mainecare benefits manual, chapters ii and iii, section 25

Department of Health and Human ServicesMaineCare Services

# 11 State House StationAugusta, Maine 04333-0011

Tel: (207) 287-2674; Fax: (207) 287-2675TTY: 1-800-423-4331

December 23, 2009

TO: Interested Parties

FROM: Anthony Marple, Director, MaineCare Services

SUBJECT: Final Rule: MaineCare Benefits Manual, Chapters II & III, Section 25, Dental Services

The Department of Health and Human Services is adopting changes to the MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services. The Department amended language in sub-section 25.03-2 (G) for Tobacco Cessation Counseling to be consistent with the language in Chapter III, Section 90, Physician’s Services. The Department is also adopting new language in sub-section 25.04-1 for Adult Dental Care Requirements. The language clarifies criteria for imminent tooth loss. Furthermore, the Department is removing Appendix III-Supplemental Payment to General Dentists. Instead, the Department is increasing the reimbursement for selected dental codes in Chapter III of this Policy.

A public hearing was held on September 28, 2009. The comment deadline was October 8, 2009.

Rules and related rulemaking documents may be reviewed at and printed from the Office of MaineCare Services website at http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html or, for a fee, interested parties may request a paper copy of rules by calling 207-287-9368. For those who are deaf or hard of hearing and have a TTY machine, the TTY number is 1-800-423-4331.

A copy of the public comments and Department responses can be viewed at and printed from the Office of MaineCare Services website or obtained by calling 207-287-9368 or TTY: (207) 287-1828 or 1-800-423-4331.

If you have any questions regarding the policy, please contact your Provider Relations Specialist at 624-7539, option 8 or 1-800-321-5557, extension option 8 or TTY: (207)287-1828 or 1-800-423-4331.

http://www.maine.gov/dhhs/oms/rules/provider_rules_policies.html

Notice of Agency Rule-making Adoption

AGENCY: Department of Health and Human Services, Office of MaineCare Services

CHAPTER NUMBER AND TITLE: MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services

ADOPTED RULE NUMBER:

CONCISE SUMMARY: The Department of Health and Human Services is adopting changes to the MaineCare Benefits Manual, Chapters II and III, Section 25, Dental Services. The Department amended language in sub-section 25.03-2 (G) for Tobacco Cessation Counseling to be consistent with the language in Chapter III, Section 90, Physician’s Services. The Department is also adopting new language in sub-section 25.04-1 For Adult Dental Care Requirements. The language clarifies criteria for imminent tooth loss. Furthermore, the Department is removing Appendix III-Supplemental Payment to General Dentists. Instead, the Department is increasing the reimbursement for selected dental codes in Chapter III of this Policy.

The rulemaking will not yield any new administrative burdens or compliance-related costs that could fiscally impact municipal or county governments. The rulemaking has no adverse impact on small business, as all providers impacted by these rules employ more than twenty employees.

See http://www.maine.gov/bms/rules/provider_rules_policies.htm for rules and related rulemaking documents.

EFFECTIVE DATE: 1/1/10

AGENCY CONTACT PERSON: Nicole Rooney, Health PlannerAGENCY NAME: Division of Policy and PerformanceADDRESS: 442 Civic Center Drive

11 State House Station Augusta, Maine 04333-0011

TELEPHONE: (207)-287-4460 FAX: (207) 287-9369 TTY: 1-800-423-4331 or 207-287-1828 (Deaf/Hard of Hearing)

______________________________________________________________________________

http://www.maine.gov/bms/rules/provider_rules_policies.htm

10-144 Chapter 101MAINECARE BENEFITS MANUAL

CHAPTER II

Section 25 DENTAL SERVICES Established: 9/1/86Last Updated: 1/1/10

TABLE OF CONTENTS

PAGE

25.01 DEFINITIONS.....................................................................................................................1

25.01-1 Adjusted Acquisition Cost.................................................................................125.01-2 Complete (or full) Denture.................................................................................125.01-3 Consultation.......................................................................................................125.01-4 Dental Services...................................................................................................125.01-5 Dentist................................................................................................................125.01-6 Dentistry.............................................................................................................125.01-7 Denturism...........................................................................................................125.01-8 Denturist.............................................................................................................125.01-9 Department.........................................................................................................225.01-10 Immediate Complete Denture............................................................................225.01-11 Immediate Removable Partial Denture..............................................................225.01-12 Public Health Supervision Hygienist.................................................................225.01-13 Professional Reviewer........................................................................................225.01-14 Referral...............................................................................................................225.01-15 Removable Partial Denture................................................................................225.01-16 Same Period of Treatment..................................................................................325.01-17 Servicing (Rendering) Provider.........................................................................325.01-18 Specialist............................................................................................................4

25.02 ELIGIBILITY FOR CARE................................................................................................4

25.03 COVERED SERVICES.......................................................................................................4

25.03-1 Diagnostic Services............................................................................................425.03-2 Preventive Services............................................................................................625.03-3 Restorative Services...........................................................................................825.03-4 Endodontic Services...........................................................................................1025.03-5 Periodontics........................................................................................................1125.03-6 Prosthodontics....................................................................................................1225.03-7 Oral Surgery.......................................................................................................1325.03-8 Orthodontic Services..........................................................................................1825.03-9 Temporomandibular Joint Services (TMJ)........................................................28

25.04 Covered Services for Adults..................................................................................................3025.04-1 Adult Care Dental Services...............................................................................3025.04-2 Other Adult Dental Services (Dentures)............................................................31

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25.05 NON-COVERED SERVICES............................................................................................33

25.06 POLICIES AND PROCEDURES......................................................................................33

25.06-1 Member’s Records.............................................................................................3325.06-2 The Division of Program Integrity.....................................................................3525.06-3 Prior Authorization of Dental Services..............................................................3525.06-4 Case Management..............................................................................................3525.06-5 Qualified Professional Staff...............................................................................36

25.07 REIMBURSEMENT...........................................................................................................37

25.07-1 Other Resources.................................................................................................3725.07-2 Maximum Allowances.......................................................................................3725.07-3 Compliance Procedures......................................................................................3725.07-4 Denturist Services..............................................................................................3725.07-5 Hygienist Services..............................................................................................37

25.08 BILLING INSTRUCTIONS...............................................................................................38

APPENDICES:

Appendix I - MaineCare Handicapping Labiolingual Deviation Index Scoring Instructions............................................................................................................................i

Appendix II - MaineCare - Handicapping Labiolingual Deviation (HLD) IndexReport.................................................................................................................................................. ii


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25.01 DEFINITIONS

25.01-1 Adjusted Acquisition Cost is the price paid to a dental laboratory by an eligible provider for a custom laboratory fabricated appliance, excluding all associated costs such as, but not limited to, postage, shipping, handling, and insurance costs.

25.01-2 Complete (or full) Denture is any denture delivered to a completely healed, completely edentulous alveolar ridge such that relining or rebasing procedures are not required within six (6) months of delivery of the denture.

25.01-3 Consultation is an opinion rendered by a dentist whose advice is requested by another dentist or physician for the further evaluation and/or management of the patient. When the consulting dentist assumes responsibility for the continuing care of the patient, any subsequent service rendered by him/her will cease to be a consultation. The Department requires a written report to be sent to the requesting practitioner.

25.01-4 Dental Services are all services provided by or under the supervision of a dentist in the practice of dentistry. Such services include treatment of the teeth and associated structures of the oral and maxillofacial regions, and of disease, injury, abnormality, or impairment that may affect the oral or general health of the individual.

For the purposes of this policy, Dental Services also include denturism, hygienist services provided by Maine’s schools of dental hygiene, hygienist services provided by public health entities, and school-based and/or school-linked programs under contract arrangement with the Maine Center for Disease Control and Prevention, Oral Health Program.

25.01-5 Dentist is any person currently licensed by the Maine State Board of Dental Examiners or by the state or province in which services are provided to practice dentistry as herein defined.

25.01-6 Dentistry is the evaluation, diagnosis, prevention and/or treatment (non-surgical, surgical, or related procedures) of diseases, disorders, and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession, applicable law, and licensure regulation.

25.01-7 Denturism is the taking of denture impression and bite registration for the purpose of making, producing, reproducing, constructing, finishing, supplying, altering, or repairing of a complete upper or complete lower prosthetic denture, or both, to be fitted to an edentulous arch or arches.

25.01-8 Denturist is any person currently licensed by the Maine State Board of Dental Examiners or by the state or province in which services are provided to practice denturism as herein defined.

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25.01 DEFINITIONS (cont.)

25.01-9 Department means the Department of Health and Human Services, acting through the Office of MaineCare Services (OMS).

25.01-10 Immediate Complete Denture is any complete denture delivered the same day of dental extraction or to a not fully healed (completely edentulous) alveolar ridge such that relining or rebasing procedures may be required after an appropriate time interval for healing.

25.01-11 Immediate Removable Partial Denture is any removable partial denture delivered the same day of dental extraction or to a not fully healed alveolar ridge such that relining or rebasing procedures may be required after an appropriate time interval for healing.

25.01-12 Public Health Supervision means supervision of a hygienist who (1) has an active Maine license; (2) is practicing in a Public Health Supervision status as described in the Maine Department of Professional and Financial Regulation, 02-313 CMR 2, under the general supervision of a dentist, although the patient being treated may not be a patient of record of the supervising dentist; and (3) is practicing in a non-traditional dental setting. These settings may include but are not necessarily limited to public and private schools, medical facilities, nursing homes, residential care facilities, dental vans, and any other setting where adequate parameters of care, infection control, and public health guidelines can and will be followed.

25.01-13 Professional Reviewer is a licensed dentist who is involved in reviewing treatment records or evaluating requests for treatment requiring prior approval as a professional reviewer.

25.01-14 Referral is the transfer of the total or specific care of a patient from one dentist to another and does not constitute a consultation.

25.01-15 Removable Partial Denture is a removable replacement, including overdentures, for missing teeth in an arch which still has some natural teeth remaining, or in any arch that has had implants placed regardless of whether or not there are any remaining teeth.

25.01-16 Same Period of Treatment is the time period required for those sequential visits necessary to perform all of the needed services identified during a diagnostic examination and included in the written treatment plan.

25.01-17 Servicing (or rendering) provider is an individual who provides medical services to MaineCare members. All MaineCare servicing or rendering providers are required to file Servicing Provider forms with the Department. Servicing providers can not submit bills or claims to MaineCare, unless they are also MaineCare providers.

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kathy.greason, 01/05/10,

Insert definition of “immediate denture,” basically either of the two definitions without the “complete denture” or the “removable partial denture” language included.


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25.01 DEFINITIONS (cont.)

MaineCare providers submit bills to MaineCare for services rendered by their employees who are servicing or rendering providers.

25.01-18 Specialist is a dentist who practices one of the American Dental Association (ADA) recognized specialties and has fulfilled all of the required training to be recognized as such.

25.02 ELIGIBILITY FOR CARE

MaineCare members are eligible for covered dental services as set forth in this Manual. The Department requires that individuals must meet the eligibility criteria and residency requirements as set forth in the MaineCare Eligibility Manual. The Department may have restrictions on the type and amount of services that some members are eligible to receive.

25.03 COVERED SERVICES

Covered services are available for:

A. eligible members under the age of twenty-one (21);

B. eligible members of any age residing in an Intermediate Care Facility for Persons with Mental Retardation (ICF-MR); and

C. limited services for eligible members over the age of twenty-one (21).

Adult members not residing in an ICF-MR and age twenty-one (21) or older are eligible only under the adult dental care guidelines described in Chapter II, Subsection 25.04. Reimbursement is not available for any member age twenty-one (21) or older for orthodontics, orthognathic surgery or repair of cleft palate procedures except in those cases where treatment is being performed to correct a post-traumatic or post-surgical disfigurement or in those cases where it is a continuation of ongoing treatment. All covered services are subject to the restrictions and requirements contained in Chapters II and III, Section 25 of this manual.

25.03-1 Diagnostic Services are available for eligible members under the age of twenty-one (21) and members of any age residing in an ICF-MR and are subject to the restrictions indicated in Chapters II and III, Section 25. Adult members, not residing in an ICF-MR and age twenty-one (21) or older are eligible only for selected procedures that are available under the adult dental care guidelines contained in Subsection 25.04.

A. Clinical Oral Examination(s)

Reimbursement for examinations or evaluations is available only when performed by a licensed dentist or denturist in accordance with Chapter III.

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25.03 COVERED SERVICES (cont.)

1. Reimbursement for periodic oral examinations will not be made more than once every six months.

2. Reimbursement for limited oral or problem focused (emergency) exams is available once per emergency episode per provider.

3. Comprehensive oral exams are for new or established patients when evaluating a member comprehensively. This applies to new patients, established patients who have had a significant change in health conditions or other unusual circumstances, or by established patients who have been absent from active treatment for three (3) or more years.

4. Reimbursement for detailed and extensive oral exams (problem focused) used to evaluate medical appropriateness for restorative, surgical, and prosthodontic services is available once per episode per provider.

Reimbursement for exams includes the preparation of charts, treatment plans, and reporting forms.

B. Radiographs

1. The limitations placed on radiographs are intended to confine radiation exposure of members to the minimum level necessary to achieve a satisfactory diagnosis for dental services. Radiographs submitted to the Department must be of good diagnostic quality, properly processed, mounted, dated, labeled for right and left views, and fully identified with the names of the dental office and the member.

2. When radiographs submitted to the Department are not of diagnostic quality, the provider may not seek payment for retake radiographs requested by the Department’s professional reviewer.

3. The type of radiographic survey that is used is at the discretion of the provider, within the accepted American Dental Association (ADA) practice parameters.

4. Posterior bitewing radiographs as an independent procedure are reimbursable only once per calendar year.

5. If the member is going to have dental extraction prior to fabricationof immediate or partial dentures, the responsible dentist making the prior authorization request must send the pre-extraction radiographs to the Department.

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6. A complete intraoral series shall consist of a minimum of twelve (12) periapical radiographs plus posterior bitewings. A complete intraoral radiographic series is reimbursable once every three (3) years, except as part of an approved orthodontic treatment plan.

7. Panoramic radiographs are:

a. included in the reimbursement for comprehensive orthodontic services; and

b. separately reimbursable for interceptive orthodontics, oral surgery, and as allowed under adult care guidelines.

8. A temporomandibular joint (TMJ) radiograph series includes right and left transcranial films in the open, closed, and rest positions. Prior authorization is not required.

C. Sialography radiographs employing a contrasting medium are reimbursable when taken of a salivary gland or duct, not for a simple salivary stone.

D. Pulp vitality tests are to be used when the vitality of the tooth is in question. The Department does not consider these tests as routine procedures and the

member’s record must document the signs and symptoms that contributed to the questioning of the tooth’s vitality.

E. Diagnostic cast models must be of good diagnostic quality and properly related in occlusion by either trimming the heels of each model flush or by an accurate bite registration submitted to the Department.

25.03-2 Preventive Services are reimbursable for eligible members under the age of twenty-one (21) and members of any age residing in an ICF-MR and are subject to the restrictions in Chapters II and III, Section 25. Adult members, not residing in an ICF-MR and age twenty-one (21) or older are eligible only for selected procedures that are available under the adult dental care guidelines contained in Subsection 25.04.

A. Prophylaxis

1. Prophylaxis is the removal of plaque, calculus and stains from the tooth structures in the permanent, primary and transitional dentition and is intended to control local irritational factors. Prophylaxis is reimbursable no more frequently than once every six months. This service may include a scaling of the teeth, and must include the removal of acquired stains and deposits, polishing of the teeth, and oral hygiene instructions to the member.

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A “toothbrush prophylaxis” is not recognized as a covered service and cannot be billed as a prophylaxis. If performed, it would be included as part of the exam, or included in oral hygiene instructions and is not separately billable.

2. Prior approval for prophylaxis more frequently than once every six months may be requested for members who are significantly physically or mentally handicapped, such that routine preventive home care is impossible as a result of the handicapping condition. Prophylaxis more frequently than twice a year may also be requested for those members who exhibit a repetitively high caries rate or when significant medical conditions other than physical or mental handicaps exist which make the member more susceptible to dental disease.

B. Topical fluoride treatment is reimbursable no more frequently than twice per year except in those cases where a high caries rate indicates that more frequent applications would be valuable (e.g., additional applications of topical fluoride are allowed when a child has current decay or has had new restorations placed in the previous eighteen (18) months).

C. Pit and fissure sealants are reimbursable for permanent teeth, once every three (3) years per member per provider, and once per lifetime for deciduous (baby) teeth.

D. Fixed space maintainers and removable bilateral space maintainers are reimbursable for members under age twenty-one (21) and for all members residing in an ICF-MR.

