Officer of the military installation should accompany the request for dental treatment. However, if extenuating circumstances are present, treatment of the emergent dental condition may be accomplished prior to the receipt of authority. Emergency dental treatment for members of the Armed Forces on active duty will be limited to such treatment as is found necessary for the relief of pain and control of acute infection, trauma or hemorrhage.
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(b) Armed Forces Personnel in VA Polytrauma Centers. Active duty military personnel with spinal cord injury, traumatic brain injury or blindness who are receiving treatment in a VA polytrauma center are eligible to receive dental care under a direct resource sharing agreement in accordance with Department of Veterans Affairs and Department of Defense Memorandum of Agreement regarding referral of active duty military personnel with effective date January 1, 2007. Dental services will be billed at the interagency rate, where one exists, or at actual cost as appropriate.
(d) Beneficiaries of Sharing Agreements. Treatment provided will be dependent on the specific language of the agreement.
(10) Disability Evaluation Examinations for Compensation and Pension Rating Purposes. Requests for an oral examination are submitted to the Dental Service at the request of the Regional Office. Examination findings must be accurately and comprehensively reported and the patient coded as a Category 20. Examinations must be completed within the timeframe required by VBA.
12. INPATIENT DENTAL PROGRAM
a. Scope of Care. Patients receiving hospital care will be provided dental services that are professionally determined by a VA dentist, in consultation with the referring physician, to be essential to the management of the patient’s medical condition. The treatment goal is specific improvement of oral conditions that directly compromise the medical condition under active treatment.
(1) The extent of dental care provided is generally limited to medically necessary services to manage oral conditions in which the symptoms of acute pain, uncontrolled bleeding, or significant infection are present.
(2) Dental care is generally limited to one time restorative procedures or extractions and appropriate pharmacological therapy.
(3) Dental care may be extended to provide services to maintain or augment adequate masticatory function, improve appearance, and correct speech deficiencies but must coincide with stated treatment objectives.
b. Hospitalization for Oral Conditions. Hospitalization of VA beneficiaries for oral conditions will be in compliance with prescribed local medical center protocols for all admissions.
c. Continuation or Termination of Dental Treatment. The Chief, Dental Service, or
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designee, is responsible for determining the proper disposition of inpatients who have received dental care. A determination must be made whether the provided dental treatment has accomplished the intended treatment goals. If essential dental treatment has been completed, the case will be closed. If essential dental care remains, the Chief, Dental Service or designee will collaborate with discharge planners to determine if dental care will be continued with the patient as a bed occupant or as an outpatient. Except in unusual circumstances, patients being discharged should have all essential dental care completed prior to discharge. Extending inpatient status for the sole purpose of completing dental care is to be avoided.
d. Post-Discharge Dental Treatment for Veterans with Statutory Eligibility for Outpatient Dental Care - Class I through VI Status. In most instances, essential dental care for inpatient veterans who have statutory outpatient dental eligibility will be completed on an outpatient basis when the essential dental treatment cannot be completed prior to discharge. The scope of care to be provided includes the completion of essential dental care identified during the inpatient episode of care plus any other dental care for which the veteran is entitled consistent with the veteran’s outpatient dental classification. When outpatient dental treatment at the discharging facility is not feasible due to geographic inaccessibility, the Chief, Dental Service or designee will determine if there is another VA healthcare facility within reasonable distance from the veteran's residence that can provide the dental care in a timely manner. If this is not available, other alternatives, such as referring the patient for care under an existing contract or sharing agreement, or on a dental fee-basis may be considered.
NOTE: A VA beneficiary will not be referred for fee-dental care without a valid and justifiable reason. The decision for fee-dental care is not the prerogative of the veteran but is a VA decision based on the lack of availability of VA or other Federal resources to provide the needed care. In all cases where referral takes place, the veteran will be notified and fully apprised of the action taken.
e. Post-Discharge Dental Treatment for Veterans Who Do Not Qualify for Statutory Outpatient Dental Care
(1) Veterans who are not eligible for outpatient dental care may be provided outpatient dental treatment within the resources of VA facilities, only when both of the following requirements are met:
(a) The treatment is a continuation of essential dental treatment that was identified while the veteran was receiving inpatient care, and
(b) The Chief, Dental Service, or designee, determines at the time of hospital discharge, that the continuation or completion of such care remains necessary relative to the medical problem(s) for which it was initially prescribed.
(2) Veterans provided post-discharge dental treatment that does not qualify for statutory outpatient dental care will be classified as Dental Category 19, Continued after Inpatient Care.
13. DENTAL FEE BASIS
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a. Responsibility of Chief, Dental Service - Outpatient Fee Dental Administration.
The Chief, Dental Service, or designee, has the primary responsibility for administering the outpatient fee dental program. This includes review of all proposed treatment plans for approval/disapproval, and adjustment of submitted fees consistent with the Schedule of Maximum Allowances for Fee Dental Services. The Chief, Dental Service, or designee, is also responsible for review of the Schedule of Maximum Allowances for their area, at least annually.
b. Procedure for Development of the Schedule of Maximum Allowances for Fee Dental Services. In the development or revision of the Schedule of Maximum Allowances, the following sources may be used:
(1) Commercially available fee schedules may be purchased by facilities that provide regional or area specific data. A regional or area survey of dentists’ usual, customary and reasonable (UCR) fee submissions corresponding up to the 80th percentile fee is considered to be reasonable for patient access to care provided by general dentists.
(2) Facility obtained survey results. This can be accomplished by analyzing historical fee payments or by obtaining area dentists’ fee schedules.
(3) Fees for care provided by specialists will be determined on an individual basis by the Chief, Dental Service or designee.
c. Confidentiality of VA Schedule of Maximum Allowances for Fee Dental Service. Distribution of these schedules will be made by the Chief, Dental Service, or designee, and restricted to appropriate facility administrative services. It is prohibited to provide a copy of the VA Schedule of Maximum Allowances for Fee Dental Services to outside parties.
d. Process for Fee Basis Authorization. VA form 2570-D or an equivalent electronic approved form will be used by the Chief, or designee, to authorize and approve fee basis treatment. Signature of the Chief, or designee, on the form will attest that the claim has been reviewed and validated.
e. Selection of Fee Basis Provider. VA will not recommend a specific dental fee provider unless that provider has been properly credentialed and privileged by VA. It will be the veteran’s responsibility to select the provider of their choice once they have been approved for fee care. Definitive treatment should not begin without pre-authorization.
f. Proposed Cases Exceeding $1,000
(1) 38 USC 1712 requires that confirmation of the appropriateness of a proposed treatment plan and associated fees be made by a VA dentist in all cases where the total fee dental treatment plan exceeds $1,000. This confirmation may be obtained by any of the following:
(a) An examination by a VA dentist to determine needs prior to fee basis authorization.
(b) A second opinion examination by a VA dentist or designated outside provider after submission of a fee dentist’s treatment plan and associated fees.
(2) Veterans who refuse to participate in a requested confirmation examination or refuse to accept a treatment plan determined by VA to be satisfactory, will have their case closed and be so informed.
14. LONG TERM CARE DENTAL PROGRAM
a. Type and Extent of Treatment Furnished. Residents in VA Residential Rehabilitation Treatment Programs, including Domiciliaries, long-term care units, and VA Community Living Centers may be provided dental treatment considered reasonably necessary to protect and maintain health. Consideration needs to be given to provide dental treatment as deemed essential to their rehabilitation.
b. Oral Assessments. In compliance with current Joint Commission standards, initial resident assessment needs to be completed within 14 days of admission or as required by law and regulation. Initial assessments and reassessments need to be performed by any health care staff who has been properly trained and who has established competency. Identified oral conditions requiring further evaluation or treatment will be referred via consultation to Dental Service. Reassessments need to be done and documented consistent with local medical center policy.
c. Residents in Non-VA Operated Long Term Care Facilities. VA is not responsible for providing an oral assessment or reassessment on individuals residing in non-VA operated nursing homes, including state veterans homes. Dental treatment may be provided to residents in these non-VA operated facilities if they are otherwise entitled to VA provided outpatient dental care.
