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UNOFFICIAL 1737-83 (6) Implanted breast prosthesis provided the surgical procedure of implantation is approved by the department.

(d) Testicular prosthesis shall not be included in the medical assistance program. [Eff 08/01/94; am 09/17/07 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§440.120)

§17-1737-75 Dental services. (a) Dental services means diagnostic, preventive, and corrective procedures administered because of a diseased condition, injury, or impairment, by or under the supervision of a dentist licensed under state law for the treatment of teeth and the associated structures of the oral cavity.

(b) Dental services for individuals under the age of twenty-one are limited to the following services:

(1) Emergency treatment which includes services to relieve dental pain, eliminate infection, and treatment of acute injuries to the teeth

and supporting structures of the oro-facial complex; (2) X-ray with the limitations of one set of two bitewing rediographs during a twelve-month period and one set of full month rediographs during a five-year period, including bitewings; (3) Preventive dental services: (A) Topical application of fluoride; (B) Sealants for occlusal surface of permanent molar teeth only for children ages six through fifteen; and (C) Dental examination and prophylaxis treatment, which shall be limited to not

more than once every six months, and which shall not cover routine examination of institutional patients; (4) Periodontic treatment limited to cases of medical necessity, includes in the procedure, post operative care for six months following treatment and recall treatment limited to three times a year. Prior authorization and a medical report is required: Osseous and

mucogingival surgeries, grafts, and implants are considered elective and are not covered; (5) Dental work done under conscious sedation (inhalation or intravenous) or general anesthesia shall be allowed only in cases of