E. Oral hygiene instruction is reimbursable as an independent service provided a charting is recorded of the member’s oral hygiene indicating poor application of the skills necessary to maintain good oral health. Up to three (3) visits per year are reimbursable per member per provider. Oral hygiene instruction is included as part of prophylaxis and is therefore not separately billable on the same day that prophylaxis is performed. Oral hygiene instruction must include disclosure of plaque, hands-on training in plaque removal and education on the etiology of dental disease.

F. Behavior management of the member is critical to providing successful dental treatment. In some cases it may take several visits to establish a relationship that will allow delivery of appropriate care. Establishing that relationship may negate the necessity for more costly interventions (i.e., general anesthesia, utilization of a specialist). The Department will reimburse up to three (3) visits per general dentist to gain the trust and cooperation of the member.

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G. Smoking Cessation Counseling is a covered service only when performed by the dentist, for members age eight (8) to twenty-one (21) and in accordance with the following requirements:

MaineCare covers counseling and treatment for smoking dependence to educate and assist members with smoking cessation. Services may be provided in the form of brief individualized behavioral therapy, which must be documented in the member’s record. Providers must educate members about the risks of smoking, the benefits of quitting and assess the member’s willingness and readiness to quit. Providers should identify barriers to cessation, provide support, and use techniques to enhance motivation for each member. Providers may also use pharmacotherapy for those member’s for whom it is clinically appropriate and who are assessed as willing and ready to quit, or in the process of quitting.

The amount of time spent with the member does not affect reimbursement. Reimbursement is available once per member, per calendar year, per dentist. Reimbursement is not available for this service when provided through the Maine Center for Disease Control and Prevention’s, Oral Health Program.

25.03-3 Restorative Services are available for eligible members under the age of twenty-one (21) and members of any age residing in an ICF-MR and are subject to the restrictions and regulations listed in Chapters II and III, Section 25. Adult members, not residing in an ICF-MR and age twenty-one (21) or older are eligible only for selected procedures that are available under the adult dental care guidelines described in Subsection 25.04.

A. Amalgam and Composite Restorations

1. Local anesthesia and bases are to be used when indicated and are not separately reimbursable.

2. No combination of restorations on a single tooth during the same period of treatment is reimbursable in excess of the fee for a four (4) surface restoration.

3. Two single-surface restorations performed on different surfaces on the same tooth, (such as occlusal and buccal on a mandibular molar), that are accomplished during the same period of treatment, must be coded as a two (2) surface restoration.

4. For anterior teeth, cuspids, lateral, and central incisors, only a one (1) surface restoration for a mesial or a distal lesion is reimbursable,

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even though a facial or a lingual approach is used when the decay extends onto the facial or labial surface.

5. Composite resin restorations may be used in all primary and permanent teeth.

6. The provision of acid etch retention is considered to be part of the reimbursement for the composite resin restorations. No additional reimbursement will be made for this service.

7. Reinforcing pins are reimbursable when used on permanent teeth where necessary for the retention of the restoration.

B. Crowns

1. Reimbursement for prefabricated stainless steel or composite resin crowns does not require prior authorization and is subject to the restrictions indicated in Chapters II and III, Section 25.

2. Reimbursement for stainless steel or resin crowns is available for adult members age twenty-one (21) or over not residing at an ICF-MR when provided:

a. in conjunction with the adult dental care requirements in Subsection 25.04; and

b. to restore an endodontically treated tooth during the same period of treatment as the original endodontic services.

3. When a stainless steel crown is used as a base for a space maintainer, the dentist may bill for a crown or a base, but not both.

4. Resin or stainless steel crowns are reimbursable for deciduous anterior teeth including cuspids.

5. Reimbursement is not available for full cast metal, porcelain to metal, porcelain or temporary crowns (except for resin and stainless steel crowns as previously indicated).

C. Sedative fillings are temporary restorations intended to sedate the pulp or to protect the vitality of the tooth. The code for sedative fillings is not to be used to identify or bill for the placement of a base material under a final restoration and is to be billed by general dentists.

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25.03-4 Endodontic Services are available for eligible members under the age of twenty-one (21) and members of any age residing in an ICF-MR and are subject to the restrictions


and regulations listed in Chapters II and III, Section 25. Adult members, not residing in an ICF-MR and age twenty-one (21) or older are eligible only for selected procedures that are available under the adult dental care guidelines described in Subsection 25.04.

A. Direct Pulp Capping

1. Direct pulp capping is only to be used when there is a pulpal exposure.

2. Reimbursement for protective bases is included in reimbursement for restoration procedures.

B. Pulpotomy

1. Pulpotomy is the complete removal of the coronal portion of the pulp to maintain the vitality of the tooth. It can be billed only in instances when a root canal is not anticipated. A pulpotomy is not reimbursable when performed on a primary tooth with roots showing signs of advanced resorption (more than two-thirds of the root structure resorbed).

2. A pulpotomy is not reimbursable in conjunction with root canal therapy during the same period of treatment when the same provider performs the pulpotomy and the root canal.

3. A pulpotomy is not reimbursable when used for the temporary relief of pain pending endodontic treatment when the same provider performs the pulpotomy and root canal.

4. A sedative filling is not reimbursable when performed in conjunction with a pulpotomy.

C. Root Canal Treatment

1. Root canal treatments are limited to permanent dentition and then only when there is a favorable prognosis for the continued health of the remaining dentition. In the course of the root canal treatment, in addition to reimbursement for the root canal procedure, reimbursement is separately available as necessary for the following procedures:

a. the simple restoration of the tooth;

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b. the placement of a prefabricated post and core;


c. the cost of pins;

d. a stainless steel crown; or

e. a resin crown.

2. If root canal treatment is initiated but not completed, the provider may submit a claim indicating the extent of the treatment completed. The Department will determine a prorated reimbursement. These claims are submitted to:

MaineCare Prior Authorization Unit Office of MaineCare Services

11 State House StationAugusta, Maine 04333-0011

D. Apexification procedures require that there is sufficient tooth structure remaining to support the subsequent root canal treatment and restoration.

E. An apicoectomy follows root canal treatment when the canal is not to be re-instrumented. Prior authorization must be obtained from the Department. Reimbursement for retrograde fillings is available as a separate procedure.

25.03-5 Periodontic services are restricted to eligible members under the age of twenty-one (21) and members of any age residing in an ICF-MR and are subject to the restrictions and regulations listed in Chapters II and III, Section 25. Adult members, not residing in an ICF-MR and age twenty-one (21) or older are eligible only for selected procedures that are available under the adult dental care guidelines described in Subsection 25.04.

A. Scaling is considered an integral part of prophylaxis as described in Subsection 25.03-2, Preventive Services.

B. Reimbursement is available for scaling and root planing as an independent procedure:

1. for members up to age twenty-one (21); and

2. when prior authorization is granted.

C. Prior authorization for scaling and root planing may be requested when the member’s record, as submitted to the Department, indicates:

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1. generalized pocket depths of four (4) millimeters or greater as evidenced by charting; and


2. calculus visible on fifty percent (50%) of interproximal surfaces as evidenced by radiographs; and

3. evidence of infection present.

D. Other periodontal procedures listed in Chapter III of this Section are subject to the restrictions therein.

25.03-6 Prosthodontics is available for eligible members under the age of twenty-one (21) and for members of any age residing in an ICF-MR and are subject to the restrictions indicated in Chapters II and III, Section 25. Adult members, not residing in an ICF-

MR and age twenty-one (21) or older are eligible only for selected procedures as indicated in Chapters II and III, Section 25, most of which are available only under the adult dental care guidelines as described in Chapter II, Subsection 25.04-1.

If the provider receives prior authorization for prosthodontic services and takes the final impressions while a member is MaineCare eligible, the Department will reimburse the provider even if the member subsequently becomes ineligible for

MaineCare. The Department will only reimburse the provider after the prosthesis is delivered. The provider must indicate on the invoice the date that impressions were taken as the date of service for billing purposes.

A. All requests for prior approval for partial dentures must include a treatment plan and radiographs.

B. Reimbursable removable prosthodontics includes partial dentures, immediate dentures, full dentures, and overdentures.

1. All dentures including partial, immediate, full and overdentures require prior approval.

2. If approval for partial dentures has been authorized, then all necessary operative dentistry must be completed prior to the placement of partial dentures.

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3. Prior approval for partial dentures may be requested for members with two (2) or more missing teeth per dental arch or for members with one (1) or more missing anterior permanent teeth.

4. Adjustments, relining, or rebasing within six (6) months of the initial delivery date is considered routine post-delivery care and reimbursement is included in the initial procedure reimbursement.

5. Adjustments, relining or rebasing six (6) months after the initial delivery date is separately reimbursable once every three (3) years from the date of delivery.

Additional adjustments, relining and rebasing is reimbursable once every three (3) years measuring from the initial date of delivery.

6. Reimbursement for immediate dentures includes reimbursement for both an initial relining and rebasing and the reimbursement for a second relining and rebasing after an appropriate time interval for healing. If a third relining or rebasing is required within three (3) years of the date of initial placement, prior authorization is required for reimbursement. If approved, separate reimbursement can be made for the third relining or rebasing. Further relining and/or rebasing is reimbursable only once every three (3) years from the date of initial placement.

7. Partial denture, full denture, immediate and overdenture fabrication is reimbursable once every five (5) years.

8. Reimbursement for overdenture attachment procedures is included in reimbursement for the initial procedure.

9. Reimbursement for procedures related to removable partial dentures or overdentures will only be paid to licensed dentists.

C. Reimbursement for fixed prosthodontics is restricted to acid etched composite luted bridgework and requires prior approval.

Prior approval may be granted to replace a single missing permanent tooth only until the member’s twenty-first (21st) birthday.

D. Non-covered prosthodontic services include:

1. temporary immediate dentures; and

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2. the placement or restoration of dental implants.


25.03-7 Oral Surgery services are available to eligible members under the age of twenty-one (21) and for members of any age residing in an ICF-MR and are subject to the restrictions indicated in Chapters II and III, Section 25. Adult members, not residing in an ICF-MR and age twenty-one (21) or older are eligible only for selected procedures as indicated in Chapters II and III of this Section that are available under the adult dental care guidelines described in Chapter II, Subsection 25.04.

A. Extraction of teeth that exhibit acute signs of dental disease, infection, decay, or traumatic injury are covered services for adult members when performed under the adult urgent care requirements in Subsection 25.04. MaineCare will cover the removal of erupted and impacted teeth for members of all ages, when a reasonable and documented treatment plan exists. The dentist must document the necessity for the extraction. All tooth removal documentation must include some form of current radiograph of reasonable quality (radiograph is reimbursable for this purpose if there is none of reasonable quality available).

The following indications are acceptable when supported by member record entries:

1. dental caries;

2. periodontal disease;

3. traumatic fracture, luxation, partial avulsion;

4. crowding or part of a serial extraction treatment plan;

5. evidence of pathology;

6. anomalies of tooth position;

7. to remove potential sources of infection in a member for whom radiation, chemotherapy, or transplant is contemplated or who is significantly immuno-compromised in some fashion;

8. impacted teeth;

9. supernumerary teeth;

10. severe attrition; and

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11. congenital conditions affecting the reasonable longevity of the tooth, e.g. amelogenesis imperfecta.


B. The allowances listed under Oral Surgery, in Chapter III of this Section, for all types of extraction include local anesthesia and routine postoperative care such as suture removal, irrigation, and spicule removal.

C. Reimbursement for alveoplasty, when performed in conjunction with extraction or within four (4) months of extraction, is separately reimbursable when six (6) or more teeth per dental arch are extracted.

D. When five (5) or fewer teeth are extracted per dental arch, reimbursement for alveoplasty is included in the payment for extraction.

E. Reimbursement for alveoplasty, to correct deformities on edentulous recipients requires prior authorization. Prior authorization will be granted only when alveoplasty is performed as a preparation for a prosthesis.

F. Extractions of teeth related to a major surgery are covered procedures, if the outcome of the major surgical procedure or the ongoing treatment of the member is directly affected by the extractions, and:

1. the major surgical procedure is a MaineCare covered procedure; and

2. the extraction is performed within six (6) months before the major surgical procedure, unless:

a. it is a life threatening situation for the member; or

b. the member will be receiving chemotherapy or radiation treatment; or

c. the extraction is performed as part of a work-up for a major organ transplant and a donor organ is not available within the six (6) month period.

G. The allowances listed in the Oral Surgery Section of Chapter III of this Section provide payment for the following:

1. pre-operative visits in the hospital;

2. surgery;

3. follow-up care, for thirty (30) days following surgery regardless of treatment setting.

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Exception: The allowances for diagnostic procedures (e.g., biopsy) include the procedure and the follow-up care related to recovery from the procedure


itself. When an additional surgical procedure(s) is carried out within the thirty (30) day follow-up period for a previous surgery, the follow-up periods will continue concurrently to their normal terminations.

1. The Department allows concurrent services by multiple surgeons/dentists, when warranted in the following situations:

a. consultation;

b. medically necessary services provided prior to surgery, and/or following the surgery (management of a medical problem, monitoring during surgery, etc.); and

c. an allowance for a dentist as a surgical assistant will be made for major surgery at twenty percent (20%) of the surgical allowance. When billing for a surgical assistant, please use the most current Departmental billing instructions and include the name of the primary surgeon.

2. Orthognathic surgery is only reimbursable when done in conjunction with orthodontic treatment, or when the surgery is being performed to correct a post-traumatic or post-surgical disfigurement. Providers must include requests for orthognathic surgery in conjunction withorthodontic treatment in the prior authorization request for orthodontic services. If orthognathic surgery is anticipated it must be indicated on the treatment plan. Active orthodontic treatment must begin within twelve (12) months of prior authorization by the Department, and be performed in accordance with Subsection 25.03.

The Department does not cover orthognathic surgery for cosmetic purposes. All orthognathic surgery requires prior authorization. The Department covers orthognathic surgery for medically necessary indications such as:

a. Jaw and craniofacial deformities causing significant functional impairment for the following clinical indications:

(1) repair or correction of a congenital anomaly that is present at birth; or

(2) restoration and repair of function following treatment for a significant accidental injury, infection, or tumor.

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b. Anteroposterior, vertical, or transverse discrepancies or asymmetries that are two (2) or more standard deviations from published norms and that cause one (1) or more of the following documented functional conditions:

(1) difficulty swallowing and/or choking, or ability to chew only soft or liquid food for at least the last four (4) months; or

(2) speech abnormalities determined by a speech pathologist or therapist; or

(3) malnutrition related to the inability to masticate, documented significant weight loss over the last four (4) months and a low serum albumin related to malnutrition; or

(4) intra-oral trauma while chewing related to malocclusion; or

(5) significant obstructive sleep apnea not responsive to treatment.

c. Reimbursement is not available for orthognathic surgery after the member’s twenty-first (21st) birthday except for facial reconstruction following facial trauma that has resulted in facial disfigurement, pain, or malfunction.

d. Reimbursement is not available for model surgery or other pre-surgical treatment planning.

e. Reimbursement is separately available for necessary surgical stents and necessary pre- and post-surgical radiographs.

Documentation must include, but is not limited to study models with appropriate bite registration, intra-oral extra-oral photographs, panoral and cephalometric radiographs, theprovider’s usual and customary fees and any other pertinent information regarding the member’s condition.

3. Other Repair Procedures

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a. Osteotomy of maxilla covers the entire maxillary surgical procedure for the correction of a maxillary skeletal malocclusion. This service includes, but is not limited to,


the “LeFort Procedure” and any sectioning, advancement, retrusion, elevation, or other movement of the maxilla and its fixation. These procedures are mutually exclusive; that is, only one of these procedures can be used for a specific surgery. These procedures include a bilateral inferior turbinectomy, and/or septoplasty, if necessary.

b. Osteotomy of maxilla, including graft, covers the entire maxillary surgical procedure for the correction of a maxillary skeletal malocclusion. This service includes, but is not limited to, the “LeFort Procedure” and any sectioning, grafting, advancement, retrusion, elevation, or other movement of the maxilla and its fixation. This procedure includes a bilateral inferior turbinectomy, and/or septoplasty, if necessary.

c. Osteotomy of mandible covers the entire mandibular surgical procedure for the correction of a mandibular skeletal malocclusion. This procedure includes, but is not limited to, a bilateral sagital or oblique osteotomy, any necessary myotomies, necessary osteotomies of the inferior border of the mandible, coronoidotomies, and any sectioning, advancement, retrusion, elevation, or other movement of themandible and its fixation. A genioplasty procedure is included in this procedure only if it is done as a part of a larger orthognathic surgical procedure. A genioplasty procedure is a covered service only if it is done for functional reasons. These procedures are mutually exclusive, that is, only one of these procedures can be billed for a specific surgery.

d. Osteotomy of mandible including graft covers the entire mandibular surgical procedure for the correction of a mandibular skeletal malocclusion. This procedure includes, but is not limited to, a bilateral sagital or oblique osteotomy, any necessary myotomies, necessary osteotomies of the sectioning, grafting, advancement, retrusion, elevation, or other movement of the mandible and its fixation. A genioplasty procedure is included in this procedure only if it is done as a part of a larger orthognathic surgical procedure. A genioplasty procedure is a covered service only if it is done for functional reasons.

