5160-5-04 Dental program: covered preventive services and limitations.

 

 

 

TO BE RESCINDED

 

5160-5-04                    Dental program: covered preventive services and limitations.

 

 

The following preventive services are covered under the dental care program subject to the specified limitations.

 

(A)  Prophylaxis.

 

(1)   Dental prophylaxis, adult.

 

(a)   This shall include the necessary scaling and/or polishing procedures of the teeth to remove coronal plaque, calculus and stains of transitional or permanent dentition for consumers ages fourteen and older.

 

(b)     Effective for dates of service on or after January 1, 2006, the dental prophylaxis shall not occur more frequently than once every one hundred eighty days for consumers twenty-years of age and younger. Those prophylaxes occurring more frequently than once every one hundred eighty days shall not be reimbursed by the department.

 

(c)   Effective for dates of service from January 1, 2006 through June 30, 2008, the dental prophylaxis shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older. Effective for dates of service from July 1, 2008 through December 31, 2009, the dental prophylaxis shall not occur more frequently than once every one hundred eighty days irrespective of the consumer's age. Those prophylaxes occurring more frequently than once every one hundred eighty days shall not be reimbursed by the department.

 

(d)    Effective for dates of service on or after January 1, 2010, the dental prophylaxis shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older.

 

(2)   Dental prophylaxis, child.

 

(a)    This shall include the necessary scaling and/or polishing procedures to remove coronal plaque, calculus and and stains of primary or transitional dentition for consumers only through age thirteen.

 

(b)    The dental prophylaxis shall not occur more frequently than once every one hundred eighty days. Those prophylaxes occurring more frequently

 

 

than once every one hundred eighty days shall not be reimbursed by the department.

(B)  Topical application of fluoride.

(1)     Topical fluoride treatments (includes sodium, stannous and acid phosphate fluoride foam, gel, varnish and in-office rinse) shall be allowed for consumers under the age of twenty-one.

(2)     Treatment that incorporates fluoride with the polishing compound shall be considered part of the prophylaxis procedure and not a separate topical fluoride treatment.

(3)     Topical application of fluoride to the prepared portion of a tooth prior to restoration, the use of self or home fluoride application procedures, and application of sodium fluoride as a desensitizing agent are not covered treatments.

(4)   The topical application of fluoride is limited to one application per one hundred eighty days.

(C)     Sealant  -  per  tooth.  Pit  and  fissure  sealants  shall  be  permitted  on  previously unrestored occlusal areas of permanent molars subject to the following limitations:

(1)    Sealants shall be allowed on permanent first molars for consumers under age eighteen.

(2)   Sealants shall be allowed on permanent second molars for consumers under age eighteen.

(D)  Space maintenance (passive appliances).

(1)    Effective for dates of service from January 1, 2006 through June 30, 2008, space maintenance (passive appliances) were not covered services for consumers twenty-one years of age and older.

(2)   Space maintainer - fixed - unilateral.

(3)   Space maintainer - fixed - bilateral.

(4)   Space maintainer - removable - unilateral.

(5)   Space maintainer - removable bilateral.

(6)     The preservation of arch length should be the main consideration in the evaluation of a consumer for a space maintainer. Space maintainers are permitted after the loss of a young permanent tooth or the premature loss of a primary tooth when an indeterminant time exists before the eruption of the permanent tooth.

Effective:                                                             01/01/2016

Five Year Review (FYR) Dates:                         10/16/2015

CERTIFIED ELECTRONICALLY

Certification

12/22/2015

Date

Promulgated Under:                           119.03

Statutory Authority:                           5164.02, Section 309.30.75 of Am. Sub. H.B. 1 (128th

G.A.)

Rule Amplifies:                                  5162.03, 5164.02, 5164.70, Section 309.30.75 of Am.

Sub. H.B. 1 (128th G.A.)

Prior Effective Dates:                         04/07/1977, 12/21/1977, 05/09/1986, 02/01/1988,

11/15/1993, 01/01/2000, 10/01/2003, 01/01/2006,

07/01/2008, 12/31/2008 (Emer), .03/31/2009,

01/01/2010, 12/31/2012 (Emer), 03/28/2013