Attach_J-2_Benefits_Amend_1.doc

Attachment J-2

Benefits, Limitations and Exclusions

INTRODUCTION

Covered dental services must meet accepted standards of dental practice. All dental procedures in this document conform to the 2013 version of the American Dental Association (ADA) Code on Dental Procedures and Nomenclature, in the Current Dental Terminology (CDT). Active Duty Service Members (ADSMs) may receive any covered services listed in this document. Treatment for the following services will be initiated within a 21-day access standard:

· Examination and Diagnosis

· Dental prophylaxis

· Preventive

· Routine Restorative

Specialty consultations will be provided within a 28-day access standard. Dental emergency treatment will be provided within a 24-hour access standard. If a Dental Treatment Facility (DTF) cannot provide a covered dental service within the access standard, the DTF may refer the ADSM for care if that treatment is available elsewhere within the access standard.

Benefits and limitations describe in this document apply to Remote ADSM care and not to DTF Referred care.

GENERAL POLICIES

Supplemental healthcare benefits are intended to be an adjunct, not a replacement for, active duty dental treatment facility (DTF) dental care. Treatment and services not immediately required to establish or maintain dental health to meet dental readiness or world-wide deployability standards may be delayed until this treatment can be provided at an active duty DTF. All treatment and procedures should be reported following the guidelines and definitions of the most current version of the ADA’s CDT.

Except as specifically provided, the following services, supplies, or charges are not covered for supplemental healthcare funding unless specifically authorized by the Services' Dental Corps Chief(s) or designated representative(s) (e.g., DSPOCs):

1. Any dental service or treatment not specifically listed as a Covered Service.

2. Any dental service or treatment determined to be unnecessary or which do not meet accepted standards of dental practice.

3. Those services not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, only those covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law will be eligible for payment or reimbursement.

4. Those services submitted by a dental provider that are for the same service(s) performed on the same date for the same member by another dental provider.

5. Those services which are experimental or investigative in nature.

6. Those services which are for any illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provision of any legislation of any governmental unit. This exclusion applies whether or not the member claims the benefits or compensation.

7. Those services which are later recovered in a lawsuit or in a compromise or settlement of any claim, except where prohibited by law.

8. Those services provided free of charge by any governmental unit, except where this exclusion is prohibited by law.

9. Those services for which the member would have no obligation to pay in the absence of this or any similar coverage.

10. Those services received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group.

11. Those services performed prior to the member’s effective coverage date. This includes any treatment for crowns, inlays, onlays, cast post and cores, or dentures/bridges initiated prior to the effective date of the member’s eligibility.

12. Those services provided after the termination date of the member’s eligibility for coverage unless otherwise indicated. This includes those prosthesis delivered after the termination date of active duty eligibility and any treatment for crowns, inlays, onlays, cast post and cores, or dentures/bridges delivered or inserted prior to the termination date of active duty eligibility. The date of service for prosthodontic services (crowns, inlays, onlays, east post and core, dentures/bridges) is the date of preparation. That date of service should be used when billing.

13. Those services which are for unusual procedures and techniques.

14. Those services performed by a dental provider who is compensated by a facility for similar covered services performed for members.

15. Those services resulting from the patient’s failure to comply with professionally prescribed treatment.

16. Telephone consultations.

17. Any charges for failure to keep a scheduled appointment.

18. Participating providers may not bill patients for the completion of claim forms.

19. Any services or restorations that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances.

20. Duplicate and temporary devices, appliances and services.

21. Plaque control programs, oral hygiene instruction, home care items and dietary instructions.

22. Services including evaluations, which are routinely performed in conjunction with, or as part of, another service are considered integral and will not be paid or reimbursed as a separate charge.

23. Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation and restoration for malalignment of teeth.

24. Gold foil restorations.

25. Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan.

26. Hospital costs or any additional fees that the dental provider or hospital charges for treatment at the hospital (inpatient or outpatient).

27. Medical procedures as well as procedures covered as adjunctive dental care under TRICARE/Medical or other medical benefit coverage.

28. Infection control procedures and fees associated with Occupational Safety and Health Administration (OSHA) and/or governmental agency compliance are considered integral to the dental service(s) provide and will not be paid or reimbursed as a separate charge.