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25.03-8 Orthodontic Services are restricted to eligible members under age twenty-one (21) and requires prior approval.


A. Limited and Interceptive Orthodontics (not comprehensive)

1. Limited: According to the American Dental Association’s Current Dental Terminology publication (CDT-5), limited orthodontic services entails treatment with a limited objective, not involving the entire dentition. Providers may direct treatment only at the existing problem, or at only one (1) aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.

Examples of this would be treatment in one (1) arch only to correct crowding, partial treatment to open spaces or upright a tooth for a bridge or implant and partial treatment for closure of a space(s).

2. Interceptive: According to the American Dental Association’s Current Dental Terminology publication (CDT-5), interceptive orthodontic treatment is indicated for procedures to lessen the severity or future effects of a malformation, eliminate its cause, and may include localized tooth movement. Such treatment may occur in the primary or transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of isolated dental crossbite or recovery of recent minor space loss where overall space is adequate.

The Department considers successful interception to be intervention in the incipient stages of a developing problem to lessen the severity of the malformation and eliminate its cause. Complicating factors such as skeletal disharmonies, overall space deficiency, or other conditions may require future comprehensive therapy.

Both limited and interceptive orthodontics require prior authorization. Prior approval for interceptive orthodontics is not considered approval for comprehensive orthodontics in a two-phase plan. If a second phase is anticipated after treatment has begun,

submission of a completed Handicapping Labiolingual Deviation(HLD) Index Report (see Appendix II for copy of form) is mandatory. In the event that less than eighteen (18) months have elapsed between the last treatment of interceptive orthodontics and the commencement of an approved comprehensive plan, the reimbursement received for the interceptive plan will be deducted

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from the reimbursement for the comprehensive plan. In the event that eighteen (18) months or more have elapsed between the two approved plans, the provider will be reimbursed independently for the comprehensive treatment plan. Providers requesting approval for comprehensive orthodontics after a period of interceptive treatment


should indicate the last date of active interceptive treatment on the HLD Index Report.

3. Prior approval for limited and interceptive orthodontics does not require the submission of an HLD Index Report, however, requests

must include:

a. a description of the problem;

b. a description of the appliance;

c. a treatment plan for this problem including the number of treatments and total visits;

d. the provider’s usual and customary fee;

e. the submission of models; and

f. panoramic films (upon Department request only).

4. Reimbursement for limited and interceptive orthodontics:

a. Reimbursement is available for fixed or removable appliance therapy and is based on the type of appliance and treatment plan up to the maximum allowance.

The one-time reimbursement for both limited and interceptive orthodontics includes the appliance, the placement of the appliance, all active treatment visits, and all the follow-up visits even if the member becomes ineligible or reaches age twenty-one (21). The Department does not allow additional or separate reimbursement for this procedure.

b. When a retainer is lost or broken beyond repair, by a member who is still within an approved retention phase of a limited orthodontic treatment, the Department will reimburse the provider the adjusted acquisition cost of the appliance and an additional fee to cover the cost of the impression and bite registration materials.

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c. A provider who normally utilizes an “in house” laboratory for the fabrication of custom-made appliances may submit a statement of the cost of the appliance in lieu of the laboratory invoice noted above. The Department shall reimburse such providers in accordance with the prices of established orthodontic laboratories.

B. Comprehensive Orthodontics

Comprehensive orthodontics is a covered service only after the Department has granted prior approval. A condition must be extreme, and if left untreated, would become an acute dental problem and/or cause irreversible damage to the teeth or supporting structures. The MaineCare Handicapping

Labiolingual Deviation (HLD) Index Report (Appendix II) is to be utilized by dentists to determine the extent of the malocclusion.

1. Orthodontic Consultation/Evaluation

a. When an eligible member is determined to possess a malocclusion, the attending dentist must fill in the HLD Index Report.

b. When a member scores less than twenty-six (26) points, the attending dentist must determine if there are other conditions present, such as clefts, occlusal interferences, functional jaw limitations, facial asymmetry, speech impairment, severe maxillary, mandibular, or bi-maxillary protrusion, or other physical deviations.

The attending dentist must also identify in his or her opinion, whether there are any indications of potential impairment of mood and/or conduct that may result from emotional distress related to the malocclusion. Such determination(s) must beindicated on the HLD Index Report. The Attending dentistmust submit the completed HLD report along with all other additional information listed in 25.03-8(B)(1)(d) of this section to the Department for a determination of malocclusion with additional number of deviations. The number and severity of these deviations will be considered

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when the determination of an extreme condition is made. Prior to making such determination, the Department may obtain additional information from other professionals and/or request that further evaluation is done.

If a question of impairment of mood and/or conduct as a result of emotional distress has been raised, the Department


shall ask an outside provider that specializes in this field whether impairment exists; what is its nature and severity;how, if at all, it relates to the malocclusion; and whether treatment of the malocclusion is likely to alleviate the impairment.

c. If no other conditions exist and the member scores less than twenty-six (26) points on the HLD Index Report, the

attending dentist must inform the member that he or she does not qualify for MaineCare coverage of orthodontic treatment. The HLD Index Report must be retained in the member’s dental record. The attending dentist may bill separately for the pre-orthodontic treatment visit (includes the completion of the HLD report) at this time.

d. Prior authorization will be expedited for those HLD Index Reports that meet the qualifying criteria and indicate the presence of cleft palate deformities, a deep impinging overbite, individual anterior teeth crossbite, severe traumatic deviations or an overjet greater than nine (9) millimeters. When a member scores twenty-six (26) or more points on the HLD report (or there are other conditions as noted above), the attending dentist must submit the following information for prior authorization:

(1) Handicapping Labiolingual Deviation Index Report;

(2) the diagnosis;

(3) a panoramic x-ray (when indicated) and cephalometric radiographs with a tracing (when orthognathic surgery is anticipated);

(4) diagnostic casts;

(5) the preparation of a written comprehensive orthodontic treatment plan including the appliances to be utilized, records, number of visits and the length of retention necessary;

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(6) information regarding possible orthognathic surgery;

(7) a list of any medical or dental treatment necessary to complete the orthodontic treatment (e.g., extractions, gingivectomy, or orthognathic surgery); and


(8) the provider’s usual and customary fees for the case.

The dentist must submit the above information and prior authorization request to:

MaineCare Prior Authorization UnitOffice of MaineCare Services11 State House StationAugusta, ME 04333-0011

e. The professional reviewer at the Office of MaineCare Services will examine the HLD Index Report for accuracy

and completeness. The professional reviewer will do one of the following:

(1) return the form to the dentist for additional information; or

(2) authorize the orthodontic services; or

(3) deny authorization for orthodontic services.

f. The dentist may request separate reimbursement, without prior approval, for each of the following: the pre-orthodontic treatment visit that includes the completion of the HLD Index Report, preparation of the diagnostic casts, panoramic films (if performed), treatment plan and records.

2. Comprehensive Orthodontic Treatment

MaineCare will approve orthodontic treatment for all eligible MaineCare members under age twenty-one (21) that meet the Departmental guidelines.

MaineCare enrolled orthodontic providers treating, or about to treat a child participating in the Division of Family Health, Children with Special Health Needs Program, must follow all requirements for orthodontic services described in this section of the MaineCare Benefits Manual for orthodontic treatment.

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a. Routine dental treatment such as cleaning and restorations are not part of an orthodontic treatment plan.

b. Prior authorization will be approved only for cases that have an adequate treatment plan that indicates a treatment sequence that will correct the malocclusion.


c. Members who are under active orthodontic treatment that started prior to the member’s date of eligibility for MaineCare, and subsequently became eligible for MaineCareDental Services under Chapter II, Section 25.02, and are less than twenty-one (21) years of age may have the completion of their orthodontic treatment covered by MaineCare. MaineCare will only cover the continued treatment if the member’s orthodontic records and pre-treatment models show that the member would have met the prior authorization criteria for the orthodontic examination and treatment.

d. Comprehensive orthodontic treatment must begin within twelve (12) months after approval by the Department.

Treatment will be considered to have begun with the extraction of teeth for orthodontic purposes, the placement of

a major orthodontic appliance, such as fixed orthodontic brackets, palatal expanders, or other functional appliances requiring active management. Once active orthodontic treatment has begun, an all-inclusive reimbursement fee will be made for the initial appliance, placing of the brackets, all treatment visits, one appliance repair or replacement, one retainer repair or replacement. Rebonding or recementing of a retainer is also considered a repair.

Once active orthodontic treatment has begun, the provider must continue to cover the orthodontic treatment even if the member becomes ineligible for MaineCare. The member must continue to meet the residency requirements in the MaineCare Eligibility Manual. If treatment is stopped or suspended or the patient moves or is dismissed from a practice, the provider must notify the Office of MaineCare Services. MaineCare will pro-rate, on a case by case basis, the amount the provider will be required to reimburse the Department based on the start date of the orthodontia treatment and the actual services and visits that have been completed.

3. Policies and Procedures

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a. Upon the receipt of authorization from the Department, the dentist will proceed to treat the orthodontic condition according to the plan, making necessary arrangements for such services as extractions. Orthodontic treatment, including the placement of the appliance, must be started within twelve (12) months of the date of the authorization of


that treatment. A new request for prior authorization must be submitted to the Department if treatment has not been started within twelve (12) months of the original authorization. No reimbursement is available for a second authorization. If the member, subsequent to the second request, becomes ineligible, an additional approval will not be granted.

b. Once treatment has begun, the provider may bill and receive an all-inclusive payment for the orthodontic services. This

all-inclusive payment includes the comprehensive orthodontic treatment (placement of appliances), all treatment visits, one appliance repair or replacement, one retainer repair or replacement. Rebonding or recementing of a retainer is also considered a repair. The provider must indicate in the member’s record the date of the first appliance and retainer repair or replacement. Subsequent repairs and replacements are separately billable and must be documented in the member’s record.

c. Reimbursement for de-banding for members currently receiving orthodontic care under an approved treatment plan is included in the all-inclusive payment for orthodontic services and is not separately reimbursable. Separate reimbursement is available for members under twenty-one (21) who are not currently receiving orthodontic care under an approved treatment plan. Reimbursement is available per dental arch.

d. Retainer checkups are part of the orthodontic package and reimbursement is included in the all-inclusive payment for orthodontia services.

e. Monitoring growth and development is not considered active treatment and, therefore, is not reimbursable.

f. The provider can obtain assistance with addressing the member’s non-compliance with the member’s treatment plan by contacting MaineCare’s Prevention, Health Promotion, and Optional Treatment Services for members under age

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twenty-one (21). A preventive care referral will then be made to the Department’s Nursing Division for assistance.

4. Records and Reports

The provider must maintain a specific record for each member including but not limited to: name, address, birth date, MaineCare ID


number, pertinent diagnostic information, radiographs, a current treatment plan, signed periodic progress reports, and documentation for dates of service.

a. Member’s records will be kept current and available to the Department as documentation of services included on claim forms. Records will be kept in accordance with the statute of limitations and pursuant to State and Federal rules and regulations.

b. The MaineCare Prior Authorization Unit will maintain a specific record for each member approved for orthodontic treatment that will include, but not be limited to: name, address, caretaker’s name, birth date, MaineCare ID number, program, referral to program, orthodontic reporting form, treatment plan, copies of bills, and all communications regarding the member.

c. Copies of pertinent correspondence will be sent toPrevention, Health Promotion, and Optional Treatment Services for members under age twenty-one (21) in order to facilitate their coordination of services with members.

5. Reimbursement Reimbursement for comprehensive orthodontics is not available after

the member’s twenty-first (21st) birthday unless treatment (placement of the brackets, extraction of teeth for orthodontic purposes or placement of orthodontic separators) has begun prior to the member’s twenty-first (21st) birthday and prior authorization was granted.

a. The all-inclusive fee covers: the acquisition and placement of major treatment appliances; the maintenance and

replacement of the parts of the appliances; all bands, brackets, arch wires, ligatures, elastics, headgear, and other mass manufactured parts of all appliances indicated in the treatment plan; all retention visits indicated in the treatment

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plan; the initial activation of appliances; instructions to the member; all necessary member records; all other associated

services and supplies, and all subsequent treatment visits. The all-inclusive reimbursement fee will be authorized in

reference to the approved treatment plan and in accordance with the overall diagnosis of the case.


b. In the event that fewer than eighteen (18) months have elapsed between the last treatment of interceptive orthodontics and the commencement of an approved comprehensive plan, then the reimbursement received for the interceptive plan will be deducted from the all-inclusive reimbursement for the comprehensive plan. In the event that eighteen (18) months or more have elapsed between the two (2) approved plans then the provider will be reimbursed independently for the comprehensive treatment plan.

c. Providers requesting approval for comprehensive orthodontics after a period of interceptive treatment should

indicate the last date of active treatment on the HLD Index Report.

d. Additional appliance allowances are reimbursable only for custom laboratory fabricated, fixed, functional appliances that were approved as part of the treatment plan.

(1) The Department will reimburse the provider the adjusted acquisition cost of the appliance and an additional fee to cover the cost of the impression and bite registration materials. The provider must request reimbursement on the standard Departmental form, and submit with that request, the original laboratory invoice, or a legible photocopy, for the fabrication of the custom fixed, functional appliance.

(2) The provider is responsible for the first repair or

replacement when a retainer is lost or broken by a member who is still within an approved retention phase of orthodontic treatment. The Department will reimburse the provider the adjusted acquisition cost of the replacement and an additional fee to cover the cost of the impression and bite registration materials for subsequent replacements.

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The provider must request reimbursement on the standard Departmental form and submit with that request the original laboratory invoice, or a legiblephotocopy for the fabrication of the replacement retainer.

The laboratory invoice for the fabrication of the custom fixed, functional appliance or the fabrication

of the replacement retainer must include the following:


(a) the provider’s name;

(b) the member’s name;

(c) the name or a short description of the appliance constructed (retainer);

(d) the cost of fabrication of the appliance or retainer; and

(e) the date of the fabrication of the appliance or retainer.

A provider who normally utilizes an “in house” laboratory for the fabrication of custom-made appliances may submit a statement of the cost of the appliance fabrication in lieu of the laboratory invoice noted above. The Department shall reimburse such providers in accordance with the prices of established orthodontic laboratories.

25.03-9 Temporomandibular Joint Services (TMJ)

Temporomandibular joint services are available for eligible members under the age of twenty-one (21) or for members of any age residing in an ICF-MR. Adult members not residing in an ICF-MR and age twenty-one (21) or older are eligible only for selected procedures as indicated in Chapter II and III of this Section, most of which are available only under the adult dental care guidelines described in Subsection 25.04.

Temporomandibular joint (TMJ) treatment is reimbursable only by prior authorization. MaineCare reimbursement will be made only in severe symptomatic cases. Prior authorization must be requested for TMJ treatment for surgical or non-surgical intervention with the exception for manipulation under anesthesia and

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physical therapy. The request for prior authorization must be accompanied by a comprehensive treatment plan. For treatments involving surgical intervention, a copy of the written second opinion described in Section 25.03-9(B) below must also be submitted when requesting prior authorization.

A. Modes of non-surgical treatment include occlusal orthotic appliances, physical therapy referral, and therapeutic medication. Reimbursement forocclusal orthotic appliances include the fabrication, placement, and follow-up adjustments. The Department requires prior authorization.

B. Treatment which involves surgical intervention, requires that a provider submit a treatment plan that includes:


1. member history and documentation as to why non-surgical treatment was an unacceptable treatment option or, if already performed, did not achieve adequate results;

2. the submission of transcranial films in the open, closed, and rest position or the submission of MRI studies with pathology documented by a radiologist;

3. a plan of care for continued treatment (e.g., if follow-up care beyond the included thirty (30) days is required, number of visits, etc.);

4. the provider’s usual and customary charges; and

5. a written second opinion from a surgeon. The surgeon who submits the second opinion must not have a professional financial relationship with the surgeon requesting prior authorization. The second opinion must confirm that non-surgical treatment either is not an acceptable treatment option or, if already performed, did not achieve adequate results.

25.04 COVERED SERVICES FOR ADULTS

Adult services are intended for adult members, age twenty-one (21) or older, not residing in an ICF-MR, and include only those services that can be performed in compliance with this Subsection.

