Common use of Diagnostic Services Clause in Contracts

Diagnostic Services. Indicated diagnostic services that can be considered every 3 months for individuals with special healthcare needs are denoted with an asterisk. Clinical oral evaluations once every 6 months * Comprehensive oral evaluation– complete evaluation which includes a comprehensive and thorough inspection of the oral cavity to include diagnosis, an oral cancer screening, charting of all abnormalities, and development of a complete treatment plan allowed once per year with subsequent service as periodic oral evaluation Periodic oral evaluation – subsequent thorough evaluation of an established patient* Oral evaluation for patient under the age of 3 and counseling with primary caregiver* Limited oral evaluations that are problem focused Detailed oral evaluations that are problem focused Diagnostic Imaging with interpretation A full mouth series can be provided every 3 years. The number of films/views expected is based on age with the maximum being 16 intraoral films/views. An extraoral panoramic film/view and bitewings may be substituted for the full mouth series with the same frequency limit. Additional films/views needed for diagnosing can be provided as needed. Bitewings, periapicals, panoramic and cephlometric radiographic images Intraoral and extraoral radiographic images Oral/facial photographic images Maxillofacial MRI, ultrasound Cone beam image capture Tests and Examinations Viral culture Collection and preparation of saliva sample for laboratory diagnostic testing Diagnostic casts – for diagnostic purposes only and not in conjunction with other services Oral pathology laboratory Accession/collection of tissue, examination – gross and microscopic, preparation and transmission of written report Accession/collection of exfoliative cytologic smears, microscopic examination, preparation and transmission of a written report Other oral pathology procedures, by report * Indicates preventive services that can be considered every 3 months for individuals with special healthcare needs are denoted with an asterisk. Dental prophylaxis once every 6 months* Topical fluoride treatment once every 6 months – in conjunction with prophylaxis as a separate service* Fluoride varnish once every 3 months for children under the age of 6 Sealants, limited to one time application to all occlusal surfaces that are unfilled and caries free, in premolars and permanent molars. Replacement of sealants can be considered with prior authorization. Space maintainers – to maintain space for eruption of permanent tooth/teeth, includes placement and removal fixed – unilateral and bilateral removable – bilateral only recementation of fixed space maintainer removal of fixed space maintainer – considered for provider that did not place appliance There are no frequency limits on replacing restorations (fillings) or crowns. Request for replacement due to failure soon after insertion, may require documentation to demonstrate material failure as the cause. Reimbursement will include the restorative material and all associated materials necessary to provide the standard of care, polishing of restoration, and local anesthesia. The reimbursement for any restoration on a tooth shall be for the total number of surfaces to be restored on that date of service. Only one procedure code is reimbursable per tooth except when amalgam and composite restorations are placed on the same tooth. Reimbursement for an occlusal restoration includes any extensions onto the occlusal one-third of the buccal, facial or lingual surface(s) of the tooth. Extension of interproximal restorations into self-cleansing areas will not be considered as additional surfaces. Extension of any restoration into less than 1/3 of an adjacent surface is not considered an additional surface and will not be reimbursable (or if paid will be recovered). Restorative service to include: Restorations (fillings) – amalgam or resin based composite for anterior and posterior teeth. Service includes local anesthesia, pulp cap (direct or indirect) polishing and adjusting occlusion. Gold foil - . Service includes local anesthesia, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Inlay/onlay restorations – metallic, service includes local anesthesia, cementation, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Service requires prior authorization and will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor long term prognosis Service includes local anesthesia, temporary crown placement, insertion with cementation, polishing and adjusting occlusion. Provisional crowns are not covered. Recement of inlay, onlay, custom fabricated/cast or prefabricated post and core and crown, Prefabricated stainless steel, stainless steel crown with resin window and resin crowns. Service includes local anesthesia, insertion with cementation and adjusting occlusion. Core buildup including pins Pin retention Indirectly fabricated (custom fabricated/cast) and prefabricated post and core Additional fabricated ( custom fabricated/cast) and prefabricated post Post removal Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture Coping Crown repair Protective restoration/sedative filling Service includes all necessary radiographs or views needed for endodontic treatment. Teeth must be in occlusion, periodontally sound, needed for function and have good long