5160-5-06 Dental program: covered endodontic services and limitations.

 

 

 

TO BE RESCINDED

 

5160-5-06                    Dental program: covered endodontic services and limitations.

 

 

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

 

(A)  Therapeutic pulpotomy and pulpal therapy.

 

(1)   Therapeutic pulpotomy and pulpal therapy shall be covered only for consumers under the age of twenty-one.

 

(2)   Theraputic pulpotomy and pulpal therapy as separate procedures shall not occur in combination with root canal therapy.

 

(3)   The restoration for the completed pulpal therapy or pulpotomy shall be billed as a separate procedure.

 

(B)  Endodonic therapy (complete root canal therapy).

 

(1)  Anterior - tooth (excluding final restoration).

 

(2)   Bicuspid - tooth (excluding final restoration).

 

(3)   Molar - tooth (excluding final restoration).

 

(4)   Endodontic therapy is covered only when the overall health of the dentition and periodontium is good except for the endodontically indicated tooth/teeth. Decay must be above the bone level. Radiographs, including periapical, must be clearly readable and show periapical radioluncency or widening of periodontal ligament and be accompanied with chronic pain (as evidenced by sensitivity to hot or cold, percussion or palpation) or presence of fistula associated with tooth or chronic infection. If pathology is not visible on radiograph, endodontic treatment must be evidenced by clinical documentation.

 

(5)   Endodontic therapy is covered only for permanent teeth.

 

(6)    All diagnostic tests, evaluations, radiographs, and postoperative treatment are included in the fee.

 

(C)  Apicoectomy/periradicular services.

 

 

 

(1)    Apicoectomy/periradicular services shall be a covered service on permanent teeth only.

(2)      Prior authorization is required for apicoectomy/periradicular services. All available radiographs of the mouth, properly mounted and clearly readable, must be submitted with each request. A periapical view of the tooth and the periapical area involved must be included.

(D)  Apexification/recalcification procedures.

(1)   Apical closure.

(a)      Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)

(i)    Apexification/recalcification includes opening tooth, preparation of canal spaces, first placement of medication and necessary radiographs.

(ii)   This procedure may include the first phase of endodontic (complete root canal) therapy.

(b)      Apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)

This  procedure  is  for  visits  in  which  the  intra-canal  medication  is replaced with new medication and necessary radiographs.

(c)    Apexification/recalcification - final visit (includes completed endodontic therapy - apical closure/calcific repair of perforations, root resorption, etc.)

(i)     This procedure includes removal of intra-canal medication and procedures necessary to place final root canal filling material including necessary radiographs.

(ii)     This procedure includes last phase of endodontic (complete root canal) therapy.

(2)   Apical closure does not include endodontic (root canal) therapy.

(3)   Prior authorization is required for each apexification/recalcification procedure.

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
Rule Amplifies:	5162.03, 5164.02
Prior Effective Dates:	04/07/1977, 12/21/1977, 05/09/1986, 11/15/1993,
	01/01/2000, 10/01/2003, 01/01/2006, 07/01/2008, 12/31/2008 (Emer), 03/31/2009, 12/30/2010 (Emer), 03/30/2011