15. DENTAL LABORATORIES
a. Requirements
(1) Dental laboratory services must be available at all facilities where dental care is provided. These services may be provided by an on-site dental laboratory, by VA Central Dental Laboratories (CDLs), by contract laboratory services, by fee-based laboratory services or by any combination of the above. Fee-based dental laboratory services may be used for situations anticipated to be non-recurring and not of significant dollar value. If these two conditions cannot be met, Acquisition and Materiel Management Service needs to be consulted to determine the appropriateness of establishing a contract.
(2) CDLs will be established as authorized by the Assistant Under Secretary for Health for Dentistry and maintained to the extent necessary for the support of VA dental clinical activities. Unless unusual circumstances arise which are mutually resolved by the respective Dental Service and CDL, chrome-cobalt partial denture frameworks, porcelain fused-to-metal, ceramic and all metal fixed prostheses, implant-supported prostheses, thermoplastic removable partial dentures,
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and other special prostheses can be referred to the CDLs for fabrication. The Dental Service must supply all necessary implant components to the CDL for fabrication of prostheses that are so supported. All other oral prosthetic fabrication is the responsibility of the local Dental Service.
b. Responsibilities
(1) VHA Office of Dentistry. The Office of Dentistry is responsible to assure that all VA facilities receiving services from the CDL are treated equitably and the requirements of any one facility do not take precedence over any other. This office is also responsible for the development of policies, standards, and scope of CDL activities. These activities include, but are not limited to, oversight of system expectations including overall performance in areas such as customer satisfaction, turn-around time, and cost-effectiveness of the laboratories.
(2) Healthcare Facilities That House CDL Activities. Issues between the facility and the CDL which cannot be resolved by local action need to be brought to the attention of the Office of Dentistry. Medical center policies will apply to CDL the same as to other services at the facility.
(3) Chiefs of Central Dental Laboratories. The Chiefs of the CDL divisions are responsible to the Office of Dentistry for administration and operations in accordance with prescribed policies and standards. Specifically, each Chief of CDL will strive to achieve the following:
(a) Prompt feedback to stations regarding the quality of cases received.
(b) Appropriate quality control of each prosthetic fabrication process step.
(d) Effective communication with the facilities they support.
(e) Adequate training for CDL technicians.
(4) Chief, Dental Service. The Chief, Dental Service is responsible for all oral prostheses provided by dentists under their supervision. This includes the following:
(a) Ensuring all prostheses are fabricated in the United States of America using materials approved by the Food and Drug Administration (FDA). The Chief must ensure that this requirement is met if contract or fee-based dental laboratory services are utilized.
(b) Ensuring staff dentists, residents, dental assistants, and dental laboratory technicians are knowledgeable of CDL protocols. Specific requirements can be found on the CDL intranet webpage, http://vaww.va.gov/ntxcdl. (This is an internal VA link not available to the public.)
(5) Staff Dentists. Staff dentists must provide casework which is of acceptable quality.
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16. CUSTODY AND DISPOSITION OF PRECIOUS METALS
a. Responsibility for Custody and Disposition of Precious Metals. The Chief of Dental Service, Chief of CDL, or their designee will have custody of all precious dental alloys, chrome-cobalt alloy, and other expendable supplies in the Dental Service or CDL, as applicable, and will be held responsible for their safekeeping. The Chief of Dental Service or of CDL may assign a responsible member of their staff to administer the system of controls for inventory and issue of these items.
b. Accounting for Precious Metals
(1) Accounting must be made for precious metals, and a ledger will be maintained to record:
(a) The date precious metals were received from Acquisition and Materiel Management Service (A&MMS).
(b) The combined gross weight of all gold alloy received.
(d) The date, name of patient, and description of unserviceable gold alloy prostheses received.
(e) The gross weight of all scrap gold alloy and other precious metals turned over to the Chief, A&MMS, or designee.
(2) The employee having custody of precious metals will issue the amount and type needed by the dentist or technician and record the date, amount, and type of prosthesis in the ledger. On completion of the prosthesis, all unused precious metal will be returned to the custodian for re-issue. Buttons, crowns, etc., which are unserviceable for reissue, will be collected as scrap gold alloy and melted into one ingot for subsequent turn-in to the Chief, A&MMS, as required.
c. Inventory Verification. The facility Director will designate a responsible official, other than a Dental Service employee, to verify receipts and balances of precious metal inventories at least annually.
d. Disposition of Unserviceable Prostheses. A patient desiring to retain an unserviceable prosthesis or extracted teeth containing gold alloy or precious metals, whether or not it was provided by VA, may be allowed to do so. A notation that this prosthesis has been returned to the patient will be documented by VA staff in a progress note. If the patient prefers not to accept the prosthesis, this decision will also be documented in a progress note by VA staff.
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17. DENTAL PROSTHESES LOST AND FOUND
a. Dental Prosthesis Lost by Facility. A request by a patient for the facility to replace a prosthesis lost or irreparably damaged at the facility due to the facility’s or a VA employee’s actions will be honored only when the circumstances of the damage or loss have been reliably substantiated and appropriately documented.
b. Dental Prosthesis Lost by Patient. Patients with continuing dental eligibility who had a prosthesis made by VA and who have lost or damaged it beyond repair within five years of insertion will be authorized one remake. Should this occur a second time, a professional determination will be made by the Chief, Dental Service regarding the appropriateness of a replacement.
c. Dental Prosthesis Found on Station. Dental prostheses recovered on VA property will be delivered to the Chief of Dental Service, or designee, for identification and appropriate disposition. There must be coordination between the Lost and Found activity of the facility and the Dental Service. If the prostheses are not claimed, they may be disposed of as unserviceable. Any prosthesis(es) containing gold alloy will have that metal recovered and disposed of as scrap gold alloy, in accordance with subparagraph 16b.2.
December 24, 2008 VHA HANDBOOK 1130.01
APPENDIX A
A-1
SCOPE OF CARE QUICK REFERENCE GUIDE
Dental Classification
Brief Description
Scope of Care
Recall
1
INP, Emergency
Treatment of an emergent/urgent oral condition involving acute pain, infection, trauma and/or hemorrhage.
Emergent/Urgent care.
No
2
INP, Compelling Medical Need
Treatment of an oral condition complicating the management of the medical condition for which the veteran was admitted.
Focused care.
No
3
INP, Extended Care
Inpatients in a non-acute care unit.
Focused care.
No
4
Community Living Center
Residents in VA Community Living Centers.
Focused care.
No
5
VA Residential Rehabilitation Treatment Programs (RRTPs)
Residents in VA Domiciliary Centers.
Focused care.
No
6
INP, Special Provision
Inpatients specified under sharing agreements and employees or patients officially authorized treatment for work related oral-dental injuries.
Per terms of the official agreement
7
INP, Non-Compelling Medical Need
Inpatients, service or non-service connected, that are provided dental care not related to the compelling medical condition for which they were admitted.
Focused care.
No
8
INP, Other
Other beneficiaries that are inpatients such as military retirees and inpatient dependents eligible under CHAMPVA.
Focused care.
No
9
OPC, Class I
10% SC or greater for a dental condition - 9900 series
Comprehensive care.
Yes
10
OPC, Class II
Recent discharge from military service.
Focused care, one episode.
No
11
OPC, Class IIA
Adjudicated, non-compensable trauma to oral structures.
Focused care.
Yes
13
OPC, Class IIC
POW
Comprehensive care.
Yes
14
OPC, Class III
Treatment of an oral condition adjunctive to the management of a service connected medical condition.
Focused care.
No
15
OPC, Class IV
100% SC Total
100% SC compensation rate by virtue of individual unemployability.
Comprehensive care.
Yes
16
OPC, Class V
Enrolled in the VA Vocational Rehabilitation Program
Focused care.
No
17
OPC, Class VI
Treatment of an oral condition adjunctive to the management of a non-service connected medical condition.
Enrolled in VA Homeless Program >60 days
Focused care.
Focused care.
No
No
18
OPC, Emergency
Treatment of an emergent/urgent oral condition involving acute pain, infection, trauma and/or hemorrhage; or suspicion of an oral malignancy.