term prognosis. Emergency services for pain do not require prior authorization. Service requires prior authorization and will not be considered for teeth that are not in occlusion or function and have poor long term prognosis. Endodontic service to include: Therapeutic pulpotomy for primary and permanent teeth Pulpal debridement for primary and permanent teeth Partial pulpotomy for apexogensis Pulpal therapy for anterior and posterior primary teeth Endodontic therapy and retreatment Treatment for root canal obstruction, incomplete therapy and internal root repair of perforation Apexification: initial, interim and final visits Pulpal regeneration Apicoectomy/Periradicular Surgery Retrograde filling Root amputation Surgical procedure for isolation of tooth with rubber dam Hemisection Canal preparation and fitting of preformed dowel or post Post removal Services require prior authorization with submission of diagnostic materials and documentation of need. Surgical services Gingivectomy and gingivoplasty Gingival flap including root planning Apically positioned flap Clinical crown lengthening Osseous surgery Bone replacement graft – first site and additional sites Biologic materials to aid soft and osseous tissue regeneration Guided tissue regeneration Surgical revision Pedicle and free soft tissue graft Subepithelial connective tissue graft Distal or proximal wedge Soft tissue allograft Combined connective tissue and double pedicle graft Non-Surgical Periodontal Service Provisional splinting – intracoronal and extracoronal – can be considered for treatment of dental trauma Periodontal root planing and scaling – with prior authorization, can be considered every 6 months for individuals with special healthcare needs Full mouth debridement to enable comprehensive evaluation Localized delivery of antimicrobial agents Periodontal maintenance

Diagnostic Services. Indicated diagnostic services that can be considered every 3 months for individuals with special healthcare needs are denoted with an asterisk. Clinical oral evaluations once every 6 months * Comprehensive oral evaluation– complete evaluation which includes a comprehensive and thorough inspection of the oral cavity to include diagnosis, an oral cancer screening, charting of all abnormalities, and development of a complete treatment plan allowed once per year with subsequent service as periodic oral evaluation Periodic oral evaluation – subsequent thorough evaluation of an established patient* Oral evaluation for patient under the age of 3 and counseling with primary caregiver* Limited oral evaluations that are problem focused Detailed oral evaluations that are problem focused Diagnostic Imaging with interpretation A full mouth series can be provided every 3 years. The number of films/views expected is based on age with the maximum being 16 intraoral films/views. An extraoral panoramic film/view and bitewings may be substituted for the full mouth series with the same frequency limit. Additional films/views needed for diagnosing can be provided as needed. Bitewings, periapicals, panoramic and cephlometric radiographic images Intraoral and extraoral radiographic images Oral/facial photographic images Maxillofacial MRI, ultrasound Cone beam image capture Tests and Examinations Viral culture Collection and preparation of saliva sample for laboratory diagnostic testing Diagnostic casts – for diagnostic purposes only and not in conjunction with other services Oral pathology laboratory Accession/collection of tissue, examination – gross and microscopic, preparation and transmission of written report Accession/collection of exfoliative cytologic smears, microscopic examination, preparation and transmission of a written report Other oral pathology procedures, by report * Indicates preventive services that can be considered every 3 months for individuals with special healthcare needs are denoted with an asterisk. Dental prophylaxis once every 6 months* Topical fluoride treatment once every 6 months – in conjunction with prophylaxis as a separate service* Fluoride varnish once every 3 months for children under the age of 6 Sealants, limited to one time application to all occlusal surfaces that are unfilled and caries free, in premolars and permanent molars. Replacement of sealants can be considered with prior authorization. Space maintainers – to maintain space for eruption of permanent tooth/teeth, includes placement and removal fixed – unilateral and bilateral removable – bilateral only recementation of fixed space maintainer removal of fixed space maintainer – considered for provider that did not place appliance There are no frequency limits on replacing restorations (fillings) or crowns. Request for replacement due to failure soon after insertion, may require documentation to demonstrate material failure as the cause. Reimbursement will include the restorative material and all associated materials necessary to provide the standard of care, polishing of restoration, and local anesthesia. The reimbursement for any restoration on a tooth shall be for the total number of surfaces to be restored on that date of service. Only one procedure code is reimbursable per tooth except when amalgam and composite restorations are placed on the same tooth. Reimbursement for an occlusal restoration includes any extensions onto the occlusal one-third of the buccal, facial or lingual