29. Adjunctive dental benefits as defined by applicable federal regulations.

30. Any request for payment more than 12 months after the month in which a service is provided is not eligible for payment. A participating dentist may not bill the member for services that are denied for this reason

EMERGENCY CARE

Emergency care is care that is required to treat or control hemorrhage, infection, swelling and pain. This includes treatment necessary to relieve pain, treat infection, or control hemorrhage to include: temporary or permanent fillings, root canal treatment, single tooth extractions, incision and drainage or other immediate required treatment. Crowns, bridges and dentures are not considered emergency care and require authorization (see below). For example, root canal therapy required to relieve pain or treat infection can be completed without authorization even if this treatment requires more than one appointment. If a crown is indicated following the root canal therapy, the crown must have authorization before initiating the crown preparation.

COVERED SERVICES

To be considered a Covered Service a procedure or treatment must meet the requirement of being appropriate and necessary to establish and maintain dental health to meet military worldwide readiness/deployment status.

In addition, non-emergency covered services that exceed $750 per procedure or appointment or $1500 for any episode of treatment requires authorization to be considered for payment or reimbursement. (See definition of Emergency Care.) This includes appointments where routine care under $750 may be combined with specialty care provided on the same date of service. In these cases, authorization for all care is required even if a portion of it has been previously approved. Certain procedures will always need an authorization regardless of the cost as indicated in this attachment. Authorization requirements may vary for each specific procedure but generally require the submission of a current diagnostic-quality periapical x-ray. A brief narrative report of the specific service(s) to be performed is recommended if there are any factors that may affect the care provided. Initiating dental care requiring authorization without written authorization may result in the service member being responsible for part or all cost of treatment. If the dental provider initiates this care without receiving written authorization, the provider has the responsibility to obtain written consent from the service member clearly explaining this financial responsibility and risk. Substitution of a non-covered service for a covered service is not allowed even if the fee for the non-covered service is less than or equal to the covered service. Therefore, obtaining a written authorization of benefit is highly recommended prior to initiating care.

For each CDT Code listed, there is a letter code define in the table below. All four codes are only applicable to remote ADDP utilization. The code ‘N’ is the only one that applies for DTF referred care.

D0100-D0999 I. DIAGNOSTIC

Benefits and Limitations for Diagnostic Services

1. For Remote ADSMs, two routine examinations per year are covered without obtaining authorization. Oral evaluations are considered integral when provided on the same date of service as palliative or surgical procedure(s) by the same dental provider. If a Remote ADSM desires a second opinion, he/she may obtain a third exam from a different performing provider without obtaining authorization.

2. Only one limited oral evaluation, problem-focused (D0140) will be allowed per patient per dentist in a 12 consecutive month period.

3. For a limited oral evaluation - problem focused or palliative (emergency) treatment to be covered, it must involve a problem or symptom that occurred suddenly and unexpectedly and require immediate attention.

4. Re-evaluations are considered integral procedures.

5. X-rays which are not of diagnostic quality are not covered and may not be charged to the patient when provided by a participating dentist.

6. Unless approved by DSPOC, one complete series of x-rays or one panoramic x-ray is covered in a 36 month period for Remote ADSMs.

7. Unless approved by DSPOC, one set of bitewing x-rays, consisting of up to four bitewing x-rays per visit, is covered during a 12 consecutive month period for Remote ADSMs.

8. Vertical bitewings (D0277) will be paid at the same allowance as four bitewings and are subject to the same benefit limitations as four bitewing x-rays.

9. Periapical x-rays are covered, when necessary.

10. X-rays are not a covered benefit when taken by an x-ray laboratory, unless billed by a licensed dental provider.

11. If the total allowance for individually reported periapical and/or bitewing x-rays equals or exceeds the allowance for a complete series, the individually reported x-rays are paid as a complete series and are subject to the same benefit limitations as a complete series. Any difference in fees may not be charged to the member by a participating dentist.

12. Periapical and/or bitewing x-rays are considered integral when performed on the same date of service, by the same dental provider, as a complete series of x-rays.

13. Bitewing x-rays are not considered integral when performed on the same date of service as a panoramic x-ray; they may be paid as a separate service.