Emergent/Urgent care.
No
19
OPC, Continued After Inpatient Care, Compelling Medical Need
Treatment of an oral condition complicating the management of the medical condition for which the patient was admitted that was initiated but not completed while the veteran was an inpatient.
Focused care.
No
20
OPC, Special Provision
C&P examinations, outpatients provided care under a sharing agreement, eligible allied beneficiaries and patients or employees officially authorized treatment for work related injuries/conditions.
Per terms of the official agreement
21
OPC, Continued After Inpatient Care, No Compelling Medical Need
Treatment provided to inpatients that are completed after hospital discharge.
Focused care.
No
22
OPC, Continued After Inpatient Care, Other
Treatment provided to active duty military, military retirees, CHAMPVA inpatients that are completed after hospital discharge.
Focused care.
No
December 24, 2008 VHA HANDBOOK 1130.01
APPENDIX B
B-1
§4.150 Schedule of ratings—dental and oral conditions.
Rating
9900 Maxilla or mandible, chronic osteomyelitis or osteoradionecrosis of:
Rate as osteomyelitis, chronic under diagnostic code 5000.
9901 Mandible, loss of, complete, between angles...............................................................100
Note: These ratings apply only to bone loss through trauma or disease such as osteomyelitis and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling.
9914 Maxilla, loss of more than half:
Not replaceable by prosthesis ................................................................................
......100
Replaceable by prosthesis ................................................................................
..............50
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APPENDIX B
B-3
9915 Maxilla, loss of half or less:
Loss of 25 to 50 percent:
Not replaceable by prosthesis ................................................................................
..40
Replaceable by prosthesis ................................................................................
........30
Loss of less than 25 percent:
Not replaceable by prosthesis ................................................................................
..20
Replaceable by prosthesis ................................................................................
..........0
9916 Maxilla, malunion or nonunion of:
Severe displacement ................................................................................
[29 FR 6718, May 22, 1964, as amended at 43 FR 45362, Oct. 2, 1978; 59 FR 2530, Jan. 18, 1994]
Supplement Highlights reference: 7(2)
There has been confusion concerning dental eligibility for veterans who have other rated, compensable service connected disabilities of the head and neck area. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even if there is no physical injury to the dental structures per se. These non-dental disabilities, which are rated under other than the 9900 series, are considered medical conditions. The decision whether or not to provide dental care will be based on a professional determination if adjunctive care is necessary, and if provided, will be done so under the Class III or Class VI category.
Question
carlie
http://www1.va.gov/VHAPUBLICATIONS/ViewPub...asp?pub_ID=1817
Department of Veterans Affairs VHA HANDBOOK 1130.01
Veterans Health Administration Transmittal Sheet
Washington, DC 20420 December 25, 2008
CRITERIA AND STANDARDS FOR DENTAL PROGRAM
1. REASON FOR ISSUE: This handbook establishes procedures for the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Dentistry Programs.
2. SUMMARY OF MAJOR CHANGES: This VHA Handbook is a revision of the VHA Handbook 1130.1, dated December 7, 1998.
3. RELATED DIRECTIVE: VHA Directive 1130.
4. RESPONSIBLE OFFICE: The Office of Dentistry (112D) is responsible for the contents in this VHA Handbook. Questions may be referred to 202-461-6947.
5. RECISSIONS: VHA Handbook 1130.1 dated December 7, 1998 is rescinded.
6. RECERTIFICATION: This VHA Handbook is scheduled for recertification on or before the last working day of December 2013.
Michael J. Kussman, MD, MS, MACP
Under Secretary for Health
DISTRIBUTION:
CO:
E-mailed 12/29/08
FLD:
VISN, MA, DO, OC, OCRO, and 200 – E-mailed 12/29/08
T-1
December 24, 2008 VHA HANDBOOK 1130.01
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CONTENTS
CRITERIA AND STANDARDS FOR DENTAL PROGRAM
PARAGRAPH PAGE
1. Purpose.........................................................................
..............................................................1
2. Background......................................................................
..........................................................1
3. Scope ................................................................................
.........................................................1
4. Responsibilities of the VHA Office of Dentistry.......................................................................
.1
5. Responsibilities of the VISN Dental Representative..................................................................
2
6. Responsibilities of the Facility Director........................................................................
.............2
7. Responsibilities of the Chief, Dental Service.........................................................................
....2
8. Responsibilities of Dental Service Personnel.......................................................................
......3
9. Local Dental Policies and Procedures......................................................................
...................3
10. Eligibility for Dental Care............................................................................
............................3
11. Outpatient Dental Program.........................................................................
..............................7
12. Inpatient Dental Program.........................................................................
...............................11
13. Dental Fee Basis...........................................................................
..........................................12
14. Long Term Care Dental Program.........................................................................
..................14
15. Dental Laboratories....................................................................
.............................................14
16. Custody and Disposition of Precious Metals..........................................................................
16
17. Dental Prosthesis Lost and Found...........................................................................
................17
APPENDICES
APPENDIX A: SCOPE OF CARE QUICK REFERENCE GUIDE.........................................A-1
APPENDIX B: SCHEDULE OF RATINGS.........................................................................
.....B-1
December 24, 2008 VHA HANDBOOK 1130.01
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CRITERIA AND STANDARDS FOR DENTAL PROGRAM
1. PURPOSE
This Veterans Health Administration (VHA) handbook describes the mandatory procedures for implementation of oral and dental care programs at the Department of Veterans Affairs (VA) healthcare facilities throughout the country.
2. BACKGROUND
a. Under current statutes codified in Title 38 United States Code (U.S.C.), as amended, VA provides oral health services to eligible veterans therein specified. All VA medical centers and selected outpatient clinics provide oral and dental examinations and treatment. For the purposes of this handbook, the term Dental Program will refer to the dental and oral health care provided to beneficiaries by VHA. The Dental Program includes both on-site dental services and dental care provided by non-VA sources under VA supervision.
b. The Dental Program is operated in conjunction with other elements of the VHA and in accordance with the policies of the Secretary of Veterans Affairs and the Under Secretary for Health.
c. High quality, cost-effective dental care for eligible veterans will be provided. All VA dentists are expected to be knowledgeable concerning the role of dentistry in the mission of the VA and their responsibility in understanding and prescribing an extent of care consistent with VA eligibility.
3. SCOPE
The criteria and standards for the Dental Program are reviewed by VHA Central Office periodically, or at least every 3 years, and revised as necessary based upon further analyses and experience with their use.
4. RESPONSIBILITIES OF THE VHA OFFICE OF DENTISTRY
The VHA Office of Dentistry is responsible for:
a. Facilitating the continuous improvement of veteran dental care;
b. Providing dental operations and consultative services to Veterans Integrated Service Networks (VISNs), facilities and Dental Services;
c. Consulting on education and research issues related to provision of VA dental care;
e. Directing the management and enhancement of the Dental Encounter System databases and associated reporting and analysis services; and
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f. Advising VA healthcare facilities on eligibility for dental services.
5. RESPONSIBILITIES OF THE VETERANS INTEGRATED SERVICE NETWORK (VISN) DENTAL REPRESENTATIVE
The VISN Dental Representative is responsible for facilitating coordination and standardization of dental activities within the network. Their role is to serve as a dental liaison between VISN leadership, and the Office of Dentistry and the Dental Service Chiefs. The VISN Dental Representative is appointed by consensus of the Office of Dentistry and VISN leadership. The representative also serves as the first resource for guidance regarding interpretation of policies or procedures. If necessary, questions may be referred to the VHA Office of Dentistry.
6. RESPONSIBILITIES OF THE FACILITY DIRECTOR
The facility Director is responsible for ensuring appropriate staffing and infrastructure are provided to optimize the quality and cost effectiveness of dental care.
