Canadian Dental Care Plan - Dental Benefits Guide

Effective date: May 2024

This guide provides information on the Canadian Dental Care Plan (CDCP), the “Plan”, and its policies relevant to participating oral health providers and clients. It explains the scope of the Plan’s coverage by describing the important elements of each associated policy.

This guide outlines the CDCP’s coverage at maturity. Services not requiring preauthorization and which are submitted electronically will be eligible beginning in May 2024 for eligible CDCP clients. Services requiring preauthorization will be available starting in November 2024. Orthodontic services that would improve oral health outcomes for eligible clients will become available beginning in 2025.

1.0 Purpose of the Dental Benefits Guide

The Dental Benefits Guide summarizes the terms and conditions, criteria, guidelines and policies under which the Plan covers dental services for eligible Plan clients.

2.0 General principles

The Plan covers a range of dental procedures that prevent and treat oral disease and/or the consequences of oral disease
Coverage of dental services is determined on an individual basis taking into consideration criteria such as the client’s oral health status
The Plan may consider coverage beyond its frequency limitations for eligible dental services where the request meets the established policies, guidelines and criteria and is submitted for preauthorization. Services requiring preauthorization will be available starting in November 2024
Certain dental services are not covered under the Plan (for example, temporomandibular joint therapy and appliances, extensive rehabilitation and cosmetic services). These services are defined as exclusions and will not be considered for coverage or for an appeal at any time
Consistent with the Plan’s policies, the Plan does not cover any dental procedures related to non-eligible dental services, nor does it cover dental procedures related to a dental service reviewed by the Plan where it did not meet the established policies, guidelines and criteria
Claims for dental benefits must be submitted by a participating oral health provider who is licensed and in good standing with the regulatory body of the province/territory in which they practice. Should a provider’s standing with their regulatory body change, the provider must contact the CDCP. A participating oral health provider may include:
- a dentist who is a general practitioner (GP) or a specialist
- an independent dental hygienist
- a denturist
The participating oral health provider may provide clients with eligible dental services, provided that the services are rendered within the CDCP’s rules, including:
- policies
- guidelines and criteria
- frequency limitations
- preauthorization requirements (note that services requiring preauthorization will be available starting in November 2024)

Persons with Disabilities

The Plan is designed to cover a range of individual care needs and circumstances, and the preauthorization process will take oral health status and medical conditions into account, including disability status. In cases where there is a demonstrated higher need for a particular kind of care, that individual may be eligible for that care. For example, the CDCP may cover the provision of higher levels of dental hygiene care through preauthorization for clients with limited ability to conduct regular cleaning and brushing on their own (or with assistance from others) when specific criteria demonstrating need are met.

3.0 Terms and conditions

This guide provides information on the CDCP and its policies relevant to providers and clients. It explains the scope of the CDCP’s coverage by describing the important elements of each associated policy.

To be eligible for payment of services rendered, providers must adhere to the CDCP Claims Processing and Payment Terms set out in the CDCP Claims Processing and Payment Agreement.