25.04-1 Adult Dental Care Covered Services

Adult dental care requirements provide for adults twenty-one (21) years of age or older limited to:

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A. Acute surgical care directly related to an accident where traumatic injury has occurred. This coverage will only be provided for the first three months after the accident;

B. Oral surgical and related medical procedures not involving the dentition and gingiva;

C. Extraction of teeth that are severely decayed and pose a serious threat of infection during a major surgical procedure of the cardiovascular system, the skeletal system or during radiation therapy for a malignant tumor;

D. Treatment necessary to relieve pain, eliminate infection or prevent imminent tooth loss; and

25.04 COVERED SERVICES FOR ADULTS (cont)

E. Other dental services, including full and partial dentures, medically necessary to correct or ameliorate an underlying medical condition, if the Department determines that the provision of those services will be cost-effective in comparison to the provision of other covered medical services for the treatment of that condition.

25.04-2 Standards of Treatment

Standards of treatment to relieve pain, eliminate infection or prevent imminent tooth loss requires the dentist to document one or more of the following in the member’s record:

A. documentation of the member’s acute tooth pain or acute infection;

B. supporting radiographs (if pertinent); or

C. documentation of any underlying medical condition that places the member at risk of imminent tooth loss; or

D. documentation of an accident where traumatic injury has occurred.

25.04-3 Other Adult Dental Services (Dentures)

Other adult dental services are only available for MaineCare members with qualifying medical conditions. The member’s physician or MaineCare enrolled primary care provider must supply current (within the last twelve (12) months), supporting documentation of medical necessity.

Documentation must be kept in the member’s file, submitted with a request for prior authorization if required, and made available upon request to the Department.

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To qualify for full dentures under A through D of this Section, a member must be edentulous. Requests for prior authorization will be considered for dentures or other appropriate dental services only if one or more of the following criteria are met:

A. Members with dysphagia, aspiration or other choking-risk conditions will qualify for dentures or other appropriate medically necessary dental care if:

1. the condition is not amenable to, or is not suitable for corrective surgery or medical treatment;

2. a swallowing study or speech therapy evaluation documenting the aspiration or choking risk is submitted; and

3. the treating physician, in consultation with the member’s dentist, states that their condition is most cost-effectively treated by dentures or other specified appropriate and medically necessary dental


services. An example would be a recurrent esophageal stricture, not responsive to endoscopic dilations with episodes of obstruction.

B. Members with the following medical conditions will qualify for dentures or other appropriate medically necessary dental care if the services are cost effective compared to other MaineCare covered services:

1. Members who have an underlying medical condition, e.g. uncontrolled diabetes mellitus. The Department requires current documentation to substantiate that uncontrolled diabetes may be appropriately treated adjunctively with the use of dentures. Documentation must include all of the following:

a. HgbA1c of > eight percent (8%) on at least two (2) occasions at least six (6) months apart;

b. documentation of at least two (2) dietary counseling sessions with a dietician regarding an edentulous diet; and

c. participation in an ADEF (Ambulatory Diabetes Education and Follow-up) program within the last year, or between the two (2) HgbA1c measurements.

2. Members with a medical condition causing documented, inappropriate weight loss of greater than ten percent (10%) of body weight within the last twelve (12) months or less that will be corrected or improved by the provision of medically necessary dental services, including full and partial dentures. Gastro-esophageal reflux disease (GERD), being overweight, morbidly obese, or being at risk for coronary artery disease are examples of diagnoses that do

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not, alone, substantiate the medical necessity for dentures. Treating these conditions with dentures has not been shown to be a more effective treatment than other means.

The Department may require a trial period of other cost effective means before dentures are approved for treatment of an underlying medical condition.

C. Members whose behavior secondary to dental pain or the psychological complications of being edentulous are causing current, severe medical or psychiatric complications, (e.g. debilitating psychiatric illness or physical harm), as documented by a licensed psychologist or psychiatrist, would qualify for necessary dental services under this Subsection.

D. The Department may waive the criterion of being edentulous in cases where extenuating medical circumstances exist. These circumstances must clearly


substantiate the medical necessity that immediate placement of dentures isnecessary for the member’s health due to a serious medical condition. Examples of this may be a member who is scheduled to have organ transplant surgery, chemotherapy in the near future, has had extreme (>20%) weight loss within the last twelve (12) months or less and has an underlying medical condition such as advanced HIV disease or uncontrolled Crohn’s disease.

E. Members with dentures who require replacement dentures and whose dentures are medically necessary to correct or ameliorate an underlying medical condition, and for whom the Department determines that the provision of those dentures will be cost effective in comparison to the provision of other covered medical services for the treatment of that condition.

25.05 NON-COVERED SERVICES

A. The Department does not allow reimbursement for any member in an ICF-MR for orthodontics, orthognathic surgery, or repair of cleft palate procedures except in those cases where said treatment is being performed to correct a post-traumatic or post-surgical disfigurement, or in those cases where these services are a continuation of ongoing treatment started before age twenty-one (21).

The Department does not allow reimbursement for any member age twenty-one (21) or older for orthodontics, orthognathic surgery, or repair of cleft palate procedures except in those cases where said treatment is being performed to correct a post-traumatic or post-surgical disfigurement, or in those cases where these services are acontinuation of ongoing treatment started before age twenty-one (21), or when these services meet the criteria in Special Requirements for Adult Services, 25-04-2 (B).

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B. The Department does not allow reimbursement for missed appointments by the member. In addition, the member cannot be billed for a missed appointment even if the member was notified in advance there would be a charge.

C. Refer to the MaineCare Benefits Manual, Chapter I and the MaineCare Benefits Manual, Section 25, Dental Services, Chapter III for additional listings of non-covered services.

25.06 POLICIES AND PROCEDURES

25.06-1 Member’s Records

A. The Department requires all providers to retain records that reflect all services billed for members, including current documentation of medical necessity, for a minimum of five (5) years and as required by Chapter I of this Manual. Dentists must maintain an office dental record for each

25.06 POLICIES AND PROCEDURES (cont.)

member. In group practices, partnerships, and other shared practices, one record is to be kept with chronological entries by specific dentists or hygienists rendering services.

1. The record is to include the essential details of the member’s health condition and of each service provided. All entries must be signed, dated, and legible.

2. The dental records corresponding to all services billed to the Department must include, but shall not be limited to:

a. member’s name and date of birth;

b. medical history;

c. pertinent findings on examination;

d. all radiographs and the date on which they were taken;

e. diagnosis of existing conditions;

f. written treatment plan including all treatment necessary;

g. date of each service;

h. name of person performing the service if it is other than the billing dentist;

i. description of all treatment;

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j. recommendations for additional treatment or consultations;

k. medications administered or prescribed;

l. supplies dispensed or prescribed; and

m. tests prescribed and results.

B. Member records and any other files pertaining to services provided through this policy and reimbursed by MaineCare shall be available for review by the

Division of Program Integrity.

25.06-2 The Division of Program Integrity

Please refer to Chapter I of the MaineCare Benefits Manual for the Division of Program Integrity requirements.


25.06-3 Prior Authorization of Dental Services

Prior Authorization requirements for certain services are identified in Chapter III of this Section, Allowances for Dental Services. The Department will not reimburse a provider for a specific service requiring prior authorization (PA) unless the provider has requested PA prior to performing the service. However, if there are documented emergency circumstances that make the request for prior authorization impossible, reimbursement may be granted.

Providers must submit prior authorization requests for dental services (other than orthodontics) on the dental claim form. The dental chart must be completed to show the entire proposed treatment plan and the original radiographs (properly mounted) must be attached to the form. The appropriate box at the top of the form must be checked and the provider’s usual and customary charges included.

A. Requests for prior authorization should be sent to:

MaineCare Prior Authorization UnitOffice of MaineCare Services11 State House StationAugusta, ME 04333-0011

B. Approved requests for prior authorization will be returned to the provider with a prior authorization number. This number must be included in the appropriate field on the claim form when requesting reimbursement.

C. A professional reviewer or other qualified staff will be available during regular working hours to discuss extraordinary circumstances, that might require expedited review for prior authorization.

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D. Authorizations are granted based on the member’s eligibility, age, and program. Radiographs submitted in support of a request for prior authorization will be returned. Although prior authorization may have been granted, the provider is responsible for checking the member’s MaineCare eligibility prior to the provision of services.

25.06-4 Case Management

Dental providers are responsible for case management coordination activities that lead to better oral health for members. Such activities may include, but are not limited to, sending appointment reminder notices, calling members prior to appointments, referring members to specialists or other health care providers as appropriate, and reporting member non-compliance with the treatment plan. The provider may also request member education and/or report significant missed appointments by using MaineCare Member Services’ “Member Education Request Form” as needed.


25.06-5 Qualified Professional Staff

The Department requires all professional staff to be conditionally, temporarily, or fully licensed as documented by written evidence from the appropriate governing body. All professional staff must provide services only to the extent permitted by Qualified Professional Staff licensure and this Section of the MaineCare Benefits Manual. Services provided by the following staff are reimbursable under this Section.

A. Licensed Dentist: Any person currently licensed by the Maine State Board of Dental Examiners as a Dentist as documented by written evidence from such board or licensed in accordance with the licensure of the state or province in which services are provided.

B. Dental Hygienist: Any person currently licensed by the Maine State Board of Dental Examiners as a Dental Hygienist as documented by written evidence from such board or licensed in accordance with the licensure of the state or province in which services are provided. Hygienists performing services under public health supervision, including those funded by the Maine Center for Disease Control and Prevention’s Oral Health Program, or supervising hygienist’s services at a school of dental hygiene must be enrolled as MaineCare servicing providers. The Department does not require dental hygienists performing services in a private dental office to enroll as servicing providers.

C. Denturist: Any person currently licensed by the Maine State Board of Dental Examiners as a Denturist as documented by written evidence fromsuch board or licensed in accordance with the licensure of the state or province in which services are provided.

34


CHAPTER II


25.07 REIMBURSEMENT

25.07-1 Other Resources

In accordance with Chapter I of the MaineCare Benefits Manual, it is the responsibility of the provider to seek payment from any other resources that are available for payment of the rendered service prior to billing MaineCare.

25.07-2 Maximum Allowances

The amount of payment for services rendered shall be the lowest of the following:

A. the amount listed in Chapter III, Section 25, “Allowances for Dental Services;”

25.07 REIMBURSEMENT (cont.)

B. the lowest amount allowed by Medicare; or

C. the provider’s usual and customary charge.

25.07-3 Compliance Procedures

Infection control, O.S.H.A. requirements and other compliance procedures are considered provider standards of care and are not billable to the member or separately reimbursable by MaineCare.

25.07-4 Denturist Services

In accordance with requirements of this Subsection and Subsection 25.03-6, denturist services shall be reimbursed to licensed denturists enrolled as MaineCare providers for services provided to members eligible for full dentures. Only the services related to providing full dentures will be reimbursed to denturists, using the appropriate codes (identified in the limits column) in Chapter III, Section 25 of the MaineCare Benefits Manual. These related services include making, producing, reproducing, construction, finishing,supplying, altering, or repairing of a complete upper and/or complete lower prosthetic denture.

25.07-5 Hygienist Services

Hygienist services shall be reimbursed to entities enrolled as MaineCare providers employing or sponsoring licensed hygienists providing hygienist services allowed under this Section and under Public Health Supervision. Services reimbursable forhygienists working under Public Health Supervision, dental hygiene schools and the Oral Health Program are designated in Chapter III, Section 25 of this Manual. These

35


CHAPTER II


services include: prophylaxis, fluoride treatments, oral hygiene instructions and sealants. MaineCare requires entities enrolling as providers to submit documentation of satisfying the requirements for Public Health Supervision status. All hygienists enrolled under Public Health Supervision status must enroll as MaineCare servicing providers with proof of licensure. The Department will reimburse schools of dental hygiene enrolled as MaineCare providers employing supervising, licensed hygienists and providing hygienist services allowed under this Section. The supervising hygienists must be enrolled as MaineCare servicing providers.

Hygienist Services shall be reimbursed to the Maine Center for Disease Control and Prevention, Oral Health Program, enrolled as a MaineCare provider performing hygienist services through its public health, school-based and/or school-linked programs. Hygienists performing these services must enroll as MaineCare servicing providers under the Maine Center for Disease Control and Prevention, Oral Health Program, with proof of licensure, and documentation of meeting the requirements for Public Health Supervision status.

25.08 BILLING INSTRUCTIONS

Billing must be accomplished in accordance with the Department’s current billing instructions. Billing instructions are available upon request or from the Department’s website at:

http://www.maine.gov/dhhs/bms/rules/provider_mcare_benefit.htm.

36

APPENDIX I

MAINECARE HANDICAPPING LABIOLINGUAL DEVIATION INDEX SCORING INSTRUCTIONS

The intent of the Handicapping Labiolingual Deviation (HLD) Index is to measure the presence or absence and the degree of the handicap caused by the components of the Index and not to diagnose “malocclusion.” All measurements are made with a BoleyGauge (or a disposable ruler) scaled in millimeters. Absence of any conditions must be recorded by entering “0” (refer to attached score sheet).

The following information helps to clarify the categories on the HLD Index Report:

Cleft Palate Deformities: Indicate an “X” on the score sheet and do not score any further if present. This condition is considered to be a handicapping malocclusion.

Deep Impinging Overbite: Indicate an “X” on the score sheet when lower incisors are destroying the soft tissue of the palate and do not score any further. This condition is considered to be a handicapping malocclusion.

Individual Anterior Teeth Crossbite: Indicate an “X” on the score sheet when destruction of soft tissue is present and do not score any further. This condition is considered to be a handicapping malocclusion.

Severe Traumatic Deviations: Traumatic deviations include loss of a premaxilla segment by burns or by accident, the result of osteomyelitis or other gross pathology. Indicate with an “X” on the score sheet, attach documentation of condition, and do not score any further. This condition is considered to be a handicapping malocclusion.

Overjet Greater than 9 mm: If the overjet is greater than 9 mm with incompetent lips or the reverse overjet (mandibular protrusion) is greater than 3.5 mm with reported masticatory and speech difficulties, indicate an “X” and score no further. If the reverse overjet is not greater than 3.5 mm, score under the “Mandibular Protrusion in Millimeters” item.

Overjet in Millimeters: This is recorded with the member’s teeth in centric occlusion and measured from the labial portion of the lower incisors to the labial of the upper incisors. The measurement may apply to a protruding single tooth as well as to the whole arch. Round this measurement to the nearest millimeter and enter on the score sheet.

Overbite in Millimeters: A pencil mark on the tooth indicating the extent of overlap facilitates this measurement. Round off to the nearest millimeter and enter on the score sheet. “Reverse” overbite may exist in certain conditions and should be measured and recorded.

Mandibular Protrusion in Millimeters: Score exactly as measured from the labial of the lower incisor to the labial of the upper incisor. The measurement in millimeters is entered on the score sheet and multiplied by five (5). A reverse overbite, if present, should be shown under “overbite.”

Open Bite in Millimeters: This condition is defined as the absence of occlusal contact in the anterior region. It is measured from edge to edge in millimeters. Enter the measurement on the score sheet and multiply by four (4). In cases of pronounced protrusion associated with open bite, measurement of the open bite is not always possible. In those cases, a close approximation can usually be estimated.

Ectopic Eruption: Count each tooth, excluding third molars. Enter the number of teeth on the score sheet and multiply by three (3). If anterior crowding is present with an ectopic eruption in the anterior portion of the mouth, score only the most severe condition. Do not score both conditions.

Anterior Crowding: Arch length insufficiency must exceed 3.5 mm. Mild rotations that may react favorably to stripping or mild expansion procedures are not to be scored as crowded. Enter five (5) points each for maxillary and mandibular anterior crowding. If ectopic eruption is also present in the anterior portion of the mouth, score the most severe condition. Do not score both conditions.

Labiolingual Spread: Use a Boley Gauge or a disposable ruler to determine the extent of deviation from a formal arch. Where there is only a protruded or lingually displaced anterior tooth, the measurement should be made from the incisal edge of that tooth to the normal arch line. Otherwise, the total distance between the most protruded tooth and the lingually displaced anterior tooth is measured. The labiolingual spread probably comes close to a measurement of overall deviation from what would have been a normal arch. In the event that multiple anterior crowding of teeth is observed, all deviations from the normal arch should be measured for labiolingual spread, but only the most severe individual measurement should be entered on the index.

Posterior Unilateral Crossbite: This condition involves two or more adjacent teeth, one of which must be a molar. The crossbite must be one in which the maxillary posterior teeth involved may be both palatal and completely buccal in relation to the mandibular posterior teeth. The presence of posterior unilateral crossbite is indicated by a score of four (4) on the score sheet.

iii

APPENDIX II

MaineCare - Handicapping Labiolingual Deviation (HLD) Index Report

Provider Name: ___________________________________ Provider MaineCare #:__________________________

Member Name: __________________ Member MaineCare ID #: __________ Member DOB: _________Has this member received ortho treatment previously? Yes No If yes, name of provider: ____________

If yes, was this member transferred from this previous provider? Yes___No Date of Last Tx, if known: _______________Instructions: (Assistance from a recorder/hygienist is recommended).