7. RESPONSIBILITIES OF THE CHIEF, DENTAL SERVICE
The Chief, Dental Service has primary responsibility for operation of the local dental program and management of related professional and administrative activities such as ensuring appropriate processes are used for credentialing and privileging, and reviewing and making recommendations concerning sharing agreements, service agreements and inter-facility agreements. The Chief serves as the local subject matter expert on oral health. The term Chief, Dental Service refers to the individual charged with direct supervision of the Dental Program. NOTE: The title of this position may vary at different sites, but for purposes of this handbook the term Chief, Dental Service, will be used to represent this position. The Chief, Dental Service is also:
a. The local liaison to dental professional organizations, other government agencies, and non-VA service providers, as well as other departments within the facility. All professional communications regarding the Dental Program need to be conducted through the Chief, Dental Service, or designee.
b. Responsible for ensuring the appropriate documentation and accurate coding of completed dental procedures performed in the clinic are recorded. Current VHA Dental Coding Standards and Requirements may be found on the Dental Reporting and Analytics website VHA Dental Coding Standards and Requirements (This is an internal VA web site not available to the public.) or by contacting VHA Dental Coding Committee Outlook mail group.
c. Responsible for ensuring that the appropriate scope of care is provided for dental patients.
d. Responsible for ensuring compliance with submission requirements of the Central Dental Laboratories (CDL). Submission requirements can be found at http://vaww1.va.gov/ntxcdl. NOTE: This is an internal VA link not available to the public.
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8. RESPONSIBILITIES OF DENTAL SERVICE PERSONNEL
Dental service personnel must be knowledgeable of the provisions of this handbook as well as local policies and procedures, and conduct their activities in accordance with these provisions. All VA dentists are to ensure appropriate diagnostic findings, dental care plans and completed procedures are recorded accurately and completely through the CPRS adjunct application, Dental Record Manager Plus (DRM) for all patients under their care.
9. LOCAL DENTAL POLICIES AND PROCEDURES
a. The leadership of each facility must develop and publish local dental policies and procedures. A Dental Service Policy and Procedure Manual will relate to matters internal to the Dental Service. Policies will conform to the dictates of this handbook and will be published over the signature of the Chief, Dental Service.
b. Dependent upon local station requirements, there may be facility policies and procedures relating to matters that impact the operations of other individuals or services, or that require cooperation between services interacting with the Dental Program. Such policies are published as facility memoranda over the signature of the Director, or designee and must be available to all personnel.
c. These policies and procedures must be readily available either electronically or in hard copy to all dental personnel.
10. ELIGIBILITY FOR DENTAL CARE
a. General
(1) VA Dental Services examine and treat eligible inpatient and outpatient beneficiaries. Eligibility for dental care is governed by statute and provided in accordance with the provisions of existing law and regulations as cited in United State Code., sections 1710© and 1712, and Title 38 Code of Federal Regulations (CFR) sections 17.160 through 17.166. Dental eligibility is determined in a different manner than medical eligibility. The Business Office, Health Eligibility Center, holds responsibility for verification of administrative aspects of dental eligibility. It is the responsibility of the Dental Service Chief to make determinations on all clinical aspects of dental eligibility.
(2) It is not the established mission of VA to provide dental care to all veterans or even to all those who are hospitalized. The extent of treatment is determined through an understanding of the patient’s dental classification and the appropriate scope of dental care to be provided based on that classification.
b. Dental Classification. The laws and regulations mandate dental care as a benefit for defined veteran groups. Specific dental classifications have been established that further define patient groups and the appropriate scope of care based on that classification. The nuances of the
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classifications are addressed in the Inpatient, Outpatient and Long Term Care sections of this Handbook. Also see Appendix A for the Scope of Care Quick Reference Guide.
(1) The following patient groups are included in the defined dental classification scheme and are to be provided dental care in compliance with VHA regulations and Directives:
(a) Residents of VA Residential Rehabilitation Treatment Programs, including Domiciliaries.
(b) VA Community Living Center (formerly known as Nursing Home Care Unit) residents.
© Inpatients with compelling medical need for dental treatment.
(d) Patients having a compelling medical need that requires completion of dental care initiated while an inpatient.
(e) Outpatient Dental Class I through VI beneficiaries.
(f) Outpatients with dental emergencies.
(2) The following patient groups are included in the defined dental classification scheme and may be provided dental care if clinic capacity is available.
(a) Hospitalized veterans whose dental conditions are not considered to be adjunct to their medical problems.
(b) Inpatients without other dental entitlement who are active duty military personnel or military retirees.
© Specially designated inpatients and outpatients such as those provided for under approved sharing agreements.
c. Professional Considerations. VA is obligated to fulfill the requirements of the statutes enacted by Congress and to follow their intent. Every Dental Service has the responsibility to provide care on the basis of the patient’s dental classification. A clearly defined and documented treatment plan, consistent with the appropriate scope of care for that patient’s classification, will be developed for each episode of care.
(1) There is no authority to expand the scope of care beyond the veteran’s level of entitlement in order to meet the demands of an educational program as a "teaching case." If a training program is dependent upon types of cases that are not available in sufficient numbers, the scope of that program should be reevaluated.
(2) The patient's ability to pay for the cost of private dental care should not be a factor in determining the extent or limitation of dental treatment that will be provided by VA.
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(3) Dental care provided for reasons of medical necessity should not exceed the scope necessary to resolve the condition that is complicating a medical problem. For example, a patient's medical problem may require only the removal of foci of infection. Even though VA may edentulate a patient to resolve the dental condition's impact on a medical problem, VA is not obligated to provide prostheses for this patient.
(4) Appropriate dental authorization for outpatient dental care for veterans that have other rated, compensable service connected conditions of the head and neck area is sometimes confusing. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even though there may be no physical trauma to the dental structures, per se. These non-dental conditions are not rated in the 9900 series of the Schedule for Rating Disabilities (See Appendix B) and are considered medical conditions. The decision as to whether or not dental care will be authorized as adjunctive care (either as Class III or Class VI) will be determined by the Chief, Dental Service, or designee and based on the same criteria as for other medical conditions.
d. Scope of Dental Care. Once a patient's dental classification has been properly established, the appropriate scope of care for that patient must be determined. The scope of dental care to be provided can be categorized as Comprehensive, Focused or Emergent/Urgent. The intent of these categories is to facilitate a consistent standard of care throughout all VA dental facilities.
(1) Comprehensive Dental Care. Patients eligible for Comprehensive Dental Care receive any dental treatment that is reasonably necessary and clinically determined by the treating dentist to meet the patient’s dental needs. A recall program should be established for those patients who are eligible for comprehensive and repeat dental care. The goal of care is to attain and sustain oral health and function including prosthetic rehabilitation as indicated.
(2) Focused Dental Care. Focused dental care is intended to resolve a specific dental condition dependent upon, and consistent with the patient’s classification. Treatment may include relief of pain, elimination of infection, or improvement of speech or esthetics. It also includes treatment of adjudicated non-compensable service connected teeth (i.e. Class II and Class IIa.) The goal of care is to provide a specific improvement of the oral conditions that directly impact the medical condition (Class III and VI), assist in vocational rehabilitation (Class V), or to provide dental care professionally determined to be medically and functionally appropriate to their status for those in a VA Community Living Center or extended care facility.
(a) Consultation requests, when applicable, from non-dental providers must identify the medical condition being aggravated or the management of which is compromised by the dental problem. The Dental Service Chief, or designee, will review the consult and make a final determination based on dental eligibility and scope of care.
(b) Dental treatment is generally limited and may include supportive periodontal therapy, endodontic therapy, restorative dentistry, and oral surgical procedures.
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© Treatment may also include the fabrication of removable and complete dentures as indicated in the approved treatment plan. Once the episode of care has been completed, subsequent treatment is the responsibility of the patient.
(3) Emergent/Urgent Dental Care. Outpatient emergency dental care is provided as a humanitarian service to individuals who do not have established dental eligibility. Dental treatment is limited to that necessary to address acute pain, significant infection, uncontrolled bleeding, or any dental condition that is determined to be a serious threat to health or endangering life. The goal of treatment is to eliminate symptoms and/or remove foci of infection. Dental care is generally limited to one time palliative procedures and appropriate pharmacological therapy.
(a) The provision of emergency dental treatment does not entitle the patient to subsequent or follow-up care unless the individual is eligible under some other provision.
