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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-41

Effective Date: 07/01/05

41 Approval Date: _____________/06 fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post, temporary (polycarbonate crowns) and stainless steel bands; crown recementation; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure are dental services covered without preauthorization. C. All covered dental services not referenced above require preauthorization by DMAS. The following services are also covered through preauthorization: medically necessary full banded orthodontics, tooth guidance appliances, complete and partial dentures, surgical preparation (alveoloplasty for prosthetics, single permanent crowns and bridges. D. Routine bases under restorations and inhalation analgesia are not covered. E. Examinations prophylaxis, fluoride treatment (one each six months); space maintenance appliance; bitewing x-ray - two films each 12 months; routine amalgam and composite restorations once each three years; dentures once each five years; extractions, orthodontics, tooth guidance appliances, permanent crowns and bridges, endodontics, patient education and sealants - one time. F. Limited oral surgery procedures, as defined and covered by Medicare when preauthorized. G. Provided only as a result of EPSDT and subject to medical necessity and preauthorization requirements specified under Dental Services.

6.2.18.A ⌧ Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Residential treatment for pregnant women. The treatment facility shall not be an institution for mental disease.

6.2.19.A ⌧ Outpatient substance abuse treatment services (Section 2110(a)(19)) Group and individual counseling. Limitation of up to 26 sessions annually. If medically necessary, additional sessions may be preauthorized. Services must be rendered by a certified or licensed provider. Day treatment for pregnant women.