Dental service

Unless provided by the official emergency or urgent care service, or in the case of the extraction of more than three teeth, anesthesia procedures performed by the specialist physician in anesthesia and intensive care in connection with gingival-dental arch surgery, gingival and dental care, as well as dental and surgical extractions, are covered by health insurance only upon prior approval from the medical control in the following situations:

• in cases of intolerance to local anesthesia
• when the presence of an acute inflammatory process requires immediate intervention, and local anesthesia does not provide adequate pain relief
• for dental treatment of mentally or physically disabled individuals for whom local anesthesia is impossible due to their disability
• during the extraction of an impacted or embedded wisdom tooth, when local anesthesia does not provide adequate pain relief, supported by a radiograph

Certain prosthetic dental procedures require prior authorisation from the Medical Control of the Social Security. These procedures, indicated by the acronym ACM (authorisation from the Medical Control of the Social Security required), may also involve exceeding tariff limits and are marked by the acronym DSD (exceeding on estimate).

To benefit from coverage for these procedures, it is necessary to present a prior estimate prepared by the dentist. This estimate must be submitted to the CMFEP, which will forward it to the Medical Control of the Social Security for approval. Once the opinion of the Medical Control is obtained, the CMFEP will then, if applicable, send approval of the estimate, indicating the amount that will be reimbursed.

In the case of prosthetic dental procedures marked by the DSD acronym, allowing for tariff exceedances based on estimates, the dentist is allowed to freely and reasonably set the fee for these procedures beyond the maximum fee reimbursed by health insurance, as defined by the nomenclature. However, the dentist is required to inform the insured individual in advance of this official tariff exceedance through a detailed estimate.

Article 40 of the CNS provides that temporary dental prostheses (DA14, DB13, DB17) are only covered if they are declared functionally indispensable by the Medical Control of the Social Security and if the masticatory/chewing coefficient is less than fifty percent.

Renewal Periods:

• fixed dental prostheses (DB21 - DB51) can only be renewed every twelve years
• removable dental prostheses (DA11 - DA45) can only be renewed every five years

However, the Medical Control of the Social Security can exceptionally reduce these renewal periods in the following situations:

• in case of maxillofacial bone fracture
• in the presence of a neoplasm affecting the maxillofacial region
• when treatment with very high-dose bisphosphonates is performed
• for dental prosthetic treatments before the age of 17

Documents to Submit:

• for a crown on a tooth: estimate with X-ray
• for a crown on an implant: estimate with implant X-ray taken a minimum of 8 weeks after implant placement
• for a splint (DS6/DS5): estimate with diagnosis or X-ray

Only implants mentioned in chapter 4 of the CNS nomenclature (DB95-DB98) can be covered if the following cumulative conditions are met:

• in the presence of a medical certificate attesting to the indication of one of the two rare diseases listed below: oligodontia (agenesis of at least 6 permanent teeth per arch, not including wisdom teeth) or anodontia (absence of all teeth)
• from the age of 18, or after growth, by maxillary and mandibular implants if indicated
• with a maximum of eight implants per arch

The coverage of orthodontic treatment is conditioned by its initiation before the age of 17. The time frame and age limit are assessed as of the date of placement of the orthodontic appliance.

Therefore, the National Health Fund or the relevant public sector fund does not cover the costs associated with orthodontic treatment for adults.

Each position in the nomenclature of medical-dental procedures related to orthodontics (DT10 - DT62) is reimbursed only once, except for position DT10. Position DT10 can be reimbursed a maximum of three times within a period of five years, with a minimum interval of 365 days between each reimbursement.

Orthodontic treatment, except for positions DT10 and DT11, is covered only if it is carried out with prior authorisation and under the supervision of the Medical Control. Authorisations from the Medical Control of the Social Security for medical-dental procedures related to orthodontics are valid only if the authorised treatment is started within twelve months following the date of authorisation by the Medical Control.

However, this timeframe does not apply to authorisations related to positions DT36 or DT46, which refer to orthodontic treatments with fixed appliances for cleft lips or labio-maxillary clefts, and which are initiated before the age of 17. These treatments are covered by an annual lump sum, and the annual period is taken into account for their completion, regardless of the twelve-month timeframe.

Documents to be sent:

• initial request (DT21/DT22/DT23/DT31/DT41): Quote with (digital) mold
• extension (DT34/DT35/DT44/DT45): Quote with a pre-treatment profile teleradiography