(b) Individuals who are not eligible for VA dental care, but who are provided outpatient emergency dental treatment will be processed in accordance with VA policy and procedures as follows:
1. Veterans presenting at VA medical facilities requesting treatment for acute pain, significant infection or uncontrolled bleeding of oral origin should initially be seen for administrative processing and triage. Triage will include, if applicable, verification of any medical condition for which there is a potential for adjunct (Class III or VI) dental care.
2. If the patient is not eligible or has limited eligibility for outpatient dental care, the patient must be informed of this fact and advised that if emergency treatment is provided for which there is no eligibility, the patient will be billed for treatment. The eligibility clerk or designee will complete and sign the statement of ineligibility on VA Form 10-2570g, Dental Outpatient Emergency Referral and Treatment Record. The applicant will sign the statement of understanding related to the emergency dental care and billing prior to referral to the Dental Service.
3. Dental Service personnel will examine the patient to determine the appropriate course of treatment based on the following options:
a. If the condition requires hospitalization, the patient will be returned to the admitting area with the necessary documents for admission.
b. If the dental condition can be treated on an outpatient basis and does not require immediate attention, the patient will be referred to community resources at their expense.
c. If the dental condition is considered emergent, appropriate care will be provided and documented.
4. Upon treatment completion, a brief description of the emergency treatment provided will be recorded, signed by the treating dentist and returned to the VA office responsible for billing.
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e. Refusal to Accept Dental Services. In those instances when patients refuse to accept Dental Service’s recommendations or do not cooperate in receiving treatment, a statement of the facts will be entered into a progress note for consideration and appropriate disposition by the Chief, Dental Service, or designee.
f. Treatment Continuation for Patients Who Relocate to Another Geographic Area. A key objective of VA Dentistry is to provide a consistent standard of dental care throughout VA dental facilities. If, however, a patient has a plan of treatment for a scope of care inconsistent with their dental classification, the receiving facility is not obligated to provide care beyond that which is justified. The Dental Service at the new facility will perform an evaluation, update the treatment plan and communicate any changes to the patient.
g. Patient Responsibility in Making and Keeping Dental Appointments. Any veteran eligible for dental treatment on a one-time completion basis only and who has not received such treatment within 3 years after filing the application shall be presumed to have abandoned the claim for dental treatment. (38 CFR 17.164)
11. OUTPATIENT DENTAL PROGRAM
a. Overview. The goal of VA Dental Services is to provide high quality, cost-effective dental treatment to eligible veterans. All VA dentists will be knowledgeable regarding the scope of care to be provided that is consistent with the patient’s dental classification.
b. Persons Eligible for Outpatient Dental Care. Statutory eligibility for outpatient dental care is granted to veteran beneficiaries and is provided in accordance with existing law and regulations. Classes of eligible dental outpatients are as follows:
(1) Class I.
(a) Veterans having a compensable (10% or greater), service connected dental disability or condition (combat or non-combat related) rated under the 9900 series of the Schedule for Rating Disabilities (See Appendix B) are eligible for any necessary dental care to maintain or restore oral health and masticatory function, including repeat care.
(b) Appropriate dental authorization for outpatient dental care for veterans that have other rated, compensable service connected conditions of the head and neck area is sometimes confusing. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even though there may be no physical trauma to the dental structures, per se. These non-dental conditions are not rated under the 9900 series, are considered medical conditions and are not eligible under Class I. The decision as to whether or not dental care will be authorized as adjunctive care (either as Class III or Class VI) will be determined by the Chief, Dental Service, or designee and based on the same criteria as for other medical conditions.
(2) Class II. Veterans having a noncompensable, service connected dental disability shown to have been in existence at the time of discharge or release from active duty may be provided
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any treatment as reasonably necessary for the one-time correction of the noncompensable, service connected dental disability if all of the following criteria are met:
(a) They are discharged or released from active duty under conditions other than dishonorable, from a period of active military service of not less than 180 days. In the case of Gulf War Era, Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, they are discharged or released from active duty under conditions other than dishonorable from a period of active military service of not less than 90 days.
(b) Application for dental treatment is made within 180 days of discharge or release from active duty.
© The certificate of discharge or release certifies that the veteran was not provided, within the 90 day period immediately before discharge or release, a complete dental examination (including dental radiographs) and all appropriate dental treatment indicated by the examination was completed. This certification is found on the DD214, line 17.
(d) Scope of care for Class II.
1. One Episode of Class II Care. When Class II eligibility for a one-time episode of dental care has been exhausted by satisfactory completion of the authorized treatment, no further care will be provided. Class II dental beneficiaries who (through no fault of the VA) have not completed authorized treatment within 3 years after filing the application shall be presumed to have abandoned the claim for dental treatment.
2. Dental Prostheses and Implants Provided by VA. Class II dental beneficiaries are not entitled to long term maintenance of fixed or removable dental prostheses or dental implants. Once adjustments are satisfactory, the episode of prosthetic care is considered to be complete and subsequent treatment is the responsibility of the patient.
3. Periodontal Conditions. Specific treatment authorized for periodontal conditions of Class II beneficiaries is expected to provide maximum benefit by the time that episode of care is completed. When that treatment is satisfactorily completed as authorized, VA will not furnish any further treatment or follow-up for the periodontal condition.
4. Impacted Teeth. Impacted teeth are a developmental condition. Consideration for surgical extraction should be based on sound professional judgment to resolve existing disease or symptoms.
5. Malposed Teeth. Malposed teeth are considered a developmental abnormality and a pre-existing condition. VA will not provide orthodontic care in this circumstance. For cases in which trauma incurred in the line of duty resulted in malalignment of the teeth or when restorative procedures for which the patient is eligible require orthodontic intervention, orthodontic care may be provided.
6. Veterans with Orthodontic Appliances. When veterans arrive at VA facilities with orthodontic appliances for the purpose of correcting developmental malocclusion and have not
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had their treatment completed by the military prior to discharge, they need to be instructed to contact the dental clinic at their last active duty military assignment to arrange for completion of the care. If the military does not complete the orthodontic treatment, VA is not obligated to assume the responsibility of any phase of the orthodontic care unless directly related to rehabilitation of combat trauma to the maxillofacial region.
7. Service Connection of Dental Conditions for Treatment Purposes. Veterans Benefits Administration (VBA) may, upon request, provide documentation to the Dental Service defining service connection of specific teeth for dental treatment purposes. (38 CFR 3.381). The regulation provides for identification of teeth treated during military service, and applies only to Class II beneficiaries who have met the criteria as specified in Para. 11 b.(2)(a-c). The Chief or designee can use the document to assist in development of appropriate treatment recommendations.
(3) Class IIA. Those veterans having a noncompensable, service connected dental disability adjudicated as resulting from combat wounds or service trauma are eligible for repeat care and maintenance or replacement of the involved tooth/teeth. A Dental Trauma Rating (VA Form 10-564-D) or VA Regional Office Rating Decision letter (VA Form 10-7131) identifies the tooth/teeth eligible for care. Public Law 83, 84th Congress, Chapter 52, H.R. 5100, Approved June 16, 1955 invalidates old dental ratings and eligibility letters dated before 1955. Prior to 1955, teeth that received routine dental care while the veteran was on active duty were listed as “service connected”. Patients with these dental ratings are not eligible for repeat care for the listed “service connected” teeth.
(4) Class IIC. Veterans who were Prisoners of War (POWs) are eligible for any needed dental care, including repeat care.
(5) Class III. Veterans with a dental condition professionally determined by VA to be aggravating or complicating the management of a service connected medical condition under active treatment are eligible for care to treat the dental condition. The goal is to provide focused care to treat only the oral conditions that directly impact the management of the service-connected medical condition. Eligibility for each episode of dental care must be predicated on referral (consult), followed by a new dental evaluation.
(6) Class IV. Veterans whose service connected disabilities have been rated at 100 percent (total) or who are receiving the 100 percent rate by reason of individual unemployability are eligible for any needed dental care, including repeat care, with the following exception: a veteran awarded a temporary total disability rating by the Veterans Benefits Administration is not eligible for comprehensive outpatient dental services based on an opinion by VA General Counsel (023) to the Under Secretary for Health (16), February 24, 2006, VAOPGCADV 2-2006. Determination of temporary status is the responsibility of the eligibility section of the Business Office.