1. Position the member’s teeth in centric occlusion.2. Record all measurements in the order given and round to the nearest millimeter (mm).3. ENTER A SCORE OF “0” IF A CONDITION IS ABSENT,4. Enter the requested provider and member information above. Provider must sign and date at the bottom.

Condition HLD ScoreCleft palate deformities (Indicate an “X” if present and score no further).Deep impinging overbite WHEN LOWER INCISORS ARE DESTROYING THE SOFTTISSUE OF THE PALATE (Indicate an “X” if present and score no further).Individual anterior teeth crossbite WHEN DESTRUCTION OF SOFT TISSUE IS PRESENT (Indicate an “X” if present and score no further).Attach description of any severe traumatic deviations. For example, loss of a premaxillasegment by burns or by accident; the result of osteomyelitis; or other gross pathology.(Indicate an “X” if present and score no further).Overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mmwith reported masticatory/speech difficulties. (Indicate an “X” if present and score no further).Overjet in mm.Overbite in mm.Mandibular protrusion in mm. _____x 5 = _____Open bite in mm. _____x 4 = _____ If both anterior crowding and ectopic eruption are present in the anterior portion of the mouth, score only the most severe condition. Do not score both conditions.Ectopic eruption: Count each tooth, excluding 3rd molar. _____ x 3 =_____Anterior crowding: Score one point for MAXILLA, and/or one point for MANDIBLE; twopoints maximum for anterior crowding. _____ x 5 =_____

Labiolingual spread in mm.If the member has a posterior unilateral crossbite; involving two or more adjacent teeth,one of which is a molar, enter/score a “4” for this item.

TOTAL SCORE:

If a member does not score an HLD Index of 26 or above, are there other conditions such as impacted canines (include panoramic film), occlusal interferences, functional jaw limitations, facial asymmetry, speech impairment, or other physical deviations? If yes, please describe and include any supporting documentation.__________________________________________________________________________________________________Are there any indications of potential impairment of mood and/or conduct that may result from emotional distress related to the malocclusion? If yes, please describe and include any supporting documentation.__________________________________________________________________________________________________Provider Signature:________________________________________________ Date: __________________________

iii


CHAPTER IIISection 25 ALLOWANCES FOR DENTAL SERVICES Established: 6-29-79

Last Updated: 12-18-09

TABLE OF CONTENTS

Introduction................................................................................................................................................................................Page ii

Definitions..................................................................................................................................................................................Page ii

Modifiers....................................................................................................................................................................................Page iii

Elements of CDT Coding...........................................................................................................................................................Page iii

CDT DENTAL CODES

I. Diagnostic.........................................................................................................................................................................Page 1

II. Preventive.........................................................................................................................................................................Page 5

III. Restorative........................................................................................................................................................................Page 7

IV. Endodontics......................................................................................................................................................................Page 11

V. Periodontics......................................................................................................................................................................Page 14

VI. Prosthodontics, Removable..............................................................................................................................................Page 17

VII. Maxillofacial Prosthetics..................................................................................................................................................Page 21

VIII Implant Services……………………………………………………………………………………………………… Page 23

IX. Prosthodontics, Fixed.......................................................................................................................................................Page 25

X. Oral and Maxillofacial Surgery........................................................................................................................................Page 29

XI. Orthodontics.....................................................................................................................................................................Page 37

XII. Adjunctive General Services............................................................................................................................................Page 39

i




INTRODUCTION

Approximately once a year, the Centers for Medicare and Medicaid Services (CMS) issues to states a Healthcare Common Procedure Coding System Transaction List that includes additions to and deletions from this schedule of codes. Providers will be notified of all such additions and deletions through the regular mail, by a revised Allowances for Dental Services or by revised billing instructions.

Providers are requested to bill their usual and customary charge for all dental services.

In accordance with policy, the MaineCare Program will continue to pay the lowest of the following:

1. The fee established by MaineCare and noted in the “Maximum Allowance” column of the fee schedule;

2. The lowest amount allowed by Medicare; or

3. The provider's usual and customary charge.

DEFINITIONS

The following are definitions for several terms that are frequently used throughout this publication.

By Report: This notation in the Maximum Allowances column indicates that the fee for the procedure is to be determined based upon an operative report. Such a procedure would be one that is rarely provided, unusual, variable, or newly developed. Pertinent information contained in the report, which must accompany the claim, should include an adequate definition or description of the nature, extent, need for the procedure, time, effort, and equipment necessary to provide the service. Additional information, such as complexity of the symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care may also be included. If there is a maximum amount listed, then reimbursement is not to exceed the maximum amount listed.

Consultation: Consultation is an opinion rendered by a dentist whose advice is requested by another dentist or physician for the further

ii




DEFINITIONS (cont.)

evaluation and/or management of the patient. When the consulting dentists assumes responsibility for the continuing care of the patient, any subsequent service rendered by him/her will cease to be a consultation. The Department requires a written report to be sent to the requesting practitioner.

Referral: A referral is the transfer of the total or specific care of a patient from one dentist to another and does not constitute a consultation.

MODIFIERS

For modifier usage, please see the most current dental billing instructions supplied by the Office of MaineCare Services.

ELEMENTS OF HCPCS/CDT CODING

Codes for services are arranged in tabular form. Specific information regarding each code is given under the following headings:

1. Procedure code: The actual CDT procedure code will be listed in this column.

2. CDT Description: The narrative description of the procedure code will be listed in this column.

3. Covered Service: This column identifies whether a particular service is covered under the MaineCare program, indicated by a "YES," or not covered, indicated by a "NO." It is further divided into two (2) sub columns indicating services for those under 21 and all ICF-MR residents (with the exception of orthodontics which is not covered for residents of an ICF-MR) and the second column, indicating coverage for adults 21 and over when allowed under Section 25, Dental Services, of the MaineCare Benefits Manual, Chapter II, 25.04, Special Requirements for Adult Services.

4. Prior Authorization Some procedures require authorization prior to the performance of a service in order for MaineCare toRequired: allow reimbursement. If prior authorization is required, it will be indicated by the message "YES" in these columns.

MaineCare will not reimburse a provider for a service that requires prior authorization if the service is provided

iii




ELEMENTS OF HCPCS/CDT CODING (cont.)

before authorization is granted. Again this column is subdivided into requirements for the same two populations as column 3.

5. Additional Limits: This column lists any additional limitations affecting reimbursement for services. Examples include reimbursement frequency or the passage of time required before further reimbursement. This column is intended to parallel restrictions also described in Section 25, Dental Services, of the MaineCare Benefits Manual, Chapter II. Codes also allowed for denturists and hygienists will be indicated in this column. If reimbursement is not available for a particular procedure "Not covered" will be listed in this column. MaineCare will not reimburse for non-covered services. Providers may bill members for non-covered services only if, prior to the provision of the service, the provider has clearly explained to the member that MaineCare does not cover the service and that the member will be responsible for the payment. Providers must document in the member’s record that the member was told, prior to provision, that the service was not a MaineCare covered service and that the member is responsible for the payment.

6. Maximum Allowance: This column will show the maximum reimbursement that MaineCare will allow for a particular procedure. MaineCare will pay the lowest of this allowance, or the dentist's/denturist’s usual and customary fee, or the lowest amount allowed by Medicare.

Some procedures are manually priced, or priced using a specific report for the service rendered. If a service is priced this way, the message "BY REPORT" will appear in the Maximum Allowance column. All BY REPORT codes suspend for a review, which interrupts the automatic claims processing and slows payment to the provider. A complete report must accompany any claim using a BY REPORT code. Please note that occasionally a description will include the term “by report.” Such a designation is part of the code description and does not indicate how MaineCare will reimburse the procedure.

Every effort should be made to utilize the correct code. Billing should be done in accordance with the CDT guidelines and Chapter II and Chapter III, Section 25.

iv


CHAPTER III

Section 25 ALLOWANCES FOR DENTAL SERVICES Established: 6-29-79 Last Updated: 11-1-07

Covered ServiceAge/ICF-MR

Prior Authorizationrequired

Proc.Code

Description under age 21 & all ICF-

MR residents*

age 21 & over when

allowed under 25.04

under age 21 & all ICF-MR residents

age 21 & over when

allowed under 25.04

Additional Limits MaxAllow

I. DIAGNOSTIC

CLINICAL ORAL EXAMINATIONS

D0120 Periodic Oral Evaluation YES NO NO One every six months $30.00D0140 Limited Oral Evaluation

(Problem Focused) YES YES NO NO Once per episode per provider.

Denturists may also use this code.$20.00

D0145 Oral Evaluation for a Patient Under Three Years of Ageand Counseling with Primary Caregiver

YES NO One every six months $20.00

D0150 Comprehensive Oral Evaluation YES NO NO Limited to once per general dentist, per member, in accordance with Section 25, Chapter II, Appendix III

$55.00

D0160 Detailed and Extensive Oral Evaluation - Problem Focused, by Report

YES NO NO $25.00

D0170 Re-evaluation – Limited, Problem Focused, (established patient, not post-operative visit)

YES NO NO $20.00

D0180 Comprehensive Periodontal Evaluation – New or Established Patient

NO NO Not Covered

RADIOGRAPHS/DIAGNOSTIC IMAGING (INCLUDING INTERPRETATION)

D0210 Intraoral - Complete Series, (including bitewings) YES YES NO NO Must include 12 periapical plus 2 posterior bitewings, allowed only once every 3 years, except as part of approved orthodontics

$43.50

1 Orthodontics are not covered services for residents of Intermediate Care Facilities for the Mentally Retarded. * MaineCare will cover all medically necessary dental services for members under age twenty-one (21) pursuant to Section 94 of the MaineCare Benefits Manual, Prevention, Health Promotion and Optional Treatment Services (formerly EPSDT).


CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04

under age 21 & all ICF-MR residents

age 21 & over when

allowed under 25.04


D0220 Intraoral - Periapical, First Film YES YES NO NO $8.00D0230 Intraoral - Periapical, Each Additional Film YES YES NO NO $6.50D0240 Intraoral - Occlusal Film YES YES NO NO $10.00D0250 Extraoral - First Film YES YES NO NO $9.00D0260 Extraoral - Each Additional Film YES YES NO NO $9.00D0270 Bitewing - Single Film YES YES NO NO Posterior bitewings alone are

once per calendar year$8.00

D0272 Bitewings - Two Films YES YES NO NO Posterior bitewings alone are once per calendar year

$15.00

D0273 Bitewings - Three Films YES YES NO NO Posterior bitewings alone are once per calendar year

$17.50

D0274 Bitewings - Four Films YES YES NO NO Posterior bitewings alone are once per calendar year

$20.00

D0277 Vertical Bitewings – 7-8 Films YES YES NO NO $30.00D0290 Posterior-Anterior or Lateral Skull and Facial Bones,

Survey FilmYES YES NO NO $25.00

D0310 Sialography YES YES NO NO For gland or duct, not allowed for salivary stone

$30.00

D0320 Temporomandibular Joint Arthrogram, Including Injection YES YES NO NO Right and left trans-cranial films in open, closed, and rest required

$35.00

D0321 Other Temporomandibular Joint Films by Report YES YES YES YES $60.00D0322 Tomographic Survey NO NO Not Covered

D0330 Panoramic Film YES YES NO NO Billable with the Pre-Orthodontic visit.

$43.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04

under age 21 & all ICF-

MR residents

age 21 & over when

allowed under 25.04


D0340 Cephalometric Film NO NO Included as part of “records” in comprehensive orthodontics, not covered separately; hospitals use revenue codes to bill.

D0350 Oral/Facial Photographic Images NO NO Not CoveredD0360 Cone Beam Ct - Craniofacial Data Capture NO NO Not CoveredD0362 Cone Beam - Two-dimensional Image Reconstruction

Using Existing Data, Includes Multiple ImagesNO NO Not Covered

D0363 Cone Beam - Three-dimensional Image Reconstruction Using Existing Data, Includes Multiple Images

NO NO Not Covered

TEST AND EXAMINATIONS

D0415 Collection of Microorganisms for Culture and Sensitivity NO NO Not CoveredD0416 Viral Culture NO NO Not CoveredD0417 Collection and preparation of saliva sample NO NO Not CoveredD0418 Analysis of saliva sample NO NO Not CoveredD0421 Genetic Test for Susceptibility to Oral Diseases NO NO Not CoveredD0425 Caries Susceptibility Test NO NO Not CoveredD0431 Adjunctive Pre-diagnostic Test that Aids in Detection of

Mucosal Abnormalities including Premalignant and Malignant Lesions, not to include Cytology or Biopsy Procedures

NO NO Not Covered

D0460 Pulp Vitality Test YES YES NO NO Requires documentation in member's chart of the vitality of the tooth

$10.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D0470 Diagnostic Casts YES NO NO $32.00ORAL PATHOLOGY LABORATORY CODES

D0472 Accession of Tissue, Gross Examination, Preparation and Transmission of Written Report

NO NO Not Covered

D0473 Accession of Tissue, Gross and Microscopic Examination, Preparation and Transmission of Written Report

NO NO Not Covered

D0474 Accession of Tissue, Gross and Microscopic Examination, Including Assessment of Surgical Margins for Presence of Disease, Preparation and Transmission of Written Report

NO NO Not Covered

D0475 Decalcification Procedure NO NO Not CoveredD0476 Special Stains for Microorganisms NO NO Not CoveredD0477 Special Stains, not for Microorganisms NO NO Not CoveredD0478 Immunohistochemical Stains NO NO Not CoveredD0479 Tissue in-situ Hybridization, including Interpretation NO NO Not CoveredD0480 Accession of Exfoliative Cytologic Smears, Microscopic

Examination, Preparation and Transmission of Written Report

NO NO Not Covered

D0481 Electron Microscopy-Diagnostic NO NO Not CoveredD0482 Direct Immunofluorescence NO NO Not CoveredD0483 Indirect Immunofluorescence NO NO Not CoveredD0484 Consultation on Slides Prepared Elsewhere NO NO Not CoveredD0485 Consultation, Including Preparation of Slides from NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


Biopsy Material Supplied by Referring SourceD0486 Accession of Brush Biopsy Sample, Microscopic

Examination, Preparation and Transmission of Written Report

NO NO Not Covered

D0502 Other Oral Pathology Procedures, by Report NO NO Not CoveredD0999 Unspecified Diagnostic Procedure, by Report NO NO Not Covered

II. PREVENTIVE

DENTAL PROPHYLAXIS D1110 Prophylaxis – Adult YES YES NO YES Limited to age 13 and over,

more than once every six months requires Prior Authorization, includes oral hygiene instruction. Hygienists may use this code.

$40.00

D1120 Prophylaxis – Child YES NO NO More than once every six months requires Prior Authorization, includes oral hygiene instruction. Hygienists may use this code.

$30.00

TOPICAL FLUORIDE TREATMENTS (Office Procedure)

D1203 Topical Application of Fluoride - Child (prophylaxis not included)

YES NO NO Twice per calendar year/three per calendar year if high caries rate or new restorations within 18 months as documented in record. Includes through age 20.

$12.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


Hygienists may use this code.D1204 Topical Application of Fluoride - Adult (prophylaxis not

included)NO NO Not Covered

D1206 Topical Fluoride Varnish; Therapeutic Application for Moderate to High Caries Risk Patients

YES NO NO Twice per calendar year/three per calendar year if high caries rate or new restorations within 18 months as documented in record. Includes through age 20 Hygienists may use this code.

$12.00

OTHER PREVENTIVE SERVICES

D1310 Nutritional Counseling for Control of Dental Disease NO NO Not CoveredD1320 Tobacco Counseling for the Control and Prevention of

Oral DiseaseYES NO NO Limited to age 8 – 20, once per

year, per member, per general dentist

$20.00

D1330 Oral Hygiene Instructions YES NO NO Three times per calendar year. Not billable the same day as prophylaxis. Hygienists may use this code.

$13.00

D1351 Sealant – Per Tooth YES NO NO Permanent teeth: once every three calendar years per provider per tooth. Primary teeth: once per lifetime of tooth unless documented good cause. Hygienists may use this code.

