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UNOFFICIAL 1737-84 medical necessity and within program policy guidelines. A medical report is required; (6) Root canal therapy with the following requirements: (A) Root canal therapy shall be covered for a maximum of once per tooth, except in cases of poor prognosis, as in the case of advanced decay or bone loss or prior root canal failure. Completed root canal x-rays shall be submitted with the claim for payment; (B) Root canal therapy shall not be covered for the purpose of overdenture

fabrication except under special medical circumstances which requires prior authorization and a medical report; (7) Extraction, whether done in the dentist's office or in a hospital under general anesthesia; (8) Restorative dentistry with the following limitations: (A) Restorative dentistry shall be limited to the use of amalgam, silicate, resin, plastic, acrylic, or composite fillings; (B) Non-duplicated restorative procedures are allowed only once per tooth every two years as needed in the treatment of fractured or carious teeth; (C) Acrylic jackets and acrylic veneer crowns, if authorized, shall be limited

to anterior teeth for a maximum of once per tooth; (D) The department shall not allow a separate charge for tooth preparation,

temporary restorations, pulp caps, cement bases, impressions, or local anesthesia; (E) An amalgam or composite buildup shall be considered a component part of the preparation for the completed restoration except in special circumstances, and by report; and (F) Amalgam restorations are allowed, but composite resin or acrylic restorations

in posterior secondary teeth (except the facial surface of permanent first premolars) shall be considered purely cosmetic dentistry and shall not be covered;