(7) Class V
(a) A veteran who is actively engaged in a Chapter 31 vocational rehabilitation program is entitled to dental care to the extent needed to meet any of the following goals listed:
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1. make possible his or her entrance into a rehabilitation program,
2. achieve the goals of the veteran's vocational rehabilitation program,
3. prevent interruption of a rehabilitation program,
4. hasten the return to a rehabilitation program of a veteran in interrupted or leave status,
5. hasten the return to a rehabilitation program of a veteran placed in discontinued status because of a dental condition,
6. secure and adjust to employment during the period of employment assistance, or
7. enable the veteran to achieve maximum independence in daily living.
(b) Requests for dental care will be forwarded to the Dental Service by the Chapter 31 Vocational Rehabilitation Program on VA Form 28-8861. This form needs to be provided for each episode of care requested. Dental care should not be provided beyond the anticipated rehabilitation date as specified on the form.
(8) Class VI
(a) Any veteran scheduled for admission or who is receiving outpatient care under 38 U.S.C. may receive dental care if the dental condition is clinically determined to be complicating the non-service connected medical condition currently under VA treatment. Eligibility for each episode of dental care will be predicated on referral and consultation, followed by a decision based upon clinical judgment. The goal is to provide focused care to treat only the oral conditions that directly impact the management of the non-service connected medical condition.
(b) Certain homeless and other enrolled veterans also are eligible for a one-time course of dental care per VHA policy, Public Law 107-95 and Title 38 United States Code (U.S.C.) § 2062. Dental workload for veterans participating in this program is recorded under the Class VI dental outpatient classification.
(9) Other Beneficiaries. Other beneficiaries who may be eligible for dental care in VA dental clinics on an outpatient basis, subject to and consistent with the provision of existing laws, VA regulations, and the availability of VA resources are:
(a) Armed Forces Personnel on Active Duty. Authority from the Commanding Officer of the military installation should accompany the request for dental treatment. However, if extenuating circumstances are present, treatment of the emergent dental condition may be accomplished prior to the receipt of authority. Emergency dental treatment for members of the Armed Forces on active duty will be limited to such treatment as is found necessary for the relief of pain and control of acute infection, trauma or hemorrhage.
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(b) Armed Forces Personnel in VA Polytrauma Centers. Active duty military personnel with spinal cord injury, traumatic brain injury or blindness who are receiving treatment in a VA polytrauma center are eligible to receive dental care under a direct resource sharing agreement in accordance with Department of Veterans Affairs and Department of Defense Memorandum of Agreement regarding referral of active duty military personnel with effective date January 1, 2007. Dental services will be billed at the interagency rate, where one exists, or at actual cost as appropriate.
© VA Employees. VA employees may be provided emergency dental treatment only to the extent necessary to permit the employee to remain on duty. Provision of care is predicated on referral from the employee health program. Employees with emergent conditions that may require follow-up care will be advised to seek private care at their expense. Injuries incurred in the performance of duty may receive necessary emergency treatment.
(d) Beneficiaries of Sharing Agreements. Treatment provided will be dependent on the specific language of the agreement.
(10) Disability Evaluation Examinations for Compensation and Pension Rating Purposes. Requests for an oral examination are submitted to the Dental Service at the request of the Regional Office. Examination findings must be accurately and comprehensively reported and the patient coded as a Category 20. Examinations must be completed within the timeframe required by VBA.
12. INPATIENT DENTAL PROGRAM
a. Scope of Care. Patients receiving hospital care will be provided dental services that are professionally determined by a VA dentist, in consultation with the referring physician, to be essential to the management of the patient’s medical condition. The treatment goal is specific improvement of oral conditions that directly compromise the medical condition under active treatment.
(1) The extent of dental care provided is generally limited to medically necessary services to manage oral conditions in which the symptoms of acute pain, uncontrolled bleeding, or significant infection are present.
(2) Dental care is generally limited to one time restorative procedures or extractions and appropriate pharmacological therapy.
(3) Dental care may be extended to provide services to maintain or augment adequate masticatory function, improve appearance, and correct speech deficiencies but must coincide with stated treatment objectives.
b. Hospitalization for Oral Conditions. Hospitalization of VA beneficiaries for oral conditions will be in compliance with prescribed local medical center protocols for all admissions.
c. Continuation or Termination of Dental Treatment. The Chief, Dental Service, or
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designee, is responsible for determining the proper disposition of inpatients who have received dental care. A determination must be made whether the provided dental treatment has accomplished the intended treatment goals. If essential dental treatment has been completed, the case will be closed. If essential dental care remains, the Chief, Dental Service or designee will collaborate with discharge planners to determine if dental care will be continued with the patient as a bed occupant or as an outpatient. Except in unusual circumstances, patients being discharged should have all essential dental care completed prior to discharge. Extending inpatient status for the sole purpose of completing dental care is to be avoided.
d. Post-Discharge Dental Treatment for Veterans with Statutory Eligibility for Outpatient Dental Care - Class I through VI Status. In most instances, essential dental care for inpatient veterans who have statutory outpatient dental eligibility will be completed on an outpatient basis when the essential dental treatment cannot be completed prior to discharge. The scope of care to be provided includes the completion of essential dental care identified during the inpatient episode of care plus any other dental care for which the veteran is entitled consistent with the veteran’s outpatient dental classification. When outpatient dental treatment at the discharging facility is not feasible due to geographic inaccessibility, the Chief, Dental Service or designee will determine if there is another VA healthcare facility within reasonable distance from the veteran's residence that can provide the dental care in a timely manner. If this is not available, other alternatives, such as referring the patient for care under an existing contract or sharing agreement, or on a dental fee-basis may be considered.
NOTE: A VA beneficiary will not be referred for fee-dental care without a valid and justifiable reason. The decision for fee-dental care is not the prerogative of the veteran but is a VA decision based on the lack of availability of VA or other Federal resources to provide the needed care. In all cases where referral takes place, the veteran will be notified and fully apprised of the action taken.
e. Post-Discharge Dental Treatment for Veterans Who Do Not Qualify for Statutory Outpatient Dental Care
(1) Veterans who are not eligible for outpatient dental care may be provided outpatient dental treatment within the resources of VA facilities, only when both of the following requirements are met:
(a) The treatment is a continuation of essential dental treatment that was identified while the veteran was receiving inpatient care, and
(b) The Chief, Dental Service, or designee, determines at the time of hospital discharge, that the continuation or completion of such care remains necessary relative to the medical problem(s) for which it was initially prescribed.
(2) Veterans provided post-discharge dental treatment that does not qualify for statutory outpatient dental care will be classified as Dental Category 19, Continued after Inpatient Care.
13. DENTAL FEE BASIS
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a. Responsibility of Chief, Dental Service - Outpatient Fee Dental Administration.
The Chief, Dental Service, or designee, has the primary responsibility for administering the outpatient fee dental program. This includes review of all proposed treatment plans for approval/disapproval, and adjustment of submitted fees consistent with the Schedule of Maximum Allowances for Fee Dental Services. The Chief, Dental Service, or designee, is also responsible for review of the Schedule of Maximum Allowances for their area, at least annually.
b. Procedure for Development of the Schedule of Maximum Allowances for Fee Dental Services. In the development or revision of the Schedule of Maximum Allowances, the following sources may be used:
(1) Commercially available fee schedules may be purchased by facilities that provide regional or area specific data. A regional or area survey of dentists’ usual, customary and reasonable (UCR) fee submissions corresponding up to the 80th percentile fee is considered to be reasonable for patient access to care provided by general dentists.
(2) Facility obtained survey results. This can be accomplished by analyzing historical fee payments or by obtaining area dentists’ fee schedules.
