Surgical Periodontal Services. Surgical periodontal service is the surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • Gingivectomy or gingivoplasty and gingival flap procedures (including root planing) – Benefits are limited to one quadrant every 24 months. • Clinical crown lengthening. • Osseous surgery, including flap entry and closure – Benefits are limited to one per quadrant every 24 months. In addition, osseous surgery performed in a limited area and in conjunction with crown lengthening on the same date of service, by the same Dentist, and in the same area of the mouth, will be processed as crown lengthening in the absence of periodontal disease. • Osseous grafts – Benefits are limited to one per site every 24 months. Benefits are not available for bone grafts in conjunction with extractions, apicoectomy or any non-covered service or non-covered implants. • Soft tissue grafts/allografts (including donor site). • Distal or proximal wedge procedure. Surgical periodontal services performed in conjunction with the placement of crowns, inlays, onlays, crown buildups, posts and cores, or basic restorations are considered part of the restoration. Benefits will not be provided for guided tissue regeneration, or for biologic materials to aid in tissue regeneration. Major Restorative Services Restorative services restore tooth structures lost as a result of dental decay or fracture and include: • Single crown restorations. • Inlay/onlay restorations. • Labial veneer restorations. Benefits will not be provided for the replacement of a lost, missing or stolen appliance and those for replacement of appliances that have been damaged due to abuse, misuse, or neglect. Benefits will not be provided to alter, restore, or correct vertical dimension of occlusion. Such procedures may include, but are not limited to equilibration dentures, crowns, inlays, onlays, bridgework, or dimension or to restore occlusion or to correct attrition, abrasion, erosion, or abfractions. Benefits will not be provided for the restoration of occlusion or incisal edges due to bruxism or harmful habits. Benefits for major restorations are limited to one per tooth every 60 months whether placement was provided under this contract or under any prior dental coverage, even if the original crown was stainless steel. Prosthodontic Services Prosthodontics involve procedures necessary for providing artificial replacements for missing natural teeth and includes: • Co...
Surgical Periodontal Services. Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • periodontal scaling and root planing – Benefits are limited to one per quadrant every 24 months. • scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime. • periodontal maintenance procedures –Benefits are limited to four every 12 months combined with prophylaxis and must be performed following active periodontal treatment. Adjunctive Services Adjunctive general services include: • palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Dentally Necessary for documented Participants with a disability or for a justifiable medical or dental condition. A person’s apprehension does not constitute Dental Necessity. • therapeutic parenteral drugs – Therapeutic parenteral drugs will be covered for a Participant under age 19. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-up care. • apexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection. Benefits will not be provided for the following “Endodontic Services”: • endodontic retreatments provided within 12 months of the initial endodontic therapy by the same Dentist on the same tooth. • pulp vitality tests, endodontic endosseous implants, intentional reimplantations, canal preparation, fitting of preformed dowel and post, or post removal. • endodontic therapy if You discontinue endodontic treatment. Oral Surgery Services Oral surgery means t...
Surgical Periodontal Services. Non‐surgical periodontal service is the non‐surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • Periodontal scaling and root planing—Benefits are limited to one per quad rant every 24 months. • Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once every 12 months. • Periodontal maintenance procedures—Benefits are limited to two every 12 months in combination with routine oral prophylaxis and must be performed following active periodontal treatment. Benefits will not be provided for chemical treatments, localized delivery of chemotherapeutic agents without history of active periodontal therapy, or when performed on the same date (or in close proximity) as active periodontal therapy. Adjunctive Services Adjunctive general services include: • Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • Deep sedation/general anesthesia and intravenous sedation/non‐intravenous conscious sedation—By report only and when determined to be medically necessary for documented persons with a disability or for a justifiable medic al or dental condition. A person's apprehension does not constitute medical necessity. IL‐G‐H‐OF‐2016 82 • Nitrous Oxide analgesia will be covered. • Therapeutic parenteral drug injections will be covered. Benefits will not be provided for local anesthesia or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. • Root canal therapy, including treatment plan, clinical procedures, working and post‐operative radiographs and follow‐up care. • Apexification/recalcification procedures and apicoectomy/periradicular ser vices including Surgery, retograde filling, root amputations and hemisection. Pulpal debridement is considered part of endodontic therapy when performed by the same Provider and not associated with a definitive emergency visit. Benefits will not be provided for the following “Endondontic Services": • Endodontic retreatments provided within 12 months of the initial endodont ic therapy by the same Dentist. • Pulp vitality tests, endodontic endosseous implants, intentional reimplanta tions, canal preparation, fitting of performed dowel and post, or post removal. • Endodontic th...
