Common use of Prosthodontic Services Clause in Contracts

Prosthodontic Services. 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

Prosthodontic Services. 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: : a) Complete dentures and immediate complete dentures – maxillary and mandibular to address masticatory deficiencies. Excludes prefabricated dentures or dentures that are temporary in nature nature b) 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. 1. Resin base and cast frame dentures including any conventional clasps, rests and teeth teeth 2. Flexible base denture including any clasps, rests and teeth teeth 3. Removable unilateral partial dentures or dentures without clasps are not considered considered c) Overdenture – complete and partial partial d) Denture adjustments –6 months after insertion or repair repair e) Denture repairs – includes adjustments for first 6 months following service service f) 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 service g) 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 service h) Precision attachment, by report report i) Maxillofacial prosthetics - includes adjustments for first 6 months following service service 1. Facial moulage, nasal, auricular, orbital, ocular, facial, nasal septal, cranial, speech aid, palatal augmentation, palatal lift prosthesis – initial, interim and replacement replacement 2. Obturator prosthesis: surgical, definitive and modifications modifications 3. Mandibular resection prosthesis with and without guide flange flange 4. Feeding aid aid 5. Surgical stents stents 6. Radiation carrier carrier 7. Fluoride gel carrier carrier 8. 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 provider9. 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 tracheotomysplint

Prosthodontic Services.  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: : a) Complete dentures and immediate complete dentures – maxillary and mandibular to address masticatory deficiencies. Excludes prefabricated dentures or dentures that are temporary in nature nature b) 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. 1. Resin base and cast frame dentures including any conventional clasps, rests and teeth teeth 2. Flexible base denture including any clasps, rests and teeth teeth 3. Removable unilateral partial dentures or dentures without clasps are not considered considered c) Overdenture – complete and partial partial d) Denture adjustments –6 months after insertion or repair repair e) Denture repairs – includes adjustments for first 6 months following service service f) 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 service g) 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 service h) Precision attachment, by report report i) Maxillofacial prosthetics - includes adjustments for first 6 months following service service 1. Facial moulage, nasal, auricular, orbital, ocular, facial, nasal septal, cranial, speech aid, palatal augmentation, palatal lift prosthesis – initial, interim and replacement replacement 2. Obturator prosthesis: surgical, definitive and modifications modifications 3. Mandibular resection prosthesis with and without guide flange flange 4. Feeding aid aid 5. Surgical stents stents 6. Radiation carrier carrier 7. Fluoride gel carrier carrier 8. 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 provider9. 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 tracheotomysplint

Prosthodontic Services. 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 abscess - 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