$16.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


SPACE MAINTENANCE (PASSIVE APPLIANCES)

D1510 Space Maintainer, Fixed Unilateral YES NO NO $95.00D1515 Space Maintainer, Fixed Bilateral YES NO NO $220.00D1520 Space Maintainer, Removable Unilateral NO NO Not CoveredD1525 Space Maintainer, Removable Bilateral YES NO NO $110.00D1550 Re-cementation of Space Maintainer YES NO NO $22.50D1555 Removal of Fixed Space Maintainer YES NO NO $50.00

III. RESTORATIVE

AMALGAM RESTORATIONS (INCLUDING POLISHING)

D2140 Amalgam - One Surfaces, Primary or Permanent YES YES NO NO $38.00D2150 Amalgam - Two Surfaces, Primary or Permanent YES YES NO NO $48.00D2160 Amalgam - Three Surfaces, Primary or Permanent YES YES NO NO $81.00D2161 Amalgam - Four or More Surfaces, Primary or

PermanentYES YES NO NO $97.00

RESIN-BASED COMPOSITE RESTORATIONS – DIRECT



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D2330 Resin-Based Composite - One Surface, Anterior YES YES NO NO $68.00D2331 Resin-Based Composite - Two Surfaces, Anterior YES YES NO NO $91.00D2332 Resin-Based Composite - Three Surfaces, Anterior YES YES NO NO $109.00D2335 Resin-Based Composite, - Four or More Surfaces or

Involving Incisal Angle (Anterior)YES YES NO NO $111.00

D2390 Resin-Based Composite Crown, Anterior YES YES NO NO $300.00D2391 Resin-Based Composite – One Surface, Posterior YES YES NO NO $68.00D2392 Resin-Based Composite – Two Surfaces, Posterior YES YES NO NO $90.00D2393 Resin-Based Composite – Three Surfaces, Posterior YES YES NO NO $103.00D2394 Resin-Based Composite – Four or More Surfaces,

PosteriorYES YES NO NO $111.00

GOLD FOIL RESTORATIONS

D2410 Gold Foil - One Surface NO NO Not CoveredD2420 Gold Foil - Two Surfaces NO NO Not CoveredD2430 Gold Foil - Three Surfaces NO NO Not Covered

INLAY/ONLAY RESTORATIONS

D2510 Inlay - Metallic-One Surface NO NO Not CoveredD2520 Inlay - Metallic-Two Surfaces NO NO Not CoveredD2530 Inlay - Metallic-Three or More Surfaces NO NO Not CoveredD2542 Onlay - Metallic-Two Surfaces NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D2543 Onlay - Metallic – Three Surfaces NO NO Not CoveredD2544 Onlay - Metallic - Four or More Surfaces NO NO Not CoveredD2610 Inlay - Porcelain/Ceramic - One Surface NO NO Not CoveredD2620 Inlay - Porcelain/Ceramic - Two Surfaces NO NO Not CoveredD2630 Inlay - Porcelain/Ceramic - Three or More Surfaces NO NO Not CoveredD2642 Onlay - Porcelain/Ceramic - Two Surfaces NO NO Not CoveredD2643 Onlay - Porcelain/Ceramic - Three Surfaces NO NO Not CoveredD2644 Onlay - Porcelain/Ceramic - Four or More Surfaces NO NO Not CoveredD2650 Inlay - Resin-Based Composite - One Surface NO NO Not CoveredD2651 Inlay - Resin-Based Composite - Two Surfaces NO NO Not CoveredD2652 Inlay - Resin-Based Composite - Three or More

SurfacesNO NO Not Covered

D2662 Onlay - Resin-Based Composite - Two Surfaces NO NO Not CoveredD2663 Onlay - Resin-Based Composite - Three Surfaces NO NO Not CoveredD2664 Onlay - Resin-Based Composite - Four or More


CROWNS - SINGLE RESTORATIONS ONLY

D2710 Crown - Resin Based Composite (indirect) YES YES NO NO $300.00

D2712 Crown-3/4 Resin-Based Composite (indirect) NO NO Not Covered

D2720 Crown - Resin with High Noble Metal NO NO Not CoveredD2721 Crown - Resin with Predominantly Base Metal NO NO Not CoveredD2722 Crown - Resin with Noble Metal NO NO Not CoveredD2740 Crown – Porcelain/Ceramic Substrate NO NO Not CoveredD2750 Crown – Porcelain Fused to High Noble Metal NO NO Not CoveredD2751 Crown - Porcelain Fused to Predominantly Base Metal NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D2752 Crown – Porcelain Fused to Noble Metal NO NO Not CoveredD2780 Crown - 3/4 Cast High Noble Metal NO NO Not CoveredD2781 Crown-3/4 Cast Predominantly Base Metal NO NO Not CoveredD2782 Crown - 3/4 Cast Noble Metal NO NO Not CoveredD2783 Crown - 3/4 Porcelain/Ceramic NO NO Not CoveredD2790 Crown - Full Cast High Noble Metal NO NO Not CoveredD2791 Crown - Full Cast Predominantly Base Metal NO NO Not CoveredD2792 Crown - Full Cast Noble Metal NO NO Not CoveredD2794 Crown - Titanium NO NO Not CoveredD2799 Provisional Crown NO NO Not Covered

OTHER RESTORATIVE SERVICES

D2910 Recement Inlay, Onlay, or Partial Coverage Restoration NO NO Not CoveredD2915 Recement Cast or Prefabricated Post and Core YES YES NO NO $30.00D2920 Recement Crown YES YES NO NO $30.00 D2930 Prefabricated Stainless Steel Crown - Primary Tooth YES NO NO $120.00D2931 Prefabricated Stainless Steel Crown - Permanent Tooth YES YES NO NO $120.00D2932 Prefabricated Resin Crown YES YES NO NO Limited to Primary and

Permanent Anteriors $120.00

D2933 Prefabricated Stainless Steel Crown with Resin Window NO NO Not CoveredD2934 Prefabricated Esthetic Coated Stainless Steel Crown –

Primary ToothNO NO Not Covered

D2940 Sedative Filling YES YES NO NO Not covered with Pulpotomy. Limited to general dentists.

$30.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D2950 Core Buildup, Including Any Pins YES YES NO NO $150.00

D2951 Pin Retention - Per Tooth, in Addition to Restoration YES YES NO NO $19.00D2952 Post & Core in Addition to Crown, Indirectly Fabricated NO NO Not CoveredD2953 Each Additional Indirectly Fabricated Post - Same

ToothNO NO Not Covered

D2954 Prefabricated Post & Core in Addition to Crown YES YES NO NO Permanent tooth only $95.00D2955 Post Removal (Not in conjunction with endodontic

therapy)NO NO Not Covered

D2957 Each Additional Prefabricated Post-Same Tooth, Use with D2954

YES YES NO NO Permanent tooth only $47.50

D2960 Labial Veneer (resin laminate)-Chairside NO NO Not CoveredD2961 Labial Veneer (resin laminate)-Laboratory NO NO Not CoveredD2962 Labial Veneer (porcelain laminate)-Laboratory NO NO Not CoveredD2970 Temporary Crown (Fractured Tooth) YES YES NO NO $40.00D2971 Additional Procedures to Construct New Crown under

Existing Partial Denture FrameworkNO NO Not Covered

D2975 Coping NO NO Not CoveredD2980 Crown Repair, by Report YES YES NO NO $34.00D2999 Unspecified Restorative Procedure, by Report YES YES YES YES Ex: Temp. crown – fractured

toothBy Report

IV. ENDODONTICS PULP CAPPING

D3110 Pulp Cap - Direct (excluding final restoration) YES YES NO NO Not covered on primary teeth with more than 2/3 of root structure reabsorbed

$7.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D3120 Pulp Cap – Indirect (excluding final restoration) YES YES NO NO $19.00

PULPOTOMY

D3220 Therapeutic Pulpotomy (excluding final restoration) – Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament

YES YES NO NO Not separately reimbursable to same provider as part of root canal in same period of treatment

$50.00

D3221 Pulpal Debridement, Primary and Permanent Teeth NO NO Not CoveredD3222 Partial pulpotomy for apexogenesis-permanent tooth

with incomplete root developmentYES YES Not separately reimbursable to

same provider as part of root canal in same period of treatment

$50.00

ENDODONTIC THERAPY ON PRIMARY TEETH

D3230 Pulpal Therapy (resorbable filling) - Anterior, Primary Tooth (excluding final restoration)

NO NO Not Covered

D3240 Pulpal Therapy (resorbable filling) - Posterior, Primary Tooth (excluding final restoration)

NO NO Not Covered

ENDODONTIC THERAPY (INCLUDING TREATMENT PLAN, CLINICAL PROCEDURES AND FOLLOW-UP CARE)

D3310 Anterior (excluding final restoration) YES YES NO NO Only on permanent teeth with favorable prognosis for dentition

$220.00

D3320 Bicuspid (excluding final restoration) YES YES NO NO $251.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D3330 Molar (excluding final restoration) YES YES NO NO $338.00D3331 Treatment of Root Canal Obstruction; Non-Surgical

AccessNO NO Not Covered

D3332 Incomplete Endodontic Therapy; Inoperable, unrestorable or Fractured Tooth

NO NO Not Covered

D3333 Internal Root Repair of Perforation Defects NO NO Not Covered

ENDODONTIC RETREATMENT

D3346 Retreatment of Previous Root Canal Therapy – Anterior YES YES NO NO $220.00D3347 Retreatment of Previous Root Canal Therapy – Bicuspid YES YES NO NO $240.00D3348 Retreatment of Previous Root Canal Therapy – Molar YES YES NO NO $320.00

APEXIFICATION/RECALCIFICATION PROCEDURES

D3351 Apexification/Recalcification-Initial Visit (apical closure/calcific repair of perforations, root resorption, etc.)

YES YES NO NO $56.00

D3352 Apexification/Recalcification-Interim Medication Replacement (apical closure/calcific repair of perforations, root resorption, etc.)


D3353 Apexification/Recalcification-Final Visit (includes completed root canal therapy-apical closure/calcific repair of perforations, root resorption, etc.)




CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


APICOECTOMY/PERIRADICULAR SERVICES

D3410 Apicoectomy/Periradicular Surgery - Anterior YES YES NO NO $170.00D3421 Apicoectomy/Periradicular Surgery - Bicuspid (first

root)NO NO Not Covered

D3425 Apicoectomy/Periradicular Surgery – Molar (first root) NO NO Not CoveredD3426 Apicoectomy/Periradicular Surgery (each additional

root)NO NO NO NO Not Covered

D3430 Retrograde Filling – Per Root YES YES NO NO $43.00D3450 Root Amputation - Per Root NO NO Not CoveredD3460 Endodontic Endosseous Implant NO NO Not CoveredD3470 Intentional Reimplantation (including necessary

splinting)NO NO Not Covered

OTHER ENDODONTIC PROCEDURES

D3910 Surgical Procedure for Isolation of Tooth with Rubber Dam

NO NO Not Covered

D3920 Hemisection (including any root removal), Not Including Root Canal Therapy

NO NO Not Covered

D3950 Canal Preparation and Fitting or Preformed Dowel or Post

NO NO Not Covered

D3999 Unspecified Endodontic Procedure, by Report YES YES YES YES By Report

V. PERIODONTICS

SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE CARE)



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D4210 Gingivectomy or Gingivoplasty – Four or More Con- tiguous Teeth or Bounded Teeth Spaces Per Quadrant

YES NO YES $162.00

D4211 Gingivectomy or Gingivoplasty – One to Three Teeth contiguous or bounded teeth spaces, Per Quadrant

YES NO YES $56.00

D4230 Anatomical Crown Exposure - Four or More Contiguous Teeth per Quadrant

NO NO Not Covered

D4231 Anatomical Crown Exposure - One to Three Teeth per Quadrant

NO NO Not Covered

D4240 Gingival Flap Procedure, Including Root Planing Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant

YES NO YES NO $250.00

D4241 Gingival Flap Procedure, Including Root Planing – One to Three Contiguous Teeth or Bounded Teeth Spaces Per Quadrant

YES NO YES NO $150.00

D4245 Apically Positioned Flap YES NO YES $162.00D4249 Clinical Crown Lengthening-Hard Tissue NO NO Not CoveredD4260 Osseous Surgery (including flap entry and closure) –

Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant

YES NO YES $280.00

D4261 Osseous Surgery (including flap entry and closure) – One to Three Contiguous Teeth or Bounded Teeth Spaces Per Quadrant

YES NO YES $140.00

D4263 Bone Replacement Graft - First Site in Quadrant YES NO YES $330.00D4264 Bone Replacement Graft - Each Additional Site in

QuadrantYES NO YES $66.00

D4265 Biologic Materials to Aid in Soft and Osseous Tissue Regeneration

NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D4266 Guided Tissue Regeneration – Resorbable Barrier, Per Site

NO NO Not Covered

D4267 Guided Tissue Regeneration – Nonresorbable Barrier, Per Site (includes membrane removal)

NO NO Not Covered

D4268 Surgical Revision Procedure, Per Tooth YES YES YES YES $200.00D4270 Pedicle Soft Tissue Graft Procedure YES NO YES $250.00D4271 Free Soft Tissue Graft Procedure (including donor site

surgery)YES NO YES $250.00

D4273 Subepithelial Connective Tissue Graft Procedures Per Tooth

NO NO Not Covered

D4274 Distal or Proximal Wedge Procedure (when not performed in conjunction with surgical procedures in the same anatomical area)

NO NO Not Covered

D4275 Soft Tissue Allograft NO NO Not CoveredD4276 Combined Connective Tissue and Double Pedicle Graft,

Per ToothNO NO Not Covered

NON-SURGICAL PERIODONTAL SERVICES

D4320 Provisional Splinting - Intracoronal NO NO Not CoveredD4321 Provisional Splinting – Extracoronal NO NO Not CoveredD4341 Periodontal Scaling and Root Planing – Four or More

Teeth Per QuadrantYES YES YES YES No PA required for diagnosis

code 101$40.00

D4342 Periodontal Scaling and Root Planing – One to Three Teeth, Per Quadrant

NO NO Not Covered

D4355 Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis

YES YES YES YES Once per year per provider. $100.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D4381 Localized Delivery of Antimicrobial Agents Via a Controlled Release Vehicle into Diseased Crevicular Tissue, Per Tooth, by Report

NO NO Not Covered

OTHER PERIODONTAL SERVICES

D4910 Periodontal Maintenance YES NO YES $39.00D4920 Unscheduled Dressing Change (by someone other than

treating dentist)YES NO NO $27.00

D4999 Unspecified Periodontal Procedure, by Report YES YES YES YES By Report

VI. PROSTHODONTICS, REMOVABLE

COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE)

D5110 Complete Denture - Maxillary YES YES YES YES Every 5 years, Denturists may also use this code

$393.00

D5120 Complete Denture - Mandibular YES YES YES YES Every 5 years, Denturists may also use this code

$393.00

D5130 Immediate Denture - Maxillary YES YES YES YES Every 5 years, Denturists may also use code

$423.00

D5140 Immediate Denture - Mandibular YES YES YES YES Every 5 years, Denturists may also use this code

$423.00

PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)

D5211 Maxillary Partial Denture-Resin Base (including any YES YES YES YES Every 5 years $280.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


conventional clasps, rests and teeth)D5212 Mandibular Partial Denture-Resin Base (including any

conventional clasps, rests and teeth)YES YES YES YES Every 5 years $280.00

D5213 Maxillary Partial Denture-Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)

YES YES YES YES Every 5 years $423.00

D5214 Mandibular Partial Denture-Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)

YES YES YES YES Every 5 years $423.00

D5225 Maxillary Partial Denture-Flexible Base (including any clasps, rests and teeth)

NO NO Not Covered

D5226 Mandibular Partial Denture-Flexible Base (including any clasps, rests and teeth)

NO NO Not Covered

D5281 Removable Unilateral Partial Denture - One Piece Case Metal (including clasps and teeth)

NO NO Not Covered

ADJUSTMENTS TO DENTURES

D5410 Adjust Complete Denture - Maxillary YES YES NO NO Denturists may also use this code

$26.00

D5411 Adjust Complete Denture - Mandibular YES YES NO NO Denturists may also use this code

$26.00

D5421 Adjust Partial Denture - Maxillary YES YES NO NO $25.00D5422 Adjust Partial Denture - Mandibular YES YES NO NO $25.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


REPAIRS TO COMPLETE DENTURES

D5510 Repair Broken Complete Denture Base YES YES NO NO Denturists may also use this code

$57.00

D5520 Replace Missing or Broken Teeth-Complete Denture (each tooth)

YES YES NO NO Denturists may also use this code

$50.00

REPAIRS TO PARTIAL DENTURES

D5610 Repair Resin Denture Base YES YES NO NO $56.00D5620 Repair Cast Framework YES YES NO NO $85.00D5630 Repair or Replace Broken Clasp YES YES NO NO $85.00D5640 Replace Broken Teeth - Per Tooth YES YES NO NO $50.00D5650 Add Tooth to Existing Partial Denture YES YES NO NO $55.00D5660 Add Clasp to Existing Partial Denture YES YES NO NO $65.00D5670 Replace All Teeth and Acrylic on Cast Metal

Framework (maxillary)NO NO Not Covered

D5671 Replace All Teeth and Acrylic on Cast Metal Framework (mandibular)

NO NO Not Covered

DENTURE REBASE PROCEDURES D5710 Rebase Complete Maxillary Denture YES YES NO NO Refer to Chapter II, 25.03.

Denturists may also use this code.

$150.00

D5711 Rebase Complete Mandibular Denture YES YES NO NO Refer to Chapter II, 25.03. Denturists may also use this code.

