Page 2355

prosthodontic treatment is not applicable;

(3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph,

(A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification;

(B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12-month period;

(C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi surface restoration code per tooth per day;

(D) final restorations are limited to not more than five surfaces per tooth; tooth preparation, temporary restorations, sedative and cement bases, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; and

(E) the department will provide payment for a crown only upon seatment of the permanent crown, and for a partial or denture only upon seatment of the appliance; the department will not provide partial payment for incomplete or in-progress dental services;

(4) endodontics, with the following limitations:

(A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment;

(B) with respect to root canal therapy, tooth preparation, filling of the root canal, and follow-up are considered components of a complete root canal and may not be billed separately; and

(5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including gingivitis, periodontitis, and periodontal abscess;

(6) prosthodontics, including replacement of a complete or partial denture only if the existing denture is unusable and only once per five calendar years;

(7) oral surgery; under this paragraph, the following services are covered:

(A) extractions; under this subparagraph,

(i) a claim submitted for up to two extractions in a single day to alleviate immediate pain or infection must be accompanied by medical justification;

Page 2355

Official source

prosthodontic treatment is not applicable;

(3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph,

(A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification;

(B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12-month period;

(C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi surface restoration code per tooth per day;

(4) endodontics, with the following limitations:

(A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment;

(B) with respect to root canal therapy, tooth preparation, filling of the root canal, and follow-up are considered components of a complete root canal and may not be billed separately; and

(5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including gingivitis, periodontitis, and periodontal abscess;

(6) prosthodontics, including replacement of a complete or partial denture only if the existing denture is unusable and only once per five calendar years;

(7) oral surgery; under this paragraph, the following services are covered:

(A) extractions; under this subparagraph,

(i) a claim submitted for up to two extractions in a single day to alleviate immediate pain or infection must be accompanied by medical justification;