Clinical Criteria

Clinical Criteria for Utilization Review Determinations 

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Benefit coverage of dental services and procedures is determined in accordance with the specific terms of a member's dental plan. It is Delta Dental’s policy to adopt objective and evidence-based written clinical criteria to be referenced as guidelines when the administration of member dental plans requires professional determination of the medical necessity or clinical appropriateness of dental services. Clinical criteria are compiled from relevant evidence-based clinical recommendations, guidelines and parameters of care of leading nationally recognized dental public health organizations, health research agencies and professional organizations, credible scientific evidence published in peer-reviewed medical and dental literature and the rules and requirements of the Centers for Medicare and Medicaid Services. 

Clinical criteria referenced by Delta Dental must be approved by the Dental Director and adopted by the Utilization Management Committee prior to their application in utilization review decision making. Clinical criteria referenced by Delta Dental and any associated benefit payment determinations do not qualify as dental or medical advice. Members must make all decisions about the desirability or necessity of dental procedures and services with their dentist. Federal or state statutes or regulations, dental plan contract provisions, local or national claim processing policies or other mandated requirements may take precedence over clinical criteria.