CMS Network Dental Benefits
Preventive Services
- Office Visits
- Cleanings/Prophylaxis
- Topical fluoride application, limit one every six months
- Sealants, limit one application per tooth every 3 years
- Space maintainers
Oral Exam
- Initial Oral Exam
- Periodic Oral Exam, limit one every 6 months
X-Rays
- Intraoral periapical
- Bitewings, limit one set (2 or 4) every 6 months
- Complete set of x-rays, limit one every 3 years
- Panoramic x-rays, limit one every 3 years
Restorative Services (Fillings and Crowns)
- Amalgam restoration (silver fillings)
- Composite/Resin restorations (white fillings)
- Prefabricated stainless steel and resin crowns
- Crowns (porcelain fused to metal)
Oral Surgery (Extractions)
- Extractions
- Biopsies
- Surgical treatment of diseases
- Injuries, deformities and defects
Endodontic Services (Root Canals)
- Root canal therapy on primary and permanent teeth
- Apicoectomy, surgery involving the root of the tooth
Periodontal Services
- Gingival curettage, including local anesthesia
- Gingival flap procedure
- Scaling and root planing
Prosthodontics (Dentures)
- Upper, lower or full set of dentures
- Partial dentures (fixed and removable)
Orthodontic Services (Braces)
- Prior authorization is required for all orthodontic services, except the initial evaluation and for partial dentures for beneficiaries of any age
- Services are limited to those circumstances where the child's condition creates a disability and is an impairment to the child’s physical development. Not covered for cosmetic purposes
Analgesia and Sedation
- Limited to children who have severe physical or mental disability or are difficult to manage. Service is limited to 3 times every 12 months
- Intravenous administration of drugs
- Non-intravenous administration of drugs, limit 3 times per year
- Nitrous Oxide
Injectable Medications
- The injection of medication to treat illness or disease
Palliative Treatment
- Covered services necessary to relieve pain and discomfort on an emergency basis
Hospitalization
- Hospitalization for dental treatment is covered only if a child's health is so jeopardized that procedures cannot be safely performed in the dental office; and/or, the child is so uncontrollable due to emotional instability or developmental and sedation has been ineffective
Exclusions
The following services are not covered:
- Fixed bridge work
- Sealants applied to deciduous (baby) teeth
- Orthodontic services are not covered for cosmetic purposes
Exceptions
The provider may request prior authorization for reimbursement for services in excess of the service limitations.
|