4.0 Definitions

Appeal process:: A client-initiated or provider-initiated process (at the request and with the consent of the client) seeking reconsideration of a denied request under the Plan. Parents/guardians of a client can submit an appeal on their behalf, if the client is under 18 years of age. Exclusions will not be considered for appeal.
Benefit period:: The CDCP coverage period extends for twelve months, from July 1 to June 30, annually. Re-enrolment will be required, and will take place by July 1 of each year for clients who continue to be eligible for coverage under the CDCP.
CDCP client:: An individual assessed by Service Canada to meet the CDCP eligibility criteria and who is enrolled in the Plan. The provider must verify that the individual has been deemed eligible for coverage prior to every appointment.
Exceptions:: These are dental procedures that are outside of the Plan’s scope of coverage or procedures that require special consideration through preauthorization.
Exclusions:: These are dental procedures that are outside the scope of the Plan and will not be considered for coverage nor considered for appeal, for example, temporomandibular joint therapy and appliances, fixed prosthodontics (bridges and all bridge-related procedures), implants and all implant-related procedures, veneers, cosmetic services, ridge augmentation, and appliances to treat bruxism. Further detail is provided in Appendix D.
Frequency limitation:: Limitations put against procedures, as specified in the current CDCP Dental Benefit Grids and in the present Dental Benefits Guide. The Plan may consider coverage beyond frequency limitations for eligible dental services where the request meets the established policies, guidelines, and criteria and is submitted for preauthorization. Services requiring preauthorization will be available starting in November 2024.
Participating oral health provider:: A licensed oral health professional (for example, a dentist who is a general practitioner (GP) or a specialist, independent dental hygienist or denturist) who is in good standing with the regulatory body in the province or territory in which they practice and participates in the CDCP.
Preauthorization (PA):: Preauthorization is a method for the administration and adjudication of coverage by seeking review of coverage for services prior to proceeding with treatment. Preauthorization enables both the oral health provider and client to understand the coverage commitments. Services requiring preauthorization will be available starting in November 2024.
Post-determination:: Post-determination is a method for the administration and adjudication of coverage for services which have been rendered. This is a submission that will be considered for coverage under specific circumstances under the Plan and must be supported with a rationale. Services requiring post-determination will be available starting in November 2024.

5.0 CDCP dental procedures

5.1 Diagnostic services

5.1.1 Examinations

Clients are eligible for up to 3 examinations in any 12 month period provided these examinations respect the frequency limitations.

These examinations can include:

complete oral examination and diagnosis
new patient limited examination
recall examination
specific examination

Frequency limitations take into account overall interactions between various examination services rendered by the same provider, different providers within the same office or different offices, as well as the eligibility period for each service.

Examinations performed by dental specialists and denturists do not count against the maximum number of eligible annual examinations.

Frequency guidelines for examinations
Dental procedure	Frequency guidelines
Complete oral examination	1 in any 60 months When a complete examination is provided, it replaces the recall examination and the new patient limited examination for the respective eligibility period
New patient limited examination	1 per lifetime, with same provider or different provider in the same office 1 in any 12 months, with different provider in a different office
Recall examination	1 in any 12 months
Specific examination	1 in any 12 months
Emergency examination	(No frequency limit)
Specialist examination – complete (requires preauthorization)	1 in any 60 months per specialty (with GP referral and justification for the referral) , and up to 2 in any 60 months if the second examination is performed by a different provider of the same specialty than the provider who performed the first examination. When a complete examination is provided within a twelve (12) month period by a specialist, it replaces the specialist examination and diagnosis – limited, within the same specialty in that 12 month period
Specialist examination – limited	1 in any 12 months per specialty (with a GP referral and justification for the referral), and up to 2 in any 12 months if the second examination is performed by a different provider of the same specialty than the provider who performed the first examination.
First dental visit/orientation – oral assessment for patients up to the age of 3 years (inclusive)	1 per lifetime

5.1.2 Radiographs

All radiographs submitted with a treatment plan must be current, mounted, include the date of service, and of good diagnostic quality. The name of both the oral health provider and client must be indicated on the mount. Whenever duplicate radiographs are submitted, the oral health provider must indicate on the radiograph whether the radiograph is on the right or left side of the client's mouth.

When submitting enlarged digital radiographs, of any type, oral health providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

Radiographs are considered "current" for preauthorization purposes if dated within the last 12 months (1 year) of the preauthorization submission.

Frequency guidelines for radiographs
Dental procedure	Frequency guidelines
Complete series of intraoral, periapical and bitewing radiographs	1 in any 60 months
Intraoral radiographs (1 to 8 films) (includes periapical, bitewing and occlusal radiographs)	8 in any 12 months
Panoramic radiographs	1 in any 60 months; up to 3 per lifetime

5.1.3 Laboratory tests, analysis

Frequency guidelines for laboratory tests, analysis
Dental procedure	Frequency guidelines
Microbiological test/analysis for the determination of pathologic agents	1 in any 12 months
Cytological smear from the oral cavity	1 in any 12 months

5.2 Preventive services

For preventive services including polishing, scaling, topical fluoride treatments, pit and fissure sealants/preventive restorative resin services, please refer to the Preventive and Periodontal Policy in Section 5.5 Preventive and periodontal services.

