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Dental Caries F007

Last amended 
26 October 2015

In this section

Current RMA Instruments:
Reasonable Hypothesis SOP
122 of 2015
Balance of Probabilities SOP
123 of 2015
Changes from previous Instruments:

ICD Coding:
  • ICD-9-CM Codes: 521.0
  • ICD-10-AM Codes: K02.0-K02.3 and K02.8-K02.9
Brief description

Dental caries is tooth decay and cavity formation.

Confirming the diagnosis

Diagnosis will be based on a report from a dentist.

Additional diagnoses covered by SOP
  • Nil

Conditions not covered by SOP
  • Dental pulp and apical disease*
  • Loss of teeth*
  • Periodontitis*

* another SOP applies  - the SOP has the same name unless otherwise specified

Clinical onset

Each occurence of dental caries can be considered as a new clinical onset and claims can be determined on a cavity by cavity, or episode by episode basis.

Clincial worsening

Development of new cavities in other locations at later times is a new onset of dental caries in the affected tooth rather than worsening of dental caries. Progression of caries to dental pulp disease or loss of a tooth (extraction) is covered under the SOPs for those conditions.  The only SOP worsening factor is for inability to obtain appropriate clinical managment.  Lack of timely treatment of a cavity could lead to worsening of that cavity.