$150.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D5720 Rebase Maxillary Partial Denture YES YES NO NO Refer to Chapter II, 25.03. $150.00 D5721 Rebase Mandibular Partial Denture YES YES NO NO Refer to Chapter II, 25.03. $150.00

DENTURE RELINE PROCEDURES

D5730 Reline Complete Maxillary Denture (chairside) YES YES NO NO Refer to Chapter II, 25.03. Denturists may also use this code.

$78.00

D5731 Reline Complete Mandibular Denture (chairside) YES YES NO NO Refer to Chapter II, 25.03. Denturists may also use this code.

$78.00

D5740 Reline Maxillary Partial Denture (chairside) NO NO Not CoveredD5741 Reline Mandibular Partial Denture (chairside) NO NO Not CoveredD5750 Reline Complete Maxillary Denture (laboratory) YES YES NO NO Refer to Chapter II, 25.03.

Denturists may also use this code.

$150.00

D5751 Reline Complete Mandibular Denture (laboratory) YES YES NO NO Refer to Chapter II, 25.03. Denturists may also use this code.

$150.00

D5760 Reline Maxillary Partial Denture (laboratory) NO NO Not CoveredD5761 Reline Mandibular Partial Denture (laboratory) NO NO Not Covered

INTERIM PROSTHESIS



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D5810 Interim Complete Denture (maxillary) NO NO Not CoveredD5811 Interim Complete Denture (mandibular) NO NO Not CoveredD5820 Interim Partial Denture (maxillary) NO NO Not CoveredD5821 Interim Partial Denture (mandibular) NO NO Not Covered

OTHER REMOVABLE PROSTHETIC SERVICES

D5850 Tissue Conditioning, Maxillary NO NO Not CoveredD5851 Tissue Conditioning, Mandibular NO NO Not CoveredD5860 Overdenture – Complete, by Report YES NO YES $473.00D5861 Overdenture – Partial, by Report YES NO YES $473.00D5862 Precision Attachment, by Report NO NO Not CoveredD5867 Replacement of Replaceable Part of Semi-Precision or

Precision Attachment (male or female component)NO NO Not Covered

D5875 Modification of Removable Prosthesis Following Implant Surgery

NO NO Not Covered

D5899 Unspecified Removable Prosthodontic Procedure, by Report

NO NO Not Covered

VII. MAXILLOFACIAL PROSTHETICS

D5911 Facial Moulage (sectional) YES YES YES YES By ReportD5912 Facial Moulage (complete) YES YES YES YES By ReportD5913 Nasal Prosthesis YES YES YES YES By ReportD5914 Auricular Prosthesis YES YES YES YES By ReportD5915 Orbital Prosthesis YES YES YES YES By Report



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D5916 Ocular Prosthesis YES YES YES YES By ReportD5919 Facial Prosthesis YES YES YES YES By ReportD5922 Nasal Septal Prosthesis YES YES YES YES By ReportD5923 Ocular Prosthesis, Interim YES YES YES YES By ReportD5924 Cranial Prosthesis YES YES YES YES By ReportD5925 Facial Augmentation Implant Prosthesis YES YES YES YES By ReportD5926 Nasal Prosthesis, Replacement YES YES YES YES By ReportD5927 Auricular Prosthesis, Replacement YES YES YES YES By ReportD5928 Orbital Prosthesis, Replacement YES YES YES YES By ReportD5929 Facial Prosthesis, Replacement YES YES YES YES By ReportD5931 Obturator Prosthesis, Surgical YES YES NO NO $1,494.43D5932 Obturator Prosthesis, Definitive YES YES NO NO $1,693.82D5933 Obturator Prosthesis, Modification YES YES NO NO By ReportD5934 Mandibular Resection Prosthesis with Guide Flange YES YES YES YES By ReportD5935 Mandibular Resection Prosthesis without Guide Flange YES YES YES YES By ReportD5936 Obturator Prosthesis, Interim YES YES YES YES By ReportD5937 Trismus Appliance (not for TMD treatment) NO NO Not CoveredD5951 Feeding Aid YES YES NO NO $433.00D5952 Speech Aid Prosthesis, Pediatric YES NO NO By ReportD5953 Speech Aid Prosthesis, Adult YES YES YES YES By ReportD5954 Palatal Augmentation Prosthesis YES YES YES YES By ReportD5955 Palatal Lift Prosthesis, Definitive YES YES YES YES By ReportD5958 Palatal Lift Prosthesis, Interim YES YES YES YES By ReportD5959 Palatal Lift Prosthesis, Modification YES YES YES YES By ReportD5960 Speech Aid Prosthesis, Modification YES YES YES YES By ReportD5982 Surgical Stent YES YES YES YES $175.00D5983 Radiation Carrier YES YES YES YES By Report



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D5984 Radiation Shield YES YES YES YES By ReportD5985 Radiation Cone Locator YES YES YES YES By ReportD5986 Fluoride Gel Carrier YES YES YES YES By ReportD5987 Commissure Splint NO NO Not CoveredD5988 Surgical Splint NO NO Not CoveredD5991 Topical medicament carrier NO NO Not CoveredD5999 Unspecified Maxillofacial Prosthesis, by Report YES YES YES YES By Report

VIII. IMPLANT SERVICES

D6010 Surgical Placement of Implant Body: Endosteal Implant NO NO Not CoveredD6012 Surgical Placement of Interim Implant Body for

Transitional Prosthesis: Endosteal ImplantNO NO Not Covered

D6040 Surgical Placement: Eposteal Implant NO NO Not CoveredD6050 Surgical Placement: Transosteal Implant NO NO Not Covered

IMPLANT SUPPORTED PROSTHETICS

D6053 Implant/Abutment Supported Removable Denture for Completely Edentulous Arch

NO NO Not Covered

D6054 Implant/Abutment Supported Removable Denture for Partially Edentulous Arch

NO NO Not Covered

D6055 Dental Implant Supported Connecting Bar NO NO Not CoveredD6056 Prefabricated Abutment - Includes Placement NO NO Not CoveredD6057 Custom Abutment - Includes Placement NO NO Not CoveredD6058 Abutment Supported Porcelain/Ceramic Crown NO NO Not CoveredD6059 Abutment Supported Porcelain Fused to Metal Crown NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


(high noble metal)D6060 Abutment Supported Porcelain Fused to Metal Crown

(predominantly base mental)NO NO Not Covered

D6061 Abutment Supported Porcelain Fused to Metal Crown (noble metal)

NO NO Not Covered

D6062 Abutment Supported Cast Metal Crown (high noble metal)

NO NO Not Covered

D6063 Abutment Supported Cast Metal Crown (predominantly base metal)

NO NO Not Covered

D6064 Abutment Supported Cast Metal Crown (noble metal) NO NO Not CoveredD6065 Implant Supported Porcelain/Ceramic Crown NO NO Not CoveredD6066 Implant Supported Porcelain Fused to Metal Crown

(titanium, titanium alloy, high noble metal)NO NO Not Covered

D6067 Implant Supported Metal Crown (titanium, titanium alloy, high noble metal)

NO NO Not Covered

D6068 Abutment Supported Retainer for Porcelain/Ceramic FPD

NO NO Not Covered

D6069 Abutment Supported Retainer for Porcelain Fused to Metal FPD (high noble mental)

NO NO Not Covered

D6070 Abutment Supported Retainer for Porcelain Fused to Metal FPD (predominantly base metal)

NO NO Not Covered

D6071 Abutment Supported Retainer for Porcelain Fused to Metal FPD (noble metal)

NO NO Not Covered

D6072 Abutment Supported Retainer for Cast Metal FPD (high noble metal)

NO NO Not Covered

D6073 Abutment Supported Retainer for Cast Metal FPD (predominantly base metal)

NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D6074 Abutment Supported Retainer for Cast Metal FPD (noble metal)

NO NO Not Covered

D6075 Implant Supported Retainer for Ceramic FPD NO NO Not CoveredD6076 Implant Supported Retainer for Porcelain Fused to Metal

FPD (titanium, titanium alloy, or high noble metal)NO NO Not Covered

D6077 Implant Supported Retainer for Cast Metal FPD (titanium, titanium alloy, or high noble metal)

NO NO Not Covered

D6078 Implant/Abutment Supported Fixed Denture for Completely Edentulous Arch

NO NO Not Covered

D6079 Implant/Abutment Supported Fixture Denture for Partially Edentulous Arch

NO NO Not Covered

OTHER IMPLANT SERVICES

D6080 Implant Maintenance Procedures, Including Removal of Prosthesis, Cleansing of Prosthesis and Abutments and Reinsertion of Prosthesis

NO NO Not Covered

D6090 Repair Implant Supported Prosthesis, by Report NO NO Not CoveredD6091 Replacement of Semi-precision or Precision Attachment

(male or female component) of Implant/Abutment Supported Prosthesis, per Attachment

NO NO Not Covered

D6092 Recement Implant/Abutment Supported Crown NO NO Not CoveredD6093 Recement Implant/Abutment Supported Fixed Partial

DentureNO NO Not Covered

D6094 Abutment Supported Crown - (titanium) NO NO Not Covered

D6095 Repair Implant Abutment, by Report NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D6100 Implant Removal, by Report NO NO Not CoveredD6190 Radiographic/Surgical Implant Index, by Report NO NO Not CoveredD6194 Abutment Supported Retainer Crown for FPD -

(titanium)NO NO Not Covered

D6199 Unspecified Implant Procedure, by Report NO NO Not Covered

IX. PROSTHODONTICS, FIXED

FIXED BRIDGES (EACH ABUTMENT AND EACH PONTIC CONSTITUTES A UNIT)

FIXED PARTIAL DENTURE PONTICS

D6205 Pontic - Indirect Resin Based Composite NO NO Not CoveredD6210 Pontic - Cast High Noble Metal NO NO Not CoveredD6211 Pontic - Cast Predominantly Base Metal NO NO Not CoveredD6212 Pontic - Cast Noble Metal NO NO Not CoveredD6214 Pontic - Titanium NO NO Not CoveredD6240 Pontic - Porcelain Fused to High Noble Metal NO NO Not CoveredD6241 Pontic - Porcelain Fused to Predominantly Base Metal YES NO YES $325.00D6242 Pontic - Porcelain Fused to Noble Metal YES NO YES $344.00D6245 Pontic - Porcelain/Ceramic NO NO Not CoveredD6250 Pontic - Resin with High Noble Metal NO NO Not CoveredD6251 Pontic - Resin with Predominantly Base Metal YES NO YES $276.00D6252 Pontic - Resin with Noble Metal YES NO YES $314.00D6253 Provisional Pontic NO NO Not Covered

FIXED PARTIAL DENTURE RETAINERS – INLAYS/ONLAYS



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D6545 Retainer-Cast Metal for Resin Bonded Fixed Prosthesis YES NO YES $150.00D6548 Retainer-Porcelain/Ceramic for Resin Bonded Fixed

ProsthesisNO NO Not Covered

D6600 Inlay – Porcelain/Ceramic, Two Surfaces NO NO Not CoveredD6601 Inlay – Porcelain/Ceramic, Three or More Surfaces NO NO Not CoveredD6602 Inlay – Cast High Noble Metal, Two Surfaces NO NO Not CoveredD6603 Inlay – Cast High Noble Metal, Three or More Surfaces NO NO Not CoveredD6604 Inlay – Cast Predominantly Base Metal, Two Surfaces NO NO Not CoveredD6605 Inlay – Cast Predominantly Base Metal, Three or More


D6606 Inlay – Cast Noble Metal, Two Surfaces NO NO Not CoveredD6607 Inlay – Cast Noble Metal, Three or More Surfaces NO NO Not CoveredD6608 Onlay – Porcelain/Ceramic, Two Surfaces NO NO Not CoveredD6609 Onlay – Porcelain/Ceramic, Three or More Surfaces NO NO Not CoveredD6610 Onlay – Cast High Noble Metal, Two Surfaces NO NO Not CoveredD6611 Onlay - Cast High Noble Metal, Three or More Surfaces NO NO Not CoveredD6612 Onlay - Cast Predominantly Base Metal, Two Surfaces NO NO Not CoveredD6613 Onlay - Cast Predominantly Base Metal, Three or More


D6614 Onlay - Cast Noble Metal, Two Surfaces NO NO Not CoveredD6615 Onlay - Cast Noble Metal, Three or More Surfaces NO NO Not CoveredD6624 Inlay - Titanium NO NO Not CoveredD6634 Onlay - Titanium NO NO Not Covered

FIXED PARTIAL DENTURE RETAINERS - CROWNS



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D6710 Crown - Indirect Resin Based Composite NO NO Not CoveredD6720 Crown - Resin with High Noble Metal NO NO Not CoveredD6721 Crown - Resin with Predominantly Base Metal NO NO Not CoveredD6722 Crown - Resin with Noble Metal NO NO Not CoveredD6740 Crown - Porcelain/Ceramic NO NO Not CoveredD6750 Crown - Porcelain Fused to High Noble Metal NO NO Not CoveredD6751 Crown - Porcelain Fused to Predominantly Base Metal NO NO Not CoveredD6752 Crown - Porcelain Fused to Noble Metal NO NO Not CoveredD6780 Crown - 3/4 Cast High Noble Metal NO NO Not CoveredD6781 Crown - 3/4 Cast Predominantly Base Metal NO NO Not CoveredD6782 Crown - 3/4 Cast Noble Metal NO NO Not CoveredD6783 Crown - 3/4 Porcelain/Ceramic NO NO Not CoveredD6790 Crown - Full Cast High Noble Metal NO NO Not CoveredD6791 Crown - Full Cast Predominantly Base Metal NO NO Not CoveredD6792 Crown - Full Cast Noble Metal NO NO Not CoveredD6793 Provisional Retainer Crown NO NO Not CoveredD6794 Crown - Titanium NO NO Not Covered

OTHER FIXED PARTIAL DENTURE SERVICES

D6920 Connector Bar NO NO Not CoveredD6930 Recement Fixed Partial Denture NO NO Not CoveredD6940 Stress Breaker NO NO Not CoveredD6950 Precision Attachment NO NO Not CoveredD6970 Post and Core in Addition to Fixed Partial Denture

Retainer, Indirectly FabricatedNO NO Not Covered

D6972 Prefabricated Post and Core in Addition to Fixed Partial NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


Denture RetainerD6973 Core Buildup for Retainer, Including Any Pins NO NO Not CoveredD6975 Coping - Metal NO NO Not CoveredD6976 Each Additional Indirectly Fabricated Post - Same Tooth NO NO Not CoveredD6977 Each Additional Prefabricated Post – Same Tooth NO NO Not CoveredD6980 Fixed Partial Denture Repair, by Report NO NO Not CoveredD6985 Pediatric Partial Denture, Fixed NO NO Not CoveredD6999 Unspecified Fixed Prosthodontic Procedure, by Report NO NO Not Covered

X. ORAL AND MAXILLOFACIAL SURGERY

EXTRACTIONS - INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED & ROUTINE POSTOPERATIVE CARE

D7111 Extraction, Coronal Remnants – Deciduous Tooth YES YES NO NO $55.00

D7140 Extraction, Erupted Tooth or exposed Root (elevation and/or forceps removal)


SURGICAL EXTRACTIONS – (INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED, & ROUTINE POSTOPERATIVE CARE)

D7210 Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth

YES YES NO NO Documented need demonstrated by X-rays

$110.00

D7220 Removal of Impacted Tooth - Soft Tissue YES YES NO NO Documented need demonstrated by X-rays

$95.00

D7230 Removal of Impacted Tooth - Partially Bony YES YES NO NO Documented need demonstrated by X-rays

$155.00

D7240 Removal of Impacted Tooth – Completely Bony YES YES NO NO Documented need demonstrated $185.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


by X-raysD7241 Removal of Impacted Tooth – Completely Bony, with

Unusual Surgical ComplicationsYES YES NO NO Documented need demonstrated

by X - rays$215.00

D7250 Surgical Removal of Residual Tooth Roots (cutting procedure)

YES YES NO NO Documented need demonstrated by X - rays

$130.00

OTHER SURGICAL PROCEDURES

D7260 Oroantral Fistula Closure YES YES NO NO $250.00D7261 Primary Closure of a Sinus Perforation YES YES NO NO $250.00D7270 Tooth Reimplantation and/or Stabilization of Accidentally

Evulsed or Displaced ToothYES YES NO NO $175.00

D7272 Tooth Transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

NO NO Not Covered

D7280 Surgical Access of an Unerupted Tooth YES NO NO $220.00D7282 Mobilization of Erupted or Malpositioned Tooth to Aid