14. Pulp vitality tests are considered integral to all services.

15. Caries susceptibility tests are not payable unless specifically authorized in writing prior to initiating this service. This service will be considered only in conjunction with an intensive regimen of home preventive therapy (including prescription mouth rinses) to determine if the therapy should be continued. The test is payable once per regimen. The regimen must be initiated immediately following completion of restorative care for a recent episode of rampant caries.

16. Caries susceptibility tests are not payable on a routine basis, for patients with un-restored carious lesions, or when performed for patient education.

17. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral to the restorative procedure. Diagnostic casts are not covered as independent procedures.

18. A panoramic radiograph (D0330) is covered when performed by an oral surgeon.

19. The Contractor may reimburse dental care not indicated on the DTF referral/authorization if the service provided is a panoramic radiograph (D0330) performed by an oral surgeon. For all provider specialties, the Contractor may issue reimbursement for up to two bitewing radiographs (D0270/D0272) or two periapical radiographs (D0220/D0230). Additionally, the Contractor may reimburse for a limited oral evaluation-problem focused (D0140).

20. Lab fees for biopsies are a covered benefit at 100% of charge. The contractor does not pay the lab directly but will reimburse the provider if a lab invoice is submitted with the claim. If the member has paid for the lab fee, the contractor will reimburse the member at 100% of charge.

CLINICAL ORAL EVALUATIONS

D0120 R periodic oral evaluation – established patient D0140 R limited oral evaluation - problem focused D0150 R comprehensive oral evaluation –new or established patient

D0160 R detailed and extensive oral evaluation - problem focused, by report D0170 R re-evaluation-limited, problem focused (established patient, not post-operative visit)

D0180 R comprehensive periodontal evaluation – new or established patient

PRE-DIAGNOSTIC SERVICES

D0190 N screening of a patient

D0191 N assessment of a patient

DIAGNOSTIC IMAGING

D0210 R intraoral - complete series of radiographic images

D0220 R intraoral - periapical first radiographic image D0230 R intraoral - periapical each additional radiographic image D0240 R intraoral - occlusal radiographic image D0250 R extraoral - first radiographic image D0260 R extraoral - each additional radiographic image D0270 R bitewing - single radiographic image D0272 R bitewings - two radiographic images D0273 R bitewings – three radiographic images D0274 R bitewings - four radiographic images D0277 R vertical bitewings - 7 to 8 radiographic images D0290 S posterior-anterior or lateral skull and facial bone survey radiographic image

D0310 R sialography

D0320 S temporomandibular joint arthrogram, including injection

D0321 S other temporomandibular joint radiographic images, by report

D0322 S tomographic survey

D0330 R panoramic radiographic image D0340 S cephalometric radiographic image D0364 S cone beam CT capture and interpretation with limited field of view – less than one whole jaw

D0365 S cone beam CT capture and interpretation with field of view of one full dental arch – mandible

D0366 S cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium

D0367 S cone beam CT capture and interpretation with field of view of both jaws, with or without cranium

D0368 S cone beam CT capture and interpretation for TMJ series including two or more exposures

D0369 S maxillofacial MRI capture and interpretation

D0370 S maxillofacial ultrasound capture and interpretation

D0371 S sialoendoscopy capture and interpretation

D0380 S cone beam CT image capture with limited field of view – less than one whole jaw

D0381 S cone beam CT image capture with field of view of one full dental arch – mandible

D0382 S cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium

D0383 S cone beam CT image capture with field of view of both jaws, with or without cranium

D0384 S cone beam CT image capture for TMJ series including two or more exposures

D0385 S maxillofacial MRI image capture

D0386 S maxillofacial ultrasound image capture

D0391 S interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

TESTS EXAMINATIONS

D0415 S collection of microorganisms for culture and sensitivity

D0416 S viral culture D0417 S collection and preparation of saliva sample for laboratory diagnostic testing

D0418 S analysis of saliva sample D0421 S genetic test for susceptibility to oral diseases D0425 S caries susceptibility test D0431 N adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

ORAL PATHOLOGY LABORATORY (Use Codes D0472 – D0502) D0472 S accession of tissue, gross examination, preparation and transmission of written report