Frequency guidelines for interproximal disking of teeth
Dental procedure	Frequency guidelines
Interproximal disking of teeth (requires preauthorization)	1 unit in any 12 months

The Plan may consider coverage under the following circumstances:

creation of space when done in conjunction with approved coverage for orthodontic services (available as of 2025)
creation of space for erupting permanent teeth (applicable only to mesial of 53, 63, 73, 83 and the distal of 55, 65, 75 and 85)

5.3 Restorative services

Repeat restorations/extensions for the same tooth performed by the same provider or different provider in the same office, excluding a core or crown, within a 2 year time frame are subject to audit and require a written rationale documented in the client's chart on the date of service delivery.

Restorations for incisal wear involving enamel and dentin are considered cosmetic/aesthetic services (exclusions) under the Plan and therefore will not be considered for payment.

5.3.1 Restorations, primary teeth

Requirements for restoration of primary incisor teeth 51, 52, 61, 62, 71, 72, 81, 82:

clients must be under the age of 5
eligibility is once per tooth in any 24-month period by the same provider, or different provider in the same office
no combination of procedure codes/surfaces/classes should exceed in one visit the cost of the collective number of procedure codes/surfaces/classes restored, up to a maximum cost of a polycarbonate crown (the lesser amount to be paid)
when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the lesser amount up to a maximum cost of a polycarbonate crown
bonded amalgams are covered at the rate of non-bonded equivalents

Requirements for restoration of primary teeth 53, 54, 55, 63, 64, 65, 73, 74, 75, 83, 84, 85:

eligibility is once per tooth in any 24-month period by the same provider, or different provider in the same office
no combination of procedure codes/surfaces/classes should exceed in one visit the cost of the collective number of procedure codes/surfaces/classes restored, up to a maximum cost of a stainless steel crown (the lesser amount to be paid)
when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the cost of the lesser amount up to a maximum cost of a stainless steel crown
bonded amalgams are covered at the rate of non-bonded equivalents

5.3.2 Restorations, permanent teeth

Requirements for restoration of permanent anterior and posterior teeth:

eligibility is once per tooth in any 24-month period by the same provider, or different provider in the same office
no combination of procedure codes/surfaces/classes should exceed in 1 visit the cost applicable to the collective number of distinct surfaces restored, up to a maximum cost of 5 surface restorations or complete tooth reconstruction (the lesser amount to be paid)
when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the cost of the lesser amount up to a maximum cost of an amalgam five surface restoration/complete tooth reconstruction
bonded amalgams are covered at the rate of non-bonded equivalents

5.3.3 Caries, trauma and pain control

If requested on the same date of service and for the same tooth, caries, trauma and pain control procedures will not be considered for coverage in conjunction with any of the following procedures:

restorations
open and drain
pulpectomy
pulpotomy
root canal treatment

5.3.4 Cores and posts

Cores are eligible only if the existing restoration is greater than 24 months old and will be considered for coverage only in conjunction with an approved preauthorized crown request.

Bonded amalgam cores are covered at the rate of non-bonded equivalents.

A prefabricated post/pin is eligible only when inadequate coronal tooth structure is remaining to retain a restoration.

Prefabricated posts in combination with a core, including pin(s) where applicable, will be considered for coverage only in conjunction with an approved preauthorized crown request. When a prefabricated post, pin(s), and core procedure codes are requested individually for the same tooth for a crown, the Plan will adjust the fee at the rate of the combined procedure codes.

Cores, and prefabricated posts in combination with cores, are only covered for clients 18 years of age and older.