(3) Fees for care provided by specialists will be determined on an individual basis by the Chief, Dental Service or designee.
c. Confidentiality of VA Schedule of Maximum Allowances for Fee Dental Service. Distribution of these schedules will be made by the Chief, Dental Service, or designee, and restricted to appropriate facility administrative services. It is prohibited to provide a copy of the VA Schedule of Maximum Allowances for Fee Dental Services to outside parties.
d. Process for Fee Basis Authorization. VA form 2570-D or an equivalent electronic approved form will be used by the Chief, or designee, to authorize and approve fee basis treatment. Signature of the Chief, or designee, on the form will attest that the claim has been reviewed and validated.
e. Selection of Fee Basis Provider. VA will not recommend a specific dental fee provider unless that provider has been properly credentialed and privileged by VA. It will be the veteran’s responsibility to select the provider of their choice once they have been approved for fee care. Definitive treatment should not begin without pre-authorization.
f. Proposed Cases Exceeding $1,000
(1) 38 USC 1712 requires that confirmation of the appropriateness of a proposed treatment plan and associated fees be made by a VA dentist in all cases where the total fee dental treatment plan exceeds $1,000. This confirmation may be obtained by any of the following:
(a) An examination by a VA dentist to determine needs prior to fee basis authorization.
(b) A second opinion examination by a VA dentist or designated outside provider after submission of a fee dentist’s treatment plan and associated fees.
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© A review of the clinical record, applicable images and/or supporting documentation by a VA dentist after submission of a fee dentist’s treatment plan and associated fees. This review does not necessarily require the patient to be present.
(2) Veterans who refuse to participate in a requested confirmation examination or refuse to accept a treatment plan determined by VA to be satisfactory, will have their case closed and be so informed.
14. LONG TERM CARE DENTAL PROGRAM
a. Type and Extent of Treatment Furnished. Residents in VA Residential Rehabilitation Treatment Programs, including Domiciliaries, long-term care units, and VA Community Living Centers may be provided dental treatment considered reasonably necessary to protect and maintain health. Consideration needs to be given to provide dental treatment as deemed essential to their rehabilitation.
b. Oral Assessments. In compliance with current Joint Commission standards, initial resident assessment needs to be completed within 14 days of admission or as required by law and regulation. Initial assessments and reassessments need to be performed by any health care staff who has been properly trained and who has established competency. Identified oral conditions requiring further evaluation or treatment will be referred via consultation to Dental Service. Reassessments need to be done and documented consistent with local medical center policy.
c. Residents in Non-VA Operated Long Term Care Facilities. VA is not responsible for providing an oral assessment or reassessment on individuals residing in non-VA operated nursing homes, including state veterans homes. Dental treatment may be provided to residents in these non-VA operated facilities if they are otherwise entitled to VA provided outpatient dental care.
15. DENTAL LABORATORIES
a. Requirements
(1) Dental laboratory services must be available at all facilities where dental care is provided. These services may be provided by an on-site dental laboratory, by VA Central Dental Laboratories (CDLs), by contract laboratory services, by fee-based laboratory services or by any combination of the above. Fee-based dental laboratory services may be used for situations anticipated to be non-recurring and not of significant dollar value. If these two conditions cannot be met, Acquisition and Materiel Management Service needs to be consulted to determine the appropriateness of establishing a contract.
(2) CDLs will be established as authorized by the Assistant Under Secretary for Health for Dentistry and maintained to the extent necessary for the support of VA dental clinical activities. Unless unusual circumstances arise which are mutually resolved by the respective Dental Service and CDL, chrome-cobalt partial denture frameworks, porcelain fused-to-metal, ceramic and all metal fixed prostheses, implant-supported prostheses, thermoplastic removable partial dentures,
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and other special prostheses can be referred to the CDLs for fabrication. The Dental Service must supply all necessary implant components to the CDL for fabrication of prostheses that are so supported. All other oral prosthetic fabrication is the responsibility of the local Dental Service.
b. Responsibilities
(1) VHA Office of Dentistry. The Office of Dentistry is responsible to assure that all VA facilities receiving services from the CDL are treated equitably and the requirements of any one facility do not take precedence over any other. This office is also responsible for the development of policies, standards, and scope of CDL activities. These activities include, but are not limited to, oversight of system expectations including overall performance in areas such as customer satisfaction, turn-around time, and cost-effectiveness of the laboratories.
(2) Healthcare Facilities That House CDL Activities. Issues between the facility and the CDL which cannot be resolved by local action need to be brought to the attention of the Office of Dentistry. Medical center policies will apply to CDL the same as to other services at the facility.
(3) Chiefs of Central Dental Laboratories. The Chiefs of the CDL divisions are responsible to the Office of Dentistry for administration and operations in accordance with prescribed policies and standards. Specifically, each Chief of CDL will strive to achieve the following:
(a) Prompt feedback to stations regarding the quality of cases received.
(b) Appropriate quality control of each prosthetic fabrication process step.
© Efficient utilization of resources to maximize productivity and minimize turn around time while maintaining quality.
(d) Effective communication with the facilities they support.
(e) Adequate training for CDL technicians.
(4) Chief, Dental Service. The Chief, Dental Service is responsible for all oral prostheses provided by dentists under their supervision. This includes the following:
(a) Ensuring all prostheses are fabricated in the United States of America using materials approved by the Food and Drug Administration (FDA). The Chief must ensure that this requirement is met if contract or fee-based dental laboratory services are utilized.
(b) Ensuring staff dentists, residents, dental assistants, and dental laboratory technicians are knowledgeable of CDL protocols. Specific requirements can be found on the CDL intranet webpage, http://vaww.va.gov/ntxcdl. (This is an internal VA link not available to the public.)
(5) Staff Dentists. Staff dentists must provide casework which is of acceptable quality.
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16. CUSTODY AND DISPOSITION OF PRECIOUS METALS
a. Responsibility for Custody and Disposition of Precious Metals. The Chief of Dental Service, Chief of CDL, or their designee will have custody of all precious dental alloys, chrome-cobalt alloy, and other expendable supplies in the Dental Service or CDL, as applicable, and will be held responsible for their safekeeping. The Chief of Dental Service or of CDL may assign a responsible member of their staff to administer the system of controls for inventory and issue of these items.
b. Accounting for Precious Metals
(1) Accounting must be made for precious metals, and a ledger will be maintained to record:
(a) The date precious metals were received from Acquisition and Materiel Management Service (A&MMS).
(b) The combined gross weight of all gold alloy received.
© The date, name of patient, and description of each prosthesis fabricated.
(d) The date, name of patient, and description of unserviceable gold alloy prostheses received.
(e) The gross weight of all scrap gold alloy and other precious metals turned over to the Chief, A&MMS, or designee.
(2) The employee having custody of precious metals will issue the amount and type needed by the dentist or technician and record the date, amount, and type of prosthesis in the ledger. On completion of the prosthesis, all unused precious metal will be returned to the custodian for re-issue. Buttons, crowns, etc., which are unserviceable for reissue, will be collected as scrap gold alloy and melted into one ingot for subsequent turn-in to the Chief, A&MMS, as required.
c. Inventory Verification. The facility Director will designate a responsible official, other than a Dental Service employee, to verify receipts and balances of precious metal inventories at least annually.
d. Disposition of Unserviceable Prostheses. A patient desiring to retain an unserviceable prosthesis or extracted teeth containing gold alloy or precious metals, whether or not it was provided by VA, may be allowed to do so. A notation that this prosthesis has been returned to the patient will be documented by VA staff in a progress note. If the patient prefers not to accept the prosthesis, this decision will also be documented in a progress note by VA staff.
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17. DENTAL PROSTHESES LOST AND FOUND
a. Dental Prosthesis Lost by Facility. A request by a patient for the facility to replace a prosthesis lost or irreparably damaged at the facility due to the facility’s or a VA employee’s actions will be honored only when the circumstances of the damage or loss have been reliably substantiated and appropriately documented.
b. Dental Prosthesis Lost by Patient. Patients with continuing dental eligibility who had a prosthesis made by VA and who have lost or damaged it beyond repair within five years of insertion will be authorized one remake. Should this occur a second time, a professional determination will be made by the Chief, Dental Service regarding the appropriateness of a replacement.
c. Dental Prosthesis Found on Station. Dental prostheses recovered on VA property will be delivered to the Chief of Dental Service, or designee, for identification and appropriate disposition. There must be coordination between the Lost and Found activity of the facility and the Dental Service. If the prostheses are not claimed, they may be disposed of as unserviceable. Any prosthesis(es) containing gold alloy will have that metal recovered and disposed of as scrap gold alloy, in accordance with subparagraph 16b.2.