D0473 S accession of tissue, gross and microscopic examination, preparation and transmission of written report

D0474 S accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

D0475 S decalicification procedure

D0476 S special stains for microorganisms

D0477 S special stains, not for microorganisms

D0478 S immunohistochemical stains

D0479 S tissue in-situ hybridization, including interpretation

D0480 S accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

D0481 S electron microscopy – diagnostic

D0482 S direct immunofluorescence

D0483 S indirect immunofluorescence

D0484 S consultation on slides prepared elsewhere

D0485 S consultation, including preparation of slides from biopsy material supplied by referring source D0486 S laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report D0502 S other oral pathology procedures, by report D0999 N unspecified diagnostic procedure, by report

D1000-D1999 II. PREVENTIVE

Benefits and Limitations for Preventive Services

1. Two routine prophylaxes are covered in a 12 consecutive month period. Additional prophylaxes in a 12-month period must be approved by the DSPOC.

2. Routine prophylaxes are considered integral when performed by the same dental provider/facility on the same day as scaling and root planing, periodontal surgery and periodontal maintenance procedures.

3. A routine prophylaxis is considered integral when performed in conjunction with, or as a finishing procedure to, periodontal scaling and root planing, periodontal maintenance, gingivectomies, gingival flap procedures, mucogingival surgery, osseous surgery or curettage.

4. A routine prophylaxis includes associated scaling and polishing procedures. There are no provisions for any additional allowance based on degree of difficulty.

5. Two topical fluoride applications are covered in a consecutive 12-month period when performed as independent procedures. Additional fluoride applications must be preauthorized. The use of a prophylaxis paste containing fluoride qualifies for payment only as a prophylaxis.

6. Topical fluoride applications (D1204) are covered when provided as part of an intensive regimen of home preventive therapy to treat rampant caries. This service is only covered if authorized in writing prior to initiating the service.

Benefits and Limitations for Sealants

1. Sealants for teeth other than permanent bicuspids and permanent molars are not covered.

2. Sealants provided on the same date of service and on the same tooth as a restoration involving the occlusal surface are considered integral procedures.

DENTAL PROPHYLAXIS

D1110 R prophylaxis – adult

TOPICAL FLUORIDE TREATMENT (Office Procedure) D1206 R topical application of fluoride varnish D1208 R topical application of fluoride

OTHER PREVENTIVE SERVICES

D1351 S sealant – per tooth

D1352 S preventive resin restoration in a moderate to high caries risk patient – permanent tooth

D2000-D2999 III. RESTORATIVE

Benefits and Limitations for Restorative Services

1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral.

2. The payment for restorations includes all related services including, but not limited to, etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments and detection agents.

3. Pin retention is covered only when reported in conjunction with an eligible restoration.

4. An amalgam or resin restoration reported with a pin (D2951), in addition to a crown, is considered to be a pin-retained core buildup (D2950).

5. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes of determining benefits.

6. Restorative services are covered only when necessary due to decay or fracture. Restorative services are not benefits when performed for cosmetic purposes.

7. Restorative services that are needed due to attrition, erosion, abrasion, or congenital or developmental defects require authorization.

8. Multiple restorations performed on the same surface of a tooth, without involvement of a second surface, on the same date of service and by the same dental provider/facility, will be processed as a single surface restoration.

9. A restoration involving two or more surfaces should be reported using the appropriate multiple surface restoration code.

10. If multiple restorations involving multiple surfaces with at least one common surface are reported, an allowance will be made for a single restoration reflecting the number of different surfaces involved.

11. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 12 months of the original restoration are considered integral procedures and a separate fee is not chargeable to the member by a participating dentist. However, payment may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth or is required to restore the tooth following root canal therapy.

12. Restorations performed on the same tooth and by the same dentist/facility within twelve months following the placement of any type of crown or onlay are considered integral.

13. For reporting and benefit purposes, the completion date for crowns, onlays and buildups is the preparation date.

14. The charge for a crown or onlay should include all charges for work related to its placement and any follow-up care including, but not limited to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try-in visits, limited occlusal adjustments and cementations of both temporary and permanent crowns.