Frequency guidelines for cores and posts
Dental procedure	Frequency guidelines
Cores (require preauthorization) and posts	4 in any 10 years per client (permanent teeth only)
Post removal	1 per lifetime, per permanent tooth

5.3.5 Crowns

5.3.5.1 Crown Policy – General principles

The following types of single unit crowns are eligible for coverage:
- cast full metal
- porcelain/ceramic-fused to metal
- porcelain/ceramic
These services require preauthorization
The Plan will consider coverage of crowns for clients 18 years of age and older
Frequency limitations are:
- 4 crowns in any 10-year period per client
- 1 crown per eligible tooth in any 8-year period (96 months)
Any types of crowns supported by implants, as well as all implant-related procedures are not covered under the Plan. These procedures are considered exclusions and cannot be considered for an appeal
All basic treatment addressing any existing active biological disease (caries and periodontal), must be completed before submitting requests for crowns
The Plan will not consider coverage of a crown in the following circumstances:
- to improve aesthetics
- to treat sensitivity due to:
  - cracked tooth syndrome
  - erosion
  - abrasion, or
  - attrition
- to treat stress fractures or chipping on teeth that have a minimal restoration or no restoration
- for high caries risk individuals or those with generalized moderate to severe periodontal disease where there is evidence of long-standing, uncontrolled and/or untreated rampant biological disease (either caries or periodontal disease)

5.3.5.2 Crown Policy – Eligibility criteria

5.3.5.2.1 Tooth eligibility

The Plan will consider coverage of a single unit crown on:

incisors, canines, bicuspids, first and second molars; and
third molars where the first and the second molars are missing and the third molar is in occlusion with a prosthetic or natural molar

5.3.5.2.2 Tooth restorability

The Plan will consider coverage of a single unit crown on endodontically and non-endodontically treated teeth when all of the following criteria are met:

adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1), visible on submitted radiographs with absence of furcation involvement
absence of active periodontal disease
adequate remaining non-diseased tooth structure to ensure that biologic width (3 mm) is maintained and adequate ferrule (1.5 mm) is achieved during restoration
an extensively restored tooth where the existing tooth structure can no longer support a direct restoration. The Plan defines an extensively restored tooth as follows:
- for all anterior teeth (endodontically and non-endodontically treated): restoration/loss of tooth structure involves the entire incisal edge, from mesial to distal, and extends cervically to both interproximal contacts
- for endodontically treated premolars and molars: restoration/loss of tooth structure involves 3 or more continuous surfaces and involves either both mesial and distal marginal ridges, or the entire destruction of a cusp, as demonstrated with radiographs. In addition, providers have the choice to submit photographs, if available
- for non-endodontically treated premolars and molars: restoration/loss of tooth structure involves 5 continuous surfaces
a mesio-distal space (vertically and horizontally) equivalent to that of the natural tooth with no loss of space due to caries or crowding
a tooth that does not require any additional treatment, such as crown lengthening, root re-sectioning or orthodontic treatment
endodontically treated teeth must demonstrate on a postoperative periapical radiograph that healing has occurred

5.3.5.3 Crown Policy – Non-inserted crowns

For non-inserted crowns, the Plan will consider paying up to 20% of the current CDCP professional fee and up to 100% of a reasonable laboratory fee associated with the fabrication of a crown, if applicable, under the following conditions:

the crown has been completed but not inserted due to circumstances beyond the control of the oral health provider
the provider has made substantial efforts to contact the client to schedule an insertion appointment
the provider has communicated the details of the situation in writing to the CDCP

Note: If a non-inserted crown has been claimed by the oral health provider without complying with the above-noted conditions, and has been paid in full by the Plan, this will result in a payment recovery.

Frequency guidelines for crowns
Dental procedure	Frequency guidelines
Crowns (require preauthorization)	4 in any 10 years per client 1 per eligible tooth in any 8 year period (96 months)
Repair to crowns	1 in any 36 months, per tooth
Recementation of crowns	1 in any 36 months, per tooth

5.4 Endodontic services

5.4.1 Endodontic Policy - General principles

Preauthorization is not required for standard root canal treatment (RCT) on anterior teeth, bicuspids, and first and second molars
Preauthorization is required for root canal re-treatment, apicoectomy, retrofilling on all teeth, and standard root canal treatment on third molars
There is a frequency limitation of 1 root canal re-treatment, 1 apicoectomy, and 1 retrofilling per tooth per lifetime
The Plan will consider coverage for a root canal treatment when the tooth eligibility and restorability criteria have been met
The Plan will not consider coverage for a root canal treatment for individuals with a high risk of caries or those with generalized moderate to severe periodontal disease when there is evidence of long-standing, uncontrolled, and/or untreated rampant biological disease (either caries or periodontal disease)