surface(s) of the tooth. Extension of interproximal restorations into self-cleansing areas will not be considered as additional surfaces. Extension of any restoration into less than 1/3 of an adjacent surface is not considered an additional surface and will not be reimbursable (or if paid will be recovered). Restorative service to include: Restorations (fillings) – amalgam or resin based composite for anterior and posterior teeth. Service includes local anesthesia, pulp cap (direct or indirect) polishing and adjusting occlusion. Gold foil - . Service includes local anesthesia, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Inlay/onlay restorations – metallic, service includes local anesthesia, cementation, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Service requires prior authorization and will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor long term prognosis Service includes local anesthesia, temporary crown placement, insertion with cementation, polishing and adjusting occlusion. Provisional crowns are not covered. Recement of inlay, onlay, custom fabricated/cast or prefabricated post and core and crown, Prefabricated stainless steel, stainless steel crown with resin window and resin crowns. Service includes local anesthesia, insertion with cementation and adjusting occlusion. Core buildup including pins Pin retention Indirectly fabricated (custom fabricated/cast) and prefabricated post and core Additional fabricated ( custom fabricated/cast) and prefabricated post Post removal Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture Coping Crown repair Protective restoration/sedative filling Service includes all necessary radiographs or views needed for endodontic treatment. Teeth must be in occlusion, periodontally sound, needed for function and have good long term prognosis. Emergency services for pain do not require prior authorization. Service requires prior authorization and will not be considered for teeth that are not in occlusion or function and have poor long term prognosis. Endodontic service to include: Therapeutic pulpotomy for primary and permanent teeth Pulpal debridement for primary and permanent teeth Partial pulpotomy for apexogensis Pulpal therapy for anterior and posterior primary teeth Endodontic therapy and retreatment Treatment for root canal obstruction, incomplete therapy and internal root repair of perforation Apexification: initial, interim and final visits Pulpal regeneration Apicoectomy/Periradicular Surgery Retrograde filling Root amputation Surgical procedure for isolation of tooth with rubber dam Hemisection Canal preparation and fitting of preformed dowel or post Post removal Services require prior authorization with submission of diagnostic materials and documentation of need. Surgical services Gingivectomy and gingivoplasty Gingival flap including root planning Apically positioned flap Clinical crown lengthening Osseous surgery Bone replacement graft – first site and additional sites Biologic materials to aid soft and osseous tissue regeneration Guided tissue regeneration Surgical revision Pedicle and free soft tissue graft Subepithelial connective tissue graft Distal or proximal wedge Soft tissue allograft Combined connective tissue and double pedicle graft Non-Surgical Periodontal Service Provisional splinting – intracoronal and extracoronal – can be considered for treatment of dental trauma Periodontal root planing and scaling – with prior authorization, can be considered every 6 months for individuals with special healthcare needs Full mouth debridement to enable comprehensive evaluation Localized delivery of antimicrobial agents Periodontal maintenancemaintenance All dentures, fixed prosthodontics (fixed bridges) and maxillofacial prosthetics require prior authorization. New dentures or replacement dentures may be considered every 7 ½ years unless dentures become obsolete due to additional extractions or are damaged beyond repair. All needed dental treatment must be completed prior to denture fabrication. Patient identification must be placed in dentures in accordance with State Board regulation. Insertion of dentures includes adjustments for 6 months post insertion. Prefabricated dentures or transitional dentures that are temporary in nature are not covered. Prosthodontic services to include: Complete dentures and immediate complete dentures – maxillary and mandibular to address masticatory deficiencies. Excludes prefabricated dentures or dentures that are temporary in nature Partial denture – maxillary and mandibular to replace missing anterior tooth/teeth (central incisor(s), lateral incisor(s) and cuspid(s)) and posterior teeth where masticatory deficiencies exist due to fewer than eight posterior teeth (natural or prosthetic) resulting in balanced occlusion. Resin base and cast frame dentures including any conventional clasps, rests and teeth Flexible base denture including any clasps, rests and teeth Removable unilateral partial dentures or dentures without clasps are not considered Overdenture – complete and partial Denture adjustments –6 months after insertion or repair Denture repairs – includes adjustments for first 6 months following service Denture rebase – following 12 months post denture insertion and subject to prior authorization denture rebase is covered and includes adjustments for first 6 months following service Denture relines – following 