15. Prefabricated stainless steel crowns (with resin windows for anterior and premolar teeth) are covered only when authorized in writing prior to initiating the procedure.

AMALGAM RESTORATIONS (Including Polishing) D2140 R amalgam - one surface, permanent or primary

D2150 R amalgam - two surfaces, permanent or primary

D2160 R amalgam - three surfaces, permanent or primary

D2161 R amalgam - four or more surfaces, permanent or primary

RESIN-BASED COMPOSITE RESTORATIONS - DIRECT

D2330 R resin-based composite - one surface, anterior

D2331 R resin-based composite - two surfaces, anterior

D2332 R resin-based composite - three surfaces, anterior

D2335 R resin-based composite - four or more surfaces or involving incisal angle (anterior) D2390 S resin-based composite crown, anterior

D2391 R resin-based composite - one surface, posterior

D2392 R resin-based composite - two surfaces, posterior

D2393 R resin-based composite - three surfaces, posterior

D2394 R resin-based composite – four or more surfaces, posterior

GOLD FOIL RESTORATIONS

D2410 N gold foil – one surface

D2420 N gold foil – two surfaces

D2430 N gold foil – three surfaces

INLAY/ONLAY RESTORATIONS

D2510 N inlay – metallic – one surface

D2520 N inlay – metallic – two surfaces

D2530 N inlay – metallic – three or more surfaces

D2542 S onlay - metallic-two surfaces

D2543 S onlay - metallic-three surfaces

D2544 S onlay - metallic-four or more surfaces

CROWNS - SINGLE RESTORATIONS ONLY

D2710 N crown – resin-based composite (indirect) D2712 N crown – ¾ resin-based composite (indirect)

D2750 S crown - porcelain fused to high noble metal

D2751 N crown - porcelain fused to predominantly base metal

D2752 S crown - porcelain fused to noble metal

D2780 S crown - ¾ cast high noble metal

D2781 N crown - ¾ cast predominantly base metal

D2782 S crown - ¾ cast noble metal

D2790 S crown - full cast high noble metal

D2791 N crown - full cast predominantly base metal

D2792 S crown - full cast noble metal

D2794 S crown - titanium

OTHER RESTORATIVE SERVICES

Benefits and Limitations for Other Restorative Services

1. For Remote ADSMs, replacement of crowns, onlays, buildups and posts and cores is covered only if the existing crown, onlay, buildup, or post and core was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing crown, onlay, buildup, or post and core is not and cannot be made serviceable. Prostheses for Remote ADSMs prior to the five-year replacement period must be approved by a DSPOC. The five year time limitation on crowns, onlays, buildups and posts and cores does not apply if the member moves as a result of a Permanent Change of Station (PCS) relocation at least 40 miles from the original servicing location. The five year service date is measured based on the actual date (day and month) of the initial service versus the first day of the initial service month.

2. Temporary crowns are usually preformed artificial crowns, which are fitted over a damaged tooth as an immediate protective device. This is not to be used as temporization during crown fabrication.

3. Recementation of prefabricated and cast crowns, bridges, onlays, inlays and posts within six months of placement by the same dental provider/facility is considered integral to the original procedure.

4. Onlays, crowns and posts and cores are payable only when necessary due to decay or fracture. If the tooth can be adequately restored with amalgam or composite (resin) filling material, then authorization for restoration of the tooth will be limited to the lesser restorative procedure. This payment cannot be applied toward other treatment.

5. Substitution of a non-covered service for a covered service is not allowed even if the fee for the non-covered service is less than or equal to the covered service.

6. Posts are only eligible when provided as part of a core buildup and are considered integral to the buildup procedure. A separate charge for a post as an independent procedure is not a covered benefit.

7. Porcelain ceramic and composite resin inlays are not covered benefits, unless approved by a DSPOC.

8. Glass ionomer restorations are not a covered benefit in load bearing areas. Payment for glass ionomer restorations in non-load bearing areas will be made based upon the fees for amalgam restorations for posterior teeth or resin restorations for anterior teeth.

9. Protective restorations are not a covered benefit. However, if a protective restoration is provided on an emergency basis, it may be considered for payment or reimbursement as palliative emergency treatment.

