5160-5-05 Dental program: covered restorative services and limitations.

 

 

 

TO BE RESCINDED

 

5160-5-05                    Dental program: covered restorative services and limitations.

 

 

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

 

(A)  Amalgam restorations (including polishing).

 

(1)  Amalgam - one surface, primary or permanent.

 

(2)   Amalgam - two surfaces, primary or permanent.

 

(3)   Amalgam - three surfaces, primary or permanent.

 

(4)   Amalgam - four or more surfaces, primary or permanent.

 

(5)    Payment shall not be made for separate occlusal restorations, other than on maxillary molars. Reimbursement for occlusal surface restorations, other than on maxillary molars, includes one or more restorations on that surface.

 

(B)   Pin retention-exclusive of amalgam restoration per tooth, in addition to restoration. A maximum of three pins per tooth restoration shall be allowed as a covered service.

 

(C)    Bases and copalite or calcium hydroxide liners placed under a restoration will be considered part of the restoration and not reimbursable as separate procedures.

 

(D)  Local anesthesia shall be included in the fee for all restorative services.

 

(E)  Resin - based composite restorations - direct.

 

(1)  Resin-based composite restorations - anterior.

 

(a)   Resin-based composite - one surface, anterior.

 

(b)   Resin-based composite - two surface, anterior.

 

(c)   Resin-based composite - three surface, anterior.

 

(d)   Resin-based composite - four or more surfaces or involving incisal angle (anterior).

 

 

 

(2)   Resin-based composite restorations - posterior.

(a)   Resin-based composite - one surface, posterior.

(b)    Effective for dates of service on or after January 1, 2004, resin-based composite - two surfaces.

(c)    Effective for dates of service on or after January 1, 2004, resin-based composite - three surfaces, posterior.

(d)    Effective for dates of service on or after January 1, 2004, resin-based composite - four or more surfaces, posterior.

(3)    Pin retention - per tooth, in addition to restoration (resin-based composite). A maximum of three pins per tooth shall be allowed as a covered service.

(4)    Resin-based composite restorations shall be permitted for anterior teeth and class I or class V restorations on posterior teeth.

(5)   Effective for dates of service on or after January 1, 2004, resin-based composite restorations shall be permitted for class II restorations on posterior teeth.

(6)   The fee for resin-based composite restorations shall include any necessary acid etching.

(F)     Maximum reimbursement for restorations shall be limited to no more than three restorations per tooth regardless of the number of surfaces restored.

(G)    Single surface resin-based composite restorations shall involve repair to decay into the dentin.

(H)   A tooth with decay on three surfaces that can be restored with separate restorations in accordance with accepted standards of dental practice may be billed and will be reimbursed as separate restorations.

(I)  Preventive resin restorations are not covered services.

(J)   Crowns.

(1)    Effective for dates of service from January 1, 2006 through June 30, 2008, crowns, posts and related services were not covered dental services for consumers twenty-one years and older.

(2)   Crown - porcelain fused to noble metal.

(a)   Prior authorization is required for porcelain fused to noble metal crowns. A periapical radiograph of the involved tooth must be submitted with each request.

(b)   The fee for crowns includes the temporary crown which is placed on the prepared tooth and worn while the permanent crown is being prepared.

(c)     Porcelain with metal crowns shall be authorized only for permanent anterior teeth.

(3)   Prefabricated stainless steel crown. Stainless steel crowns shall be allowed only for teeth where multisurface restorations are needed and amalgam restorations and other materials have a poor prognosis.

(a)   Prefabricated stainless steel crown - primary tooth

(b)   Prefabricated stainless steel crown - permanent tooth.

(4)   Prefabricated stainless steel crown with resin window. Open face stainless steel crown with aesthetic resin facing or veneer.

(a)    Prefabricated stainless steel crowns with resin window shall be covered for anterior teeth only.

(b)     The fee for prefabricated stainless steel crowns with resin window includes any necessary composite restoration.

(5)   Cast post and core in addition to crown.

(a)     Prior authorization is required for crowns with a post and core. A periapical radiograph of the involved tooth must be submitted with each request.

(b)    Crowns with a post and core shall be approved only for endodontically

treated permanent anterior teeth without sufficient tooth structure to support a crown.

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:	5162.20, 5164.02
Rule Amplifies:	5162.03, 5164.02, 5164.70
Prior Effective Dates:	04/07/1977, 12/21/1977, 05/09/1986, 02/01/1988, 11/15/1993, 12/29/1995 (Emer), 03/21/1996, 01/01/2000, 10/01/2003, 01/01/2006, 07/01/2008