EruptionNO NO Not Covered

D7283 Placement of Device to Facilitate Eruption of Impacted Tooth

YES NO NO $225.00

D7285 Biopsy of Oral Tissue – Hard (bone, tooth) YES YES NO NO $110.00D7286 Biopsy of Oral Tissue – Soft YES YES NO NO $85.00D7287 Exfoliative Cytological Sample Collection NO NO Not CoveredD7288 Brush Biopsy-Transepithelial Sample Collection YES YES By ReportD7290 Surgical Repositioning of Teeth YES YES NO NO $175.00D7291 Transseptal Fiberotomy/Supra Crestal Fiberotomy, by

ReportYES NO NO $45.00

D7292 Surgical Placement: Temporary Anchorage Device NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


(screw retained plate) Requiring Surgical FlapD7293 Surgical Placement: Temporary Anchorage Device

Requiring Surgical FlapNO NO Not Covered

D7294 Surgical Placement: Temporary Anchorage Device Without Surgical Flap

NO NO Not Covered

ALVEOLOPLASTY - SURGICAL PREPARATION OF RIDGE FOR DENTURES

D7310 Alveoloplasty in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant


D7311 Alveoloplasty in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per Quadrant

NO NO Not Covered

D7320 Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per Quadrant

YES YES YES YES Only after approval for prosthesis

$94.00

D7321 Alveoloplasty not in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per Quadrant

YES YES YES YES Only after approval for prosthesis

$47.00

VESTIBULOPLASTY

D7340 Vestibuloplasty - Ridge Extension (secondary epithelialization)

NO NO Not Covered

D7350 Vestibuloplasty - Ridge Extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment, and management of hypertrophied and hyperplastic tissue)

NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


SURGICAL EXCISION OF SOFT TISSUE LESIONS

D7410 Excision of Benign Lesion Up to 1.25 Cm YES YES NO NO $75.00D7411 Excision of Benign Lesion Greater Than 1.25 Cm YES YES NO NO $120.00D7412 Excision of Benign Lesion, Complicated YES YES NO NO $200.00D7413 Excision of Malignant Lesion up to 1.25 Cm YES YES NO NO $350.00D7414 Excision of Malignant Lesion Greater Than 1.25 Cm YES YES NO NO $750.00D7415 Excision of Malignant Lesion, Complicated YES YES NO NO $750.00D7465 Destruction of Lesion(s) by Physical or Chemical

Method, by ReportYES YES NO NO $75.00

SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS

D7440 Excision of Malignant Tumor - Lesion Diameter Up to 1.25 Cm


D7441 Excision of Malignant Tumor - Lesion Diameter Greater Than 1.25 Cm


D7450 Removal of Benign Odontogenic Cyst or Tumor - Lesion Diameter Up to 1.25 Cm


D7451 Removal of Benign Odontogenic Cyst or Tumor - Lesion Diameter Greater Than 1.25 Cm


D7460 Removal of Benign Nonodontogenic Cyst or Tumor - Lesion Diameter up to 1.25 Cm


D7461 Removal of Benign Nonodontogenic Cyst or Tumor - Lesion Diameter Greater Than 1.25 Cm




CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


EXCISION OF BONE TISSUE

D7471 Removal of Lateral Exostosis (maxilla or mandible) YES YES YES YES $300.00D7472 Removal of Torus Palatinus YES YES YES YES By ReportD7473 Removal of Torus Mandibularis YES YES YES YES By ReportD7485 Surgical Reduction of Osseous Tuberosity NO NO Not CoveredD7490 Radical Resection of Maxilla or Mandible NO NO Not Covered

SURGICAL INCISION

D7510 Incision and Drainage of Abscess – Intraoral Soft Tissue YES YES NO NO $75.00D7511 Incision and Drainage of Abscess - Intraoral Soft Tissue

Complicated (includes drainage of multiple fascial spaces)


D7520 Incision and Drainage of Abscess – Extraoral Soft Tissue


D7521 Incision and Drainage of Abscess - Extraoral Soft Tissue-Complicated (includes drainage of multiple fascial spaces)


D7530 Removal of Foreign Body from Mucosa, Skin, or Subcutaneous Alveolar Tissue


D7540 Removal of Reaction Producing Foreign Bodies, Musculoskeletal System

YES YES NO NO By Report

D7550 Partial Ostectomy/Sequestrectomy for Removal of Non-Vital Bone

YES YES NO NO By Report

D7560 Maxillary Sinusotomy for Removal of Tooth Fragment or Foreign Body




CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


TREATMENT OF FRACTURES - SIMPLE

D7610 Maxilla - Open Reduction (teeth immobilized, if present) YES YES NO NO $900.00D7620 Maxilla - Closed Reduction (teeth immobilized, if

present)YES YES NO NO $450.00

D7630 Mandible - Open Reduction (teeth immobilized, if present)


D7640 Mandible - Closed Reduction (teeth immobilized, if present)


D7650 Malar and/or Zygomatic Arch - Open Reduction YES YES NO NO $750.00D7660 Malar and/or Zygomatic Arch - Closed Reduction YES YES NO NO $300.00D7670 Alveolus – Closed Reduction, May Include Stabilization

of TeethYES YES NO NO $400.00

D7671 Alveolus – Open Reduction, May Include Stabilization of Teeth

NO NO Not Covered

D7680 Facial Bones - Complicated Reduction with Fixation and Multiple Surgical Approaches

YES YES NO NO $1,383.00

TREATMENT OF FRACTURES - COMPOUND

D7710 Maxilla - Open Reduction YES YES NO NO $900.00D7720 Maxilla - Closed Reduction YES YES NO NO $450.00D7730 Mandible - Open Reduction YES YES NO NO $900.00D7740 Mandible - Closed Reduction YES YES NO NO $450.00D7750 Malar and/or Zygomatic Arch - Open Reduction YES YES NO NO $750.00D7760 Malar and/or Zygomatic Arch - Closed Reduction YES YES NO NO $300.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D7770 Alveolus – Open Reduction Stabilization of Teeth YES YES NO NO $400.00D7771 Alveolus, Closed Reduction Stabilization of Teeth YES YES NO NO $400.00D7780 Facial Bones - Complicated Reduction with Fixation and

Multiple Surgical ApproachesYES YES NO NO $1,383.00

REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHER TEMPOROMANDIBULAR JOINT DYSFUNCTIONS

D7810 Open Reduction of Dislocation NO NO Not CoveredD7820 Closed Reduction of Dislocation NO NO Not CoveredD7830 Manipulation Under Anesthesia NO NO Not CoveredD7840 Condylectomy NO NO Not CoveredD7850 Surgical Discectomy, with/without Implant YES YES YES YES $1,185.50D7852 Disc Repair NO NO Not CoveredD7854 Synovectomy NO NO Not CoveredD7856 Myotomy NO NO Not CoveredD7858 Joint Reconstruction NO NO Not CoveredD7860 Arthrotomy YES YES YES YES $1,185.50D7865 Arthroplasty NO NO Not CoveredD7870 Arthrocentesis NO NO Not CoveredD7871 Non-arthroscopic Lysis and Lavage NO NO Not CoveredD7872 Arthroscopy - Diagnosis, with or without Biopsy NO NO Not CoveredD7873 Arthroscopy - Surgical; Lavage and Lysis of Adhesions NO NO Not CoveredD7874 Arthroscopy – Surgical; Disc Repositioning and

StabilizationNO NO Not Covered

D7875 Arthroscopy – Surgical; Synovectomy NO NO Not CoveredD7876 Arthroscopy – Surgical; Discectomy NO NO Not CoveredD7877 Arthroscopy – Surgical; Debridement NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D7880 Occlusal Orthotic Device, by Report YES YES YES YES $250.00D7899 Unspecified TMD Therapy, by Report NO NO Not Covered

REPAIR OF TRAUMATIC WOUNDS

D7910 Suture of Recent Small Wounds Up to 5 cm YES YES NO NO $84.75

COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE)

D7911 Complicated Suture - Up to 5 cm YES YES NO NO $193.00D7912 Complicated Suture – Greater Than 5 cm YES YES NO NO $263.50

OTHER REPAIR PROCEDURES

D7920 Skin Grafts (identify defect covered, location, and type of graft)

NO NO Not Covered

D7940 Osteoplasty for Orthognathic Deformities YES YES YES YES By ReportD7941 Osteotomy – Mandibular Rami YES YES YES YES By ReportD7943 Osteotomy – Mandibular Rami with Bone Graft;

Includes Obtaining The GraftYES YES YES YES $2,529.00

D7944 Osteotomy - Segmented or Subapical YES YES YES YES $2,213.00D7945 Osteotomy - Body of The Mandible YES YES YES YES $2,213.00D7946 LeFort I (maxilla - total) YES YES YES YES $2,213.00D7947 LeFort I (maxilla - segmented) YES YES YES YES $2,213.00D7948 LeFort II or LeFort III (Osteoplasty of Facial Bones for

Midface Hypoplasia or Retrusion) - without Bone GraftYES YES YES YES $2,213.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D7949 LeFort II or LeFort III – with Bone Graft YES YES YES YES $2,529.00D7950 Osseous, Osteoperiosteal, or Cartilage Graft of The

Mandible or Maxilla - Autogenous or Nonautogenous, by Report

YES YES YES YES By Report

D7951 Sinus Augmentation with Bone or Bone Substitutes NO NO Not CoveredD7953 Bone Replacement Graft for Ridge Preservation - Per Site YES YES NO YES $325.00D7955 Repair of Maxillofacial Soft and/or Hard Tissue Defect YES YES NO NO $412.00D7960 Frenulectomy (Frenectomy or Frenotomy) - Separate

ProcedureYES YES NO YES $97.00

D7963 Frenuloplasty YES YES NO YES $125.00D7970 Excision of Hyperplastic Tissue - Per Arch YES YES YES YES $356.00D7971 Excision of Pericoronal Gingiva YES YES YES YES $ 58.00D7972 Surgical Reduction of Fibrous Tuberosity YES YES YES YES $70.00D7980 Sialolithotomy YES YES YES YES $263.50D7981 Excision of Salivary Gland, by Report YES YES YES YES By ReportD7982 Sialodochoplasty YES YES YES YES By ReportD7983 Closure of Salivary Fistula YES YES YES YES By ReportD7990 Emergency Tracheotomy YES YES NO NO $159.50D7991 Coronoidectomy YES YES YES YES By ReportD7995 Synthetic Graft - Mandible or Facial Bones, by Report YES YES YES YES $1,106.50D7996 Implant - Mandible for Augmentation Purposes

(Excluding Alveolar Ridge), by ReportNO NO Not Covered

D7997 Appliance Removal (not by dentist who placed appliance), Includes Removal of Archbar

YES NO YES By Report

D7998 Intraoral Placement of a Fixation Device Not in Conjunction with a Fracture

NO NO Not Covered

D7999 Unspecified Oral Surgery Procedure, by Report YES YES YES YES By Report



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


XI. LIMITED ORTHODONTIC TREATMENT (Orthodontics are not covered services for residents of ICF/MR facilities)

D8010 Limited Orthodontic Treatment of The Primary Dentition

YES NO YES $332.50

D8020 Limited Orthodontic Treatment of The Transitional Dentition

YES NO YES $332.50

D8030 Limited Orthodontic Treatment of The Adolescent Dentition

YES NO YES $332.50

D8040 Limited Orthodontic Treatment of The Adult Dentition NO NO Not Covered

INTERCEPTIVE ORTHODONTIC TREATMENT

D8050 Interceptive Orthodontic Treatment of The Primary Dentition

YES NO YES $592.00

D8060 Interceptive Orthodontic Treatment of The Transitional Dentition

YES NO YES $592.00

COMPREHENSIVE ORTHODONTIC TREATMENT

D8070 Comprehensive Orthodontic Treatment of The Transitional Dentition

YES NO YES D8070, D8080 and D8090 - all inclusive fee includes

$2,725.00

D8080 Comprehensive Orthodontic Treatment of The Adolescent Dentition

YES NO YES appliances, brackets, treatment visits, one appliance repair or

$2,725.00

D8090 Comprehensive Orthodontic Treatment of The Adult Dentition

YES NO YES replacement, and one retainer repair or replacement. Covered to age 21

$2,725.00



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


MINOR TREATMENT TO CONTROL HARMFUL HABITS

D8210 Removable Appliance Therapy YES NO YES $375.00D8220 Fixed Appliance Therapy YES NO YES $375.00

OTHER ORTHODONTIC SERVICES

D8660 Pre-Orthodontic Treatment Visit YES NO NO $22.50

D8670 Periodic Orthodontic Treatment Visit (as part of contract)

YES NO YES Cannot be billed in conjunction with D8070, D8080, D8090

$66.00

D8680 Orthodontic Retention (removal of appliances, construction and placement of retainer(s))

NO NO Not Covered

D8690 Orthodontic Treatment (alternative billing to a contract fee)

NO NO Not Covered

D8691 Repair of Orthodontic Appliance YES NO YES $75.00D8692 Replacement of Lost or Broken Retainer YES NO NO $125.00D8693 Rebonding or Recementing; and/or Repair, as Required,

of Fixed RetainersYES NO NO $50.00

D8999 Unspecified Orthodontic Procedure, by Report YES NO YES By Report

XII. ADJUNCTIVE GENERAL SERVICES



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


UNCLASSIFIED TREATMENT

D9110 Palliative (emergency) Treatment of Dental Pain - Minor Procedure


D9120 Fixed Partial Denture Sectioning NO NO Not Covered

ANESTHESIA

D9210 Local Anesthesia not in Conjunction with Operative or Surgical Procedures

NO NO Not Covered

D9211 Regional Block Anesthesia NO NO Not CoveredD9212 Trigeminal Division Block Anesthesia NO NO Not CoveredD9215 Local Anesthesia NO NO Not CoveredD9220 Deep Sedation/General Anesthesia – First 30 Minutes YES YES NO NO $150.00D9221 Deep Sedation/General Anesthesia - Each Additional 15

MinutesYES YES NO NO $50.00

D9230 Analgesia Anxiolysis, Inhalation of Nitrous Oxide YES YES NO NO $19.00D9241 Intravenous Conscious Sedation/Analgesia - First 30

MinutesYES YES $150.00

D9242 Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes

YES YES $50.00

D9248 Non-Intravenous Conscious Sedation NO NO Not Covered

PROFESSIONAL CONSULTATION



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D9310 Consultation - diagnostic service provided by dentist or physician other than Requesting Dentist or Physician

YES YES NO NO Denturists may also use this code

$31.00

PROFESSIONAL VISITS

D9410 House/Extended Care Facility Call YES YES NO NO Limited to dentist/denturist, only if medically necessary and providing a covered service under this policy

$60.00

D9420 Hospital Call YES YES NO NO Use for emergency room trauma care

$100.00

D9430 Office Visit for Observation (during regularly scheduled hours) - No Other Services Performed


D9440 Office Visit - After Regularly Scheduled Hours YES YES NO NO $38.00D9450 Case Presentation, Detailed and Extensive Treatment

PlanningYES NO NO Limited to orthodontia $127.50

DRUGS

D9610 Therapeutic Parenteral Drug, Single Administration YES YES NO NO Acquisition cost only By ReportD9612 Therapeutic Parenteral Drugs, Two or More

Administrations, Different MedicationsYES YES NO NO Acquisition cost only. Not to be

reported in addition to D9610.By Report

D9630 Other Drugs and/or Medications, by Report YES YES NO NO Acquisition cost only By Report

MISCELLANEOUS SERVICES

D9910 Application of Desensitizing Medicament NO NO Not Covered



CHAPTER III




Proc.Code


MR residents*

age 21 & over when

allowed under 25.04


MR residents

age 21 & over when

allowed under 25.04


D9911 Application of Desensitizing Resin for Cervical and/or Root Surface, Per Tooth

NO NO Not Covered

D9920 Behavior Management, by Report YES NO NO Limit 3 visits per member per provider. Limited to general dentist only.

$13.00

D9930 Treatment of Complications (post-surgical) - Unusual Circumstances, by Report


D9940 Occlusal Guard, by Report YES YES YES YES $110.00D9941 Fabrication of Athletic Mouthguard NO NO Not CoveredD9942 Repair and/or Reline of Occlusal Guard NO NO Not CoveredD9950 Occlusion Analysis - Mounted Case NO NO Not CoveredD9951 Occlusal Adjustment - Limited NO NO Not CoveredD9952 Occlusal Adjustment - Complete NO NO Not CoveredD9970 Enamel Microabrasion NO NO Not CoveredD9971 Odontoplasty 1-2 Teeth; Includes Removal of Enamel

ProjectionsNO NO Not Covered

D9972 External Bleaching – Per Arch NO NO Not CoveredD9973 External Bleaching – Per Tooth NO NO Not CoveredD9974 Internal Bleaching – Per Tooth NO NO Not CoveredD9999 Unspecified Adjunctive Procedure, by Report YES YES YES YES By Report


mainecare benefits manual, chapters ii and iii, section 25

Documents

department responses

department amendedlanguage

physicians services

language insubsection

dental servicesestablished

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