D2910 R recement inlay, onlay, or partial coverage restoration D2915 S recement cast or prefabricated post and core

D2920 R recement crown D2931 S prefabricated stainless steel crown - permanent tooth

D2932 N prefabricated resin crown

D2933 N prefabricated stainless steel crown with resin window D2940 E protective restoration D2950 S core buildup, including any pins D2951 R pin retention - per tooth, in addition to restoration

D2952 S post and core in addition to crown, indirectly fabricated D2953 N each additional indirectly fabricated post - same tooth D2954 S prefabricated post and core in addition to crown D2955 S post removal D2957 N each additional prefabricated post - same tooth D2960 N labial veneer (resin laminate) – chairside D2970 S temporary crown (fractured tooth) D2971 S additional procedures to construct new crown under existing partial denture framework

D2975 S coping

D2980 R crown repair, necessitated by restorative material failure D2981 N inlay repair necessitated by restorative material failure

D2982 N onlay repair necessitated by restorative material failure

D2983 N veneer repair necessitated by restorative material failure

D2990 S resin infiltration of incipient smooth surface lesions

D2999 N unspecified restorative procedure, by report

D3000-D3999 IV. ENDODONTICS

Benefits and Limitations for Endodontic Services

1. When endodontic services are performed by a general dentist, post treatment radiograph is required prior to approval of payment for services.

2. Direct pulp caps are considered an integral service when provided on the same date as a restoration.

3. Indirect pulp caps are considered integral to the restoration.

4. Pulpotomies are considered integral when performed by the same dentist who completes the root canal therapy.

5. Pulpotomies performed on permanent teeth are considered integral to root canal therapy and are not reimbursable unless specific rationale is provided and root canal therapy is not and will not be provided on the same tooth.

6. Pulpal therapy (resorbable filling) is limited to primary teeth with unerupted succedaneous permanent teeth only and therefore not generally covered for active duty service members. If covered, it is a benefit once per tooth per lifetime. Payment for the pulpal therapy will be offset by the allowance for a pulpotomy provided within 45 days preceding pulpal therapy on the same tooth by the same dental provider.

7. Gross pulpal debridement is considered integral to root canal therapy or palliative emergency treatment when provided on the same day by the same dental provider.

8. Treatment of a root canal obstruction is considered an integral procedure to the root canal therapy.

9. Incomplete endodontic therapy is not a covered benefit when due to the patient discontinuing treatment. All other circumstances require a report.

10. The placement of a post is not a covered benefit when provided as an independent procedure. Posts are eligible only when provided as part of a crown buildup and are considered integral to the buildup procedure.

11. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed.

12. Final restoration is covered separately and not part of endodontic therapy.

13. Simple incision and drainage reported without root canal therapy will be processed as palliative treatment.

14. Simple incision drainage reported with root canal therapy is considered integral to the root canal therapy.

PULPOTOMY

D3220 N therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament D3221 R pulpal debridement, primary and permanent teeth ENDODONTIC THERAPY (Including Treatment Plan, Clinical Procedures and Follow-Up Care) D3310 S endodontic therapy - anterior (excluding final restoration)

D3320 S endodontic therapy - bicuspid (excluding final restoration) D3330 S endodontic therapy - molar (excluding final restoration)

D3331 S treatment of root canal obstruction; non-surgical access

D3332 S incomplete endodontic therapy; inoperable, unrestorable, or fractured tooth D3333 S internal root repair of perforation defects

ENDODONTIC RETREATMENT

D3346 S retreatment of previous root canal therapy - anterior

D3347 S retreatment of previous root canal therapy - bicuspid

D3348 S retreatment of previous root canal therapy - molar

APEXIFICATION/RECALCIFICATION AND PULPAL REGENERATION PROCEDURES

D3351 S apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)

D3352 S apexification/recalcification/pulpal regeneration - interim medication replacement D3353 S apexification/recalcification - final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.)

D3354 N pulpal regeneration – (completion of regenerative treatment in an immature permanent tooth with a necrotic pulp); does not include final restoration

APICOECTOMY/PERIRADICULAR SERVICES

D3410 S apicoectomy/periradicular surgery - anterior D3421 S apicoectomy/periradicular surgery - bicuspid (first root) D3425 S apