Diagnostic and Preventitive Care |
Office Visits
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- Routine comprehensive or recall examination – limited to 2 visits in a 12-month period
- Problem-focused examination – limited to 2 visits in a 12-month period
- Prophylaxis (adult or child treatment during office visit) – limited to 2 treatments in a 12-month period
- Topical application of fl uoride – limited to 1 course of treatment in a 12-month period and limited to treatment of children under age 16
- Sealants (per tooth) – limited to 1 application every 36 months on permanent molars only and limited to treatment of children under age 16
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X-Rays
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- Periapical x-rays – single films up to a total of 13 films per visit
- Bitewing x-rays – limited to 2 sets in a calendar year
- Complete x-ray series, including bitewings, if necessary, or panoramic film – limited to 1 set every 36 months
- Vertical bitewing x-rays – limited to 1 set every 36 months
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Space Maintainers
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Only covered when needed to preserve space resulting from premature loss of primary teeth. The procedure includes all adjustments which occur within 6 months of the installation.
- Only covered when needed to preserve space resulting from premature loss of primary teeth. The procedure includes all adjustments which occur within 6 months of the installation.
- Removable unilateral or bilateral space maintainers
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Basic Restorative Care |
Visits
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- Professional visits after hours – payment will be based upon the greater of the service rendered or the visit charge
- Emergency palliative treatment – paid per visit
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X-Ray and Pathology
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- Intra-oral, occlusal view, maxillary or mandibular
- Upper or lower jaw, extra-oral
- Biopsy and histopathologic examination of oral tissue
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Oral Surgery
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- Extractions – erupted tooth or exposed root
- Extractions – coronal remnants
- Extractions – surgical removal of erupted tooth/root tip
- Impacted teeth – removal of tooth (soft tissue)
- Odontogenic cysts and neoplasms – incision and drainage of abscess
- Odontogenic cysts and neoplasms – removal of odontogenic cysts or tumor
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Other surgical procedures
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- Alveoplasty, in conjunction with extractions – per quadrant
- Alveoplasty, in conjunction with extractions, 1 to 3 teeth or tooth spaces – per quadrant
- Alveoplasty, not in conjunction with extractions – per quadrant
- Alveoplasty, not in conjunction with extractions, 1 to 3 teeth or tooth spaces – per quadrant
- Sialolithotomy: removal of salivary calculus
- Closure of salivary fistula
- Excision of hyperplastic tissue
- Removal of exostosis
- Transplantation of tooth or tooth bud
- Closure of oral fistula of maxillary sinus
- Sequestrectomy
- Crown exposure to aid eruption
- Removal of foreign body from soft tissue
- Frenectomy
- Suture of soft tissue injury
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Periodontics
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- Occlusal adjustments (other than with an appliance or by restoration)
- Root planing and scaling, per quadrant – limited to 4 separate quadrants every 24 months
- Root planing and scaling, 1 to 3 teeth per quadrant – limited to 1 per site every 24 months
- Gingivectomy, per quadrant – limited to 1 per quadrant every 36 months
- Gingivectomy, 1 to 3 teeth per quadrant – limited to 1 per site every 36 months
- Gingival flap procedure, per quadrant – limited to 1 per quadrant every 36 months
- Gingival flap procedure, 1 to 3 teeth per quadrant – limited to 1 per site every 36 months
- Periodontal maintenance procedures following active therapy shall be limited to 2 procedures in a 12-month period
- Localized delivery of antimicrobial agents
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Endodontic
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- Pulp capping
- Pulpotomy
- Apexification/recalcification
- Apicoectomy
- Root canal therapy, including necessary x-rays – anterior or bicuspid
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Restorative dentistry
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Excluding inlays, crowns (other than prefabricated stainless steel or resin) and bridges. Multiple restorations in 1 surface will be considered one restoration.
- Amalgam restoration
- Resin-based composite restorations (other than for molars)
- Pins – pin retention, allowed per tooth in addition to amalgam or resin restoration
- Crowns when tooth cannot be restored with a filling material – including prefabricated stainless steel or prefabricated resin crown (excluding temporary crowns)
- Recementation including inlay, crown and bridge
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Major Restorative Care |
Oral Surgery
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- Removal of impacted teeth (partially bony)
- Removal of impacted teeth (completely bony)
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Periodontics
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- Osseous surgery, including flap and closure, 1 to 3 teeth per quadrant, limited to 1 site,in a 36 month period
- Osseous surgery, including flap and closure, limited to 1 per quadrant, in a 36 month period
- Soft-tissue graft procedures
- Clinical crown lengthening, hard tissue
- Full mouth debridement, limited to once every 36 months
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Endodonic
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- Root canal therapy, including necessary x-rays
- Molar root canal therapy, including necessary x-rays
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Restorative
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This category includes inlays, onlays, labial veneers and crowns only when they are employed as treatment for decay or acute traumatic injury and only when teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed bridge (limited to 1 per tooth every 5 years [see replacement rule])
- Inlays/Overlays
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Labial veneers
- Laminate – chairside
- Resin laminate – laboratory
- Porcelain laminate – laboratory
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Crowns
- Resin
- Resin with noble metal
- Resin with base metal
- Porcelain/ceramic substrate
- Porcelain with noble metal
- Porcelain with base metal
- Base metal (full cast)
- Noble metal (full cast)
- 3/4 cast metallic or porcelain/ceramic
- Post and core
- Core buildup, including any pins
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Prosthodontics
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The first installation of dentures and bridges is covered only if needed to replace teeth extracted while coverage was in force and which were not abutments to a denture or bridge fewer than 5 years old. [See the Plan’s Tooth Missing but not Replaced Rule.] Replacement of existing bridges or dentures will be covered no more frequently than once every 5 years. [See the Plan’s Replacement Rule.]
- Bridge abutments (See Inlays and Crowns)
- Pontics
- Base metal (full cast)
- Noble metal (full cast)
- Porcelain with noble metal
- Porcelain with base metal
- Resin with noble metal
- Resin with base metal
- Removable bridge (unilateral) – one-piece casting, chrome cobalt alloy clasp attachment (all types) per unit, including pontics
- Dentures and partials – fees for dentures and partial dentures include relines, rebases and adjustments within 6 months after installation. Fees for relines and rebases include adjustments within 6 months after installation. Specialized techniques and characterizations are not eligible
- Complete upper denture
- Complete lower denture
- Partial upper or lower, resin base (including any conventional clasps, rests and teeth)
- Stress breakers
- Interim partial denture (stayplate), anterior only
- Office reline
- Laboratory reline
- Special tissue conditioning, per denture
- Rebase, per denture – adjustments to denture more than 6 months after installation
- Full and partial denture repairs
- Broken denture, no teeth involved
- Repair cast framework
- Replacing missing or broken teeth, each tooth
- Adding teeth to existing partial denture – each tooth and each clasp
- Repairs:crowns and bridges
- Occlusal guard (for bruxism only), limited to 1 every 36 months
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General anesthesia and intensive sedation
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Only when Medically Necessary and only when provided in conjunction with a covered surgical procedure
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Orthodontic Care
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Interceptive orthodontic treatment
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Limited orthodontic treatment
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Comprehensive orthodontic treatment of adolescent dentition
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Post-treatment stabilization
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Removable appliance therapy to control harmful habits
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Fixed-appliance therapy to control harmful habits
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