12 months post denture insertion denture relines are covered once a year without prior authorization and includes adjustments for first 6 months following service Precision attachment, by report Maxillofacial prosthetics - includes adjustments for first 6 months following service Facial moulage, nasal, auricular, orbital, ocular, facial, nasal septal, cranial, speech aid, palatal augmentation, palatal lift prosthesis – initial, interim and replacement Obturator prosthesis: surgical, definitive and modifications Mandibular resection prosthesis with and without guide flange Feeding aid Surgical stents Radiation carrier Fluoride gel carrier Commissure splint Surgical splint Topical medicament carrier Adjustments, modification and repair to a maxillofacial prosthesis Maintenance and cleaning of maxillofacial prosthesis Implant Services – are limited to cases where facial defects and or deformities resulting from trauma or disease result in loss of dentition capable of supporting a maxillofacial prosthesis or cases where documentation demonstrates lack of retention and the inability to function with a complete denture for a period of two years. Covered services include: implant body, abutment and crown. Fixed prosthodontics (fixed bridges) – are selective and limited to cases with an otherwise healthy dentition with unilateral missing tooth or teeth generally for anterior replacements where adequate space exists. The replacement of an existing defective fixed bridge is also allowed when noted criteria are met. A child with special health needs that result in the inability to tolerate a removable denture can be considered for a fixed bridge or replacement of a removable denture with a fixed bridge. Considerations and requirements noted for single crowns apply Posterior fixed bridge is only considered for a unilateral case when there is masticatory deficiency due to fewer than eight posterior teeth in balanced occlusion with natural or prosthetic teeth. Abutment teeth must be periodontally sound and have a good long term prognosis Repair and recementation Pediatric partial denture – for select cases to maintain function and space for permanent anterior teeth with premature loss of primary anterior teeth, subject to prior authorization. Local anesthesia, suturing and routine post op visit for suture removal are included with service. Extraction of teeth: Extraction of coronal remnants – deciduous tooth, Extraction, erupted tooth or exposed root Surgical removal of erupted tooth or residual root Impactions: removal of soft tissue, partially boney, completely boney and completely bony with unusual surgical complications Extractions associated with orthodontic services must not be provided without proof that the orthodontic service has been approved. Other surgical Procedures Oroantral fistula Primary closure of sinus perforation and sinus repairs Tooth reimplantation of an accidentally avulsed or displaced by trauma or accident Surgical access of an unerupted tooth Mobilization of erupted or malpositioned tooth to aid eruption Placement of device to aid eruption Biopsies of hard and soft tissue, exfoliative cytological sample collection and brush biopsy Surgical repositioning of tooth/teeth Transseptal fiberotomy/supra crestal fiberotomy Surgical placement of anchorage device with or without flap Harvesting bone for use in graft(s) Alveoloplasty in conjunction or not in conjunction with extractions Vestibuloplasty Excision of benign and malignant tumors/lesions Removal of cysts (odontogenic and nonodontogenic) and foreign bodies Destruction of lesions by electrosurgery Removal of lateral exostosis, torus palatinus or torus madibularis Surgical reduction of osseous tuberosity Resections of maxilla and mandible - Includes placement or removal of appliance and/or hardware to same provider. Surgical Incision Incision and drainage of abcess - intraoral and extraoral Removal of foreign body Partial ostectomy/sequestrectomy Maxillary sinusotomy Fracture repairs of maxilla, mandible and facial bones – simple and compound, open and closed reduction. Includes placement or removal of appliance and/or hardware to same provider. Reduction of dislocation and management of other temporomandibular joint dysfunctions (TMJD), with or without appliance. Includes placement or removal of appliance and/or hardware to same provider. Reduction - open and closed of dislocation. Includes placement or removal of appliance and/or hardware to same provider. Manipulation under anesthesia Condylectomy, discectomy, synovectomy Joint reconstruction Services associated with TMJD treatment require prior authorization Arthrotomy, arthroplasty, arthrocentesis and non-arthroscopic lysis and lavage Arthroscopy Occlusal orthotic device – includes placement and removal to same provider Surgical and other repairs Repair of traumatic wounds – small and complicated Skin and bone graft and synthetic graft Collection and application of autologous blood concentrate Osteoplasty and osteotomy XxXxxx I, II, III with or without bone graft Graft of the mandible or maxilla – autogenous or nonautogenous Sinus augmentations Repair of maxillofacial soft and hard tissue defects Frenectomy and frenoplasty Excision of hyperplastic tissue and pericoronal gingiva Sialolithotomy, sialodochoplasty, excision of the salivary gland and closure of salivary fistula Emergency tracheotomy