5.4.2 Endodontic Policy - Eligibility criteria

5.4.2.1 Tooth eligibility

The Plan will consider coverage of a root canal treatment on:

incisors, canines, bicuspids, first and second molars; and
third molars where the first and the second molars are missing and the third molar is in occlusion due to a prosthetic or natural molar

5.4.2.2 Tooth restorability

The Plan will consider coverage of a root canal treatment when all of the following criteria are met:

adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs with absence of furcation involvement
absence of active periodontal disease
adequate remaining non-diseased tooth structure to ensure that biologic width (3 mm) can be maintained during restoration
a mesio-distal space (vertically and horizontally) equivalent to that of the natural tooth with no loss of space due to caries or crowding; and
a tooth that does not require any additional dental treatment such as crown lengthening, root resectioning or orthodontic treatment

5.4.3 Endodontic Policy - Pulpectomies and pulpotomies

Pulpectomy/pulpotomy will be covered at a frequency of 1 per tooth/per lifetime
Incomplete approved root canal treatment requests will be paid up to the equivalent of a pulpectomy
The final fee for a root canal treatment includes the cost associated with a pulpectomy/pulpotomy and open and drain within the 3-month period prior to the completion of the root canal treatment, when performed by the same provider/same office
The final fee for a root canal treatment or pulpectomy/pulpotomy includes the fee for the temporary restoration and its replacement if required
Stainless steel crowns are indicated for restoring teeth following either a pulpectomy or pulpotomy

Frequency guidelines for root canal therapy
Dental procedure	Frequency guidelines
Root canal re-treatment, apicoectomy, retrofilling	1 root canal re-treatment, 1 apicoectomy and 1 retrofilling per tooth, per lifetime

5.5 Preventive and periodontal services

5.5.1 General principles

The general principles for the preventive and periodontal policy are as follows:

preauthorization is not required for scaling and root planing services up to the annual maximum allowable units; for any additional units, preauthorization is required
all preventive and periodontal procedures claimed must be supported with proper, clear, and detailed documentation for verification purposes as per the terms and conditions of the Plan

5.5.2 Preventive services

5.5.2.1 Polishing, topical fluoride treatment, topical application of an antimicrobial or remineralization agent, scaling and root planing

Frequency guidelines for polishing, topical fluoride treatment, topical application of an antimicrobial or remineralization agent, scaling and root planing
Dental procedure	Frequency guidelines - Age 0 to 11 years	Frequency guidelines - Age 12 to 16 years	Frequency guidelines - Age 17+ years
Polishing	½ unit in any 12 months	½ unit in any 12 months	½ unit in any 12 months
Topical fluoride (includes fluoride varnish and other topical fluoride eligible treatments)	1 treatment in any 6 months	1 treatment in any 6 months	1 treatment in any 12 months
Topical application to hard tissue lesion(s) of an antimicrobial or remineralization agent (includes silver diamine fluoride)	2 treatments in any 12 months	2 treatments in any 12 months	2 treatments in any 12 months
Scaling	½ unit in any 12 months	1 unit in any 12 months	4 units in any 12 months (in combination with root planing)
Desensitization	2 units in any 12 months	2 units in any 12 months	2 units in any 12 months

5.5.2.2 Sealants and preventive resin restorations

Clients 17 years of age and under are covered for sealants and preventive resin restorations on the occlusal surface of permanent molars (16, 26, 36, 46, 17, 27, 37, 47), bicuspids (14, 15, 24, 25, 34, 35, 44, 45), and on the lingual surface of permanent maxillary incisors (11, 12, 21, 22), where surfaces are unrestored
There will be a lifetime limit of 2 sealants/preventive resin restorations per eligible tooth

Frequency guidelines for the management of oral disease
Dental procedure	Frequency guidelines
Management of oral manifestations, oral mucosal disorders, mucocutaneous disorders and diseases of localized mucosal conditions.	2 units in any 12 months (in combination with management of oral manifestations of systemic disease or complications of medical therapy)
Management of oral manifestations of systemic disease or complications of medical therapy.	2 units in any 12 months (in combination with management of oral manifestations, oral mucosal disorders, mucocutaneous disorders and diseases of localized mucosal conditions)

5.6 Prosthodontic services – Removable prosthodontics

5.6.1 Removable Prosthodontic Policy - General principles

The general principles of the Removable Prosthodontic Policy are as follows:

complete and partial dentures supported by implants as well as all implant-related procedures are exclusions and not covered under the Plan
the fee for complete and partial dentures includes a 3 month period of post-insertion care
denture adjustments done on the same date of service and in conjunction with the delivery of new dentures, denture repairs, relines, rebases and/or tissue conditioning are included in the fees billed and paid for these services
the fee for immediate dentures includes the tissue conditioner, but not the processed reline/rebase
the overall cost of replacement for a denture may be adjusted in situations where the client's history shows that claims for reline/rebase were paid within 3 months prior to the request
the Plan will consider coverage for denture labelling of new dentures by denturists

5.6.2 Removable Prosthodontic Policy - Removable partial dentures

5.6.2.1 General principles

The general principles of removable partial dentures are as follows:

preauthorization is required for initial placements of removable partial dentures (preauthorization is not required for replacements)
removable partial acrylic dentures are covered once in any 5 year period (60 months) per arch
removable partial transitional/provisional acrylic dentures are covered once in any 5 year period (60 months) per arch
removable partial cast dentures are covered once in any 8 year period (96 months) per arch

5.6.2.2 Eligibility

The Plan will consider coverage for a partial denture for teeth numbered 16 to 26 and 36 to 46 inclusive, under the following conditions:

general conditions:
- all basic treatment must be completed including:
  - control of caries and of periodontal and periapical disease for all teeth, and
  - restoration of major structural defects in the abutment teeth
- the space to be replaced is greater than or equal to the corresponding natural teeth (vertically and horizontally)
- if there is an existing partial cast denture, it must be at least 8 years old
- if there is an existing partial acrylic denture, it must be at least 5 years old
specific conditions:
- there must be 1 or more missing teeth in the anterior sextant, or
- there must be 2 or more missing posterior teeth in a quadrant excluding second and third molars

5.6.3 Removable Prosthodontic Policy - Complete dentures

5.6.3.1 General principles

The general principles of complete dentures are as follows:

preauthorization is not required for standard complete dentures and for transitional/provisional complete dentures. All other types of complete dentures require preauthorization
transitional/provisional complete dentures are covered once in a lifetime per arch. All other types of complete dentures are covered once in any 8 year period per arch

5.6.3.2 Eligibility

The Plan will consider coverage for a complete denture:

for an initial placement, or
for replacement of an existing complete denture that is at least 8 years old

5.6.4 Non-inserted removable prosthodontic policy

5.6.4.1 Standard partial and complete dentures

For non-inserted standard partial and complete dentures, the Plan will consider paying up to 50% of the current CDCP professional fee and up to 100% of a reasonable laboratory fee associated with the fabrication of a denture, if applicable, under the following conditions:

the partial or complete denture has been fabricated but not inserted due to circumstances beyond the control of the oral health provider
the provider has made substantial efforts to contact the client to schedule an insertion appointment, and
the provider has communicated the details of the situation in writing to the CDCP

5.6.4.2 Immediate partial and complete dentures

For non-inserted immediate partial and complete dentures, the Plan will consider paying up to 50% of the current CDCP professional fee and up to 100% of a reasonable laboratory fee associated with the fabrication of a denture, if applicable, under the following conditions:

the provider who manufactured the immediate denture is different from the provider who was scheduled to do the extraction(s) and insertion
substantial efforts have been made by both providers to contact the client to reschedule the missed extraction/insertion appointment, and
the provider who manufactured the immediate denture has communicated the details of the situation in writing to the CDCP

Note:

if a non-inserted denture of any type that has been claimed by an oral health provider without complying with the above-noted conditions and has been paid in full by the Plan, this will result in a payment recovery
at the Plan's discretion, providers may be required to provide a detailed invoice for any laboratory work

Frequency guidelines for dentures
Dental procedure	Frequency guidelines
Complete dentures – standard, immediate, overdentures	1 per arch in any 96 months
Complete dentures – transitional/provisional	1 per arch in a lifetime
Partial cast dentures (initial placements require preauthorization)	1 per arch in any 96 months
Partial acrylic dentures – standard, immediate, overdentures (initial placements require preauthorization)	1 per arch in any 60 months
Partial acrylic dentures – transitional/provisional (initial placements require preauthorization)	1 per arch in any 60 months
Repairs/additions	1 per prosthesis in any 12 months
Reline/rebase	1 per prosthesis in any 24 months
Tissue conditioning	1 per prosthesis in any 24 months

5.7 Oral surgery services

Implants and ridge augmentation are exclusions under the Plan.

Major surgical procedures (for example, tooth exposure, fracture reduction etc.) require preauthorization.

5.8 Orthodontic services

Orthodontic services that would improve oral health outcomes for clients will be available beginning in 2025. Preauthorization will be required for orthodontic treatment.

The Plan will consider coverage for orthodontic treatment when eligibility and clinical criteria are met. Criteria include (but may not be limited to):

children (under 18 years of age) that meet the clinical criteria of a severe and functionally handicapping malocclusion as set out by the Modified Handicapping Labio-Lingual Deviation (HLD) Index, taking into consideration any clinical evidence associated with the child's condition that impacts the child
adults with a craniofacial anomaly (for example, cleft lip and palate) that is associated with a severe and functionally handicapping malocclusion, as set out by the Modified Handicapping Labio-Lingual Deviation (HLD) Index

5.9 Adjunctive services

5.9.1 Sedation and General Anesthesia Policy - General principles

The Plan provides coverage for the following sedation services:
- minimal sedation
- moderate sedation
- deep sedation and general anesthesia (including facilities where applicable)
Fees for eligible sedation and general anesthesia codes include the cost of sedation medication and the induction technique procedure, regardless of route of administration (for example, parenteral, injection)
Providers must adhere to the conditions of licensing, certification, and accreditation as per provincial or territorial dental regulations
Where applicable, pediatric treatment (for clients aged 0-11 years) under sedation and general anesthesia is to include stainless steel crowns. In agreement with the American Academy of Pediatric Dentistry and the Canadian Academy of Pediatric Dentistry, Stainless steel crowns are indicated in the following situations:
- restoration of primary and permanent teeth with extensive caries, cervical decalcification, and/or developmental defects (for example, hypoplasia, hypocalcification)
- following pulpotomy or pulpectomy
- when failure of other available restorative materials is likely (for example, interproximal caries extending beyond line angles, patients with bruxism)
- definitive restorative treatment for high caries-risk children
- intermediate restoration of fractured teeth

5.9.2 Sedation and General Anesthesia Policy - Minimal sedation

5.9.2.1 General principles

Applicable to nitrous oxide, a single oral sedative drug, or a combination of nitrous oxide and a single oral sedative drug
Preauthorization is not required for minimal sedation eligible procedure codes
Frequency limitation of 4 sessions in any 12 month period
Additional sessions above the listed frequency will be considered through preauthorization

5.9.2.2 Coverage eligibility

Clients aged 0 to 11 years

Treatment cannot be rendered in a normal clinical setting without sedation

Clients aged 12 years and older

Treatment attempted and was unsuccessful in a normal clinical setting without sedation, or
Significant mental and/or physical impairment

