Dental Services

Policy

The TAC can fund the reasonable cost of dental services for injuries sustained in a transport accident where the dental practitioner is registered with the Dental Board of Australia.

Transport Accident Act 1986 reference: s.3 'medical service' and s.60

Definition

In this policy Dental Implant refers to an implant based dental prosthesis which provides the support required for a crown, denture or a fixed bridge when replacing missing teeth.

Guidelines

Who is eligible for TAC funded dental services?

Clients who require dental treatment as a direct result of their transport injuries, are eligible for TAC funded dental services.

The TAC will consider funding the cost of a dental implant or implant supported prosthesis where the total cost of the procedure has been submitted prior to the commencement of treatment.

Clients are eligible for dental implants where:

• the client's dental damage is transport accident-related, and
• the client's standard of dental health warrants restoration of his/her mouth with an implant supported prosthesis, in preference to the traditional methods used to replace missing teeth, and
• the client understands the limitations of an implant supported prosthesis and accepts the responsibility for its daily care and maintenance, e.g. brushing and flossing.

What dental services can the TAC fund?

General Dental Services

In relation to general dental services the TAC can fund:

• the reasonable costs of general dental services provided by a registered dentist to restore a client's mouth, that has been damaged as a direct result of transport accident injuries, to a level that is consistent with the pre-accident standard of dental care and in accordance with accepted dental practice,
• the reasonable cost of dental services provided by a suitably qualified advanced dental technician registered with the Advanced Dental Technicians Qualifications Board to provide:
  • a partial or full denture
  • relining of a full denture
  • a mouth guard or
  • repairs to, or replacement of a client's denture that was damaged or lost in the transport accident. See the Equipment policy.
• dental services in accordance with the Schedule of Fees for Dental Services when submitted on a fully itemised account from a registered dentist or registered advanced dental technician.

Only emergency treatment may be carried out without prior approval from the TAC.

Dental Implants

In relation to dental implants the TAC can fund:

• the reasonable cost of bone grafts in accordance with the TAC's Schedule of Oral and Maxillo-facial Services Rates
• the reasonable costs of surgical fees for intra-oral implants in accordance with the TAC's Schedule of Oral and Maxillo-facial Services Rates including:
  • a consultation and a report
  • extra oral implantation of titanium fixture or fixation of transcutaneous abutment for the osseo-integration procedure
  • implantation of a titanium fixture applies regardless of whether the fixture is placed in a cavity that has been excavated in the bone for that purpose, or in the enlarged socket of a recently extracted tooth. In the latter case, the fee listed includes that for the exodontia
• anaesthetists' fees at the applicable TAC rate if surgery is performed in a hospital
• soft tissue grafts according to fees listed in the TAC's Schedule of Dental Fees 
• the retail cost of any implant hardware provided to a client for insertion in the prosthesis.

Dental Implants for Adolescents

Where a client is an adolescent, the TAC can fund the reasonable cost of:

• an interim implant-supported acrylic prosthesis until the soft and hard tissues and the occlusion have stabilised. (The benchmark accepted by authorities is when closure of the root apices of the upper second molar teeth occurs, which is generally between the ages of 17½ and 19 years)
• tooth-borne removable appliances. For example, partial dentures for clients involved in contact sports, until the sport is discontinued.

Prosthodontic Fees

The TAC can fund the construction and insertion of an implant-supported prosthesis according to the Schedule of Fees for Dental Services. The provision of an implant supported prosthesis also includes:

• drawing up, coordinating and presenting the overall treatment plan to the TAC
• implant-based porcelain-gold crown or porcelain-gold pontics for implant bridgework
• supplying a temporary acrylic partial denture

The TAC can fund:

• the reasonable fee for an implant template if required
• reimbursement of the reasonable retail cost of expendable implant hardware provided by the practitioner for use by the client.

All fees are based on the premise that the dental practitioner will meet the fees charged by the dental technician.

Implant Based Bridge Maintenance

• The TAC can fund maintenance services in accordance with the TAC's fee schedule. For example, removing, cleaning or adjusting larger implant-based bridges that are usually screwed into place.
• The TAC will not pay this fee for a routine inspection of an implant-supported crown nor a small bridge that is cemented onto its base.

Associated Dental Services

• The TAC requires prior advice of any associated dental services provided to the adjoining teeth. For example, periodontic or orthodontic treatment may be required when an implant-based prosthesis is inserted.
• The proposed service and fee should be approved by the TAC before treatment commences.

The TAC may obtain a second opinion, before agreeing to contribute to the cost of any treatment plan for dental implants.

What information does the TAC require to consider a request for dental services?

The TAC can fund dental services where a report and treatment plan, quoting item numbers and fees from the Schedule of Fees for Dental Services are submitted by the treating dentist or advanced dental technician and approved by TAC prior to treatment commencing.

The TAC requires the information contained on the Dental Report Form to determine its liability for dental services.

The TAC requires the information contained on the Maxillo-facial Report Form to determine its liability for maxillo-facial services.

How does the multiple operation rule apply to dental services?

The multiple operation rule applies to dental services:

• when an individual practitioner performs two or more surgical procedures on a client on the one occasion. This rule also applies to surgery performed by doctors, oral and maxillo-facial surgeons. The 'one occasion of service' for surgical procedures is defined as:
  • a single visit to the rooms of a dentist or an oral and maxillofacial surgeon
  • all surgery performed under a single anaesthetic. The operation has not finished until the patient leaves the recovery room, so if the patient is recalled to theatre from the recovery room, the subsequent services would be subject to the multiple operation rule.
• that are surgical services listed in the TAC Schedule of Dental Fees as well as from the Medicare Benefits Schedule (MBS) book performed by oral and maxillo-facial surgeons. The multiple operation rule will apply to all the surgical services provided at the operation. Surgical services are defined as:
  • all oral and maxillofacial surgery (CMBS items 51800 - 51803 and 51900 - 53460)
  • the insertion of the fixtures for osseogenic implants (dental items 679, 684 and 691)
  • the fee for the extraction of more than one tooth (dental item 311 and 316)
  • periodontics (dental items 232, 233, 234, 235, 236, 237 and 238)
• The TAC will apply the multiple-operation rule where two or more procedures are carried out under one anaesthetic. This is 100% of the TAC fee for the most expensive item, 50% of the TAC fee for the next most expensive item, and 25% of the TAC fee thereafter.

Can the TAC fund dental services performed by a member of a client's immediate family?

Refer to the Funding Treatment by a Member of a Client's Immediate Family policy.

In relation to dental services what will the TAC not fund?

The TAC will not fund:

• treatment or services for persons other than the client
• treatment or services for an injury, condition or circumstance that existed before a transport accident or that is not a direct result of a transport accident
• treatment, services or equipment where there is no published evidence in a recent peer-reviewed journal article that the treatment, service or equipment is safe and effective. Refer to the Non-Established, New or Emerging Treatments and Services policy
• treatment or services that are of no clear benefit to a client
• fees associated with non-attendance or phone consultations
• the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
• treatment or services received by the injured person outside the Commonwealth of Australia
• treatment or services inconsistent with pre accident standard of dental care
• repeat treatment required due to a client not caring for their teeth
• dental treatment that is not required as a direct result of transport accident injuries
• treatment or services provided by a dental technician who is not an advanced dental technician
• treatment or services provided more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.