P.R. Laws tit. 24, § 7061
The health services company or insurer that provides coverage for general anesthesia services, hospitalization services and dental services in the subscriber’s service contract, shall not be able to exclude or deny coverage for general anesthesia to be administered by an anesthesiologist and hospitalization services, in the following cases:
(a) When a pediatric dentist, an oral or maxillofacial surgeon who is a member of the medical faculty of a hospital, licensed by the Government of Puerto Rico, pursuant to §§ 81 et seq. of Title 20, determines that the condition or ailment of the patient is significantly complex according to the criteria established by the American Academy of Pediatric Dentistry;
(b) when the patient, because of his/her age, impediment, or disability, is unable to resist or tolerate pain, or cooperate with the treatment indicated in the dental procedures;
(c) when the infant, boy, girl, adolescent, or person with a physical or mental impediment has a medical condition in which it is indispensable to carry out dental treatment under general anesthesia in an ambulatory surgical center or in a hospital, and that otherwise could pose a significant threat to the patient’s health;
(d) when local anesthesia is ineffective or contraindicated because of an acute infection, anatomic variation, or allergic condition;
(e) when the patient is an infant, a boy, a girl, an adolescent, or a person with physical or mental disability, and is in a state of fear or anxiety that prevents performing the dental treatment under the procedure traditionally used in dental treatments and the condition is so critical that postponing or deferring treatment would result in pain, infection, loss of teeth, or dental morbidity;
(f) when a patient has received an extensive and severe dental trauma where the use of local anesthesia would jeopardize the quality of the services or would be ineffective to handle the pain and apprehension.
History —Dec. 22, 1999, No. 352, § 1.