5.9.3 Sedation and General Anesthesia Policy - Moderate sedation

5.9.3.1 General principles

Preauthorization is required for moderate sedation; in emergency situations, post-determination will be considered
Providers are to ensure that other modes of sedation (for example, minimal sedation) have been attempted in a normal clinical setting, when possible, prior to requesting moderate sedation
There is a frequency limitation of 1 session in any 12 month period
Additional sessions above frequency will be considered
To limit the associated risks with repeat moderate sedation sessions, when possible, providers are strongly encouraged to complete all necessary treatment in 1 session

5.9.3.2 Coverage eligibility

Clients aged 0 to 11 years

Complex or extensive treatment needs, or
Age-related behaviour management issues, significant mental and/or physical impairment

Clients aged 12 years and older

Complex or extensive treatment needs, or
Significant mental and/or physical impairment

5.9.4 Sedation and General Anesthesia Policy - Deep sedation and general anesthesia

5.9.4.1 General principles

Preauthorization is required for deep sedation and general anesthesia; in emergency situations, post-determination will be considered
Providers are to ensure that other modes of sedation (for example, minimal and moderate sedation), when possible, have been attempted in a normal clinical setting prior to requesting deep sedation or general anesthesia
There is a frequency limitation of 1 session in any 12 month period
To limit the associated risks with repeat deep sedation or general anesthesia sessions, when possible, providers are strongly encouraged to complete all necessary treatment in 1 session
Pediatric clients (aged 0-11 years) who require more than 1 deep sedation/general anesthesia session should be considered for referral to a specialist, when possible

5.9.4.2 Coverage eligibility

Clients aged 0 to 11 years

Complex or extensive treatment needs, when all deciduous molars are erupted, or
Age-related behaviour management issues, significant mental and/or physical impairment

Clients aged 12 years and older

Complex or extensive treatment needs, or
Significant mental and/or physical impairment

6.0 Appendices

Appendix A: CDCP Dental Benefit Grids

The CDCP Dental Benefit Grids list what services are eligible by placing coverage into 2 schedules:

schedule for services that do not require preauthorization: outlines services that may be completed and billed directly to the claims processor for payment (without requiring preauthorization) within Plan policies (for example, frequency limitations)
schedule for services requiring preauthorization: outlines services that always require an approved preauthorization (prior approval) to be claimed under the Plan. Services requiring preauthorization will be available starting in November 2024

Appendix B: Payment and reimbursement

All claims must be received by the CDCP within 1 year from the date of service to be eligible for payment or reimbursement. The service must be eligible for coverage under the CDCP as of the date of service, and all policies and requirements for coverage apply.

Note:

the 1 year policy applies to the initial claim submission and includes all subsequent resubmissions following a rejection under CDCP (for example, missing required data elements; incorrect procedure code used, client has alternative coverage, etc.)
the coordination of benefits with other plans must also be completed within 1 year of the date of service

Claims older than 1 year from the date of service are not eligible for payment or reimbursement and therefore will not be accepted for processing.

A procedure code or procedure name in a client record is not sufficient to substantiate a claim for payment.

If applicable, a detailed statement or Explanation of Benefits (EOB) from all other health plan(s)/program(s), through which the client receives coverage for dental services, must be provided.

Laboratory fee submission: Certain dental services require laboratory work. Laboratory fee submissions will be considered for coverage under the CDCP only in conjunction with an approved procedure code. However, the CDCP reserves the right to require a copy of the laboratory report and to adjust the laboratory fee requested by oral health providers.

Appendix C: Appeal Process

Further detail regarding the CDCP’s appeal process will be made available on the CDCP website.

Appendix D: Exclusions

These are dental procedures that are outside the scope of the Plan and will not be considered for coverage nor considered for appeal. The list of exclusions will be available to participating providers, and will include (but not be limited to):

veneers in composite or ceramic
all ¾ crowns
teeth whitening
inlays/onlays in composite, precious metal or ceramic
temporomandibular joint therapy and appliances
fixed prosthodontics (bridges)
bruxism appliances
mouthguards
crown lengthening
root re-sectioning
implants and any associated procedures
treatment for changing vertical dimension
bone grafts
ridge augmentation
complex complete/partial dentures
extensive rehabilitation
precision attachment partial dentures
fluorescent diagnostic light

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Date modified:: 2024-02-06