December 24, 2008 VHA HANDBOOK 1130.01
APPENDIX A
A-1
SCOPE OF CARE QUICK REFERENCE GUIDE
Dental Classification
Brief Description
Scope of Care
Recall
1
INP, Emergency
Treatment of an emergent/urgent oral condition involving acute pain, infection, trauma and/or hemorrhage.
Emergent/Urgent care.
No
2
INP, Compelling Medical Need
Treatment of an oral condition complicating the management of the medical condition for which the veteran was admitted.
Focused care.
No
3
INP, Extended Care
Inpatients in a non-acute care unit.
Focused care.
No
4
Community Living Center
Residents in VA Community Living Centers.
Focused care.
No
5
VA Residential Rehabilitation Treatment Programs (RRTPs)
Residents in VA Domiciliary Centers.
Focused care.
No
6
INP, Special Provision
Inpatients specified under sharing agreements and employees or patients officially authorized treatment for work related oral-dental injuries.
Per terms of the official agreement
7
INP, Non-Compelling Medical Need
Inpatients, service or non-service connected, that are provided dental care not related to the compelling medical condition for which they were admitted.
Focused care.
No
8
INP, Other
Other beneficiaries that are inpatients such as military retirees and inpatient dependents eligible under CHAMPVA.
Focused care.
No
9
OPC, Class I
10% SC or greater for a dental condition - 9900 series
Comprehensive care.
Yes
10
OPC, Class II
Recent discharge from military service.
Focused care, one episode.
No
11
OPC, Class IIA
Adjudicated, non-compensable trauma to oral structures.
Focused care.
Yes
13
OPC, Class IIC
POW
Comprehensive care.
Yes
14
OPC, Class III
Treatment of an oral condition adjunctive to the management of a service connected medical condition.
Focused care.
No
15
OPC, Class IV
100% SC Total
100% SC compensation rate by virtue of individual unemployability.
Comprehensive care.
Yes
16
OPC, Class V
Enrolled in the VA Vocational Rehabilitation Program
Focused care.
No
17
OPC, Class VI
Treatment of an oral condition adjunctive to the management of a non-service connected medical condition.
Enrolled in VA Homeless Program >60 days
Focused care.
Focused care.
No
No
18
OPC, Emergency
Treatment of an emergent/urgent oral condition involving acute pain, infection, trauma and/or hemorrhage; or suspicion of an oral malignancy.
Emergent/Urgent care.
No
19
OPC, Continued After Inpatient Care, Compelling Medical Need
Treatment of an oral condition complicating the management of the medical condition for which the patient was admitted that was initiated but not completed while the veteran was an inpatient.
Focused care.
No
20
OPC, Special Provision
C&P examinations, outpatients provided care under a sharing agreement, eligible allied beneficiaries and patients or employees officially authorized treatment for work related injuries/conditions.
Per terms of the official agreement
21
OPC, Continued After Inpatient Care, No Compelling Medical Need
Treatment provided to inpatients that are completed after hospital discharge.
Focused care.
No
22
OPC, Continued After Inpatient Care, Other
Treatment provided to active duty military, military retirees, CHAMPVA inpatients that are completed after hospital discharge.
Focused care.
No
December 24, 2008 VHA HANDBOOK 1130.01
APPENDIX B
B-1
§4.150 Schedule of ratings—dental and oral conditions.
Rating
9900 Maxilla or mandible, chronic osteomyelitis or osteoradionecrosis of:
Rate as osteomyelitis, chronic under diagnostic code 5000.
9901 Mandible, loss of, complete, between angles...............................................................100
9902 Mandible, loss of approximately one-half:
Involving temporomandibular articulation....................................................................
.50
Not involving temporomandibular articulation..............................................................30
9903 Mandible, nonunion of:
Severe 30
Moderate 10
Note: Dependent upon degree of motion and relative loss of masticatory
function.
9904 Mandible, malunion of:
Severe displacement....................................................................
....................................20
Moderate displacement....................................................................
...............................10
Slight displacement....................................................................
......................................0
Note: Dependent upon degree of motion and relative loss of masticatory
function.
9905 Temporomandibular articulation, limited motion of:
Inter-incisal range:
0 to 10 mm..............................................................................
..................................40
11 to 20 mm ................................................................................
.............................30
21 to 30 mm..............................................................................
................................20
31 to 40 mm..............................................................................
................................10
Range of lateral excursion:
0 to 4 mm..............................................................................
....................................10
Note: Ratings for limited inter-incisal movement shall not be combined
with ratings for limited lateral excursion.
9906 Ramus, loss of whole or part of:
Involving loss of temporomandibular articulation:
Bilateral.......................................................................
..............................................50
Unilateral......................................................................
.............................................30
Not involving loss of temporomandibular articulation:
VHA HANDBOOK 1130.01 December 24, 2008
APPENDIX B
B-2
Bilateral.......................................................................
..............................................30
Unilateral......................................................................
.............................................20
9907 Ramus, loss of less than one-half the substance of, not involving loss
of continuity:
Bilateral.......................................................................
..............................................20
Unilateral......................................................................
.............................................10
9908 Condyloid process, loss of, one or both sides.................................................................30
9909 Coronoid process, loss of:
Bilateral 20
Unilateral 10
9911 Hard palate, loss of half or more:
Not replaceable by prosthesis......................................................................
...................30
Replaceable by prosthesis......................................................................
.........................10
9912 Hard palate, loss of less than half of:
Not replaceable by prosthesis ................................................................................
........20
Replaceable by prosthesis ................................................................................
................0
9913 Teeth, loss of, due to loss of substance of body of maxilla or mandible
without loss of continuity:
Where the lost masticatory surface cannot be restored by suitable
prosthesis:
Loss of all teeth...........................................................................
........................40
Loss of all upper teeth ................................................................................
........30
Loss of all lower teeth ................................................................................
........30
All upper and lower posterior teeth missing ......................................................20
All upper and lower anterior teeth missing ........................................................20
All upper anterior teeth missing .........................................................................10
All lower anterior teeth missing .........................................................................10
All upper and lower teeth on one side missing ..................................................10
Where the loss of masticatory surface can be restored by
suitable prosthesis ................................................................................
......................0
Note: These ratings apply only to bone loss through trauma or disease such as osteomyelitis and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling.
9914 Maxilla, loss of more than half:
Not replaceable by prosthesis ................................................................................
......100
Replaceable by prosthesis ................................................................................
..............50
December 24, 2008 VHA HANDBOOK 1130.01
APPENDIX B
B-3
9915 Maxilla, loss of half or less:
Loss of 25 to 50 percent:
Not replaceable by prosthesis ................................................................................
..40
Replaceable by prosthesis ................................................................................
........30
Loss of less than 25 percent:
Not replaceable by prosthesis ................................................................................
..20
Replaceable by prosthesis ................................................................................
..........0
9916 Maxilla, malunion or nonunion of:
Severe displacement ................................................................................
.......................30
Moderate displacement ................................................................................
..................10
Slight displacement....................................................................
.......................................0
[29 FR 6718, May 22, 1964, as amended at 43 FR 45362, Oct. 2, 1978; 59 FR 2530, Jan. 18, 1994]
Supplement Highlights reference: 7(2)
There has been confusion concerning dental eligibility for veterans who have other rated, compensable service connected disabilities of the head and neck area. Conditions such as loss of soft tissue, scarring or cranial nerve involvement may have significant impact on oral function even if there is no physical injury to the dental structures per se. These non-dental disabilities, which are rated under other than the 9900 series, are considered medical conditions. The decision whether or not to provide dental care will be based on a professional determination if adjunctive care is necessary, and if provided, will be done so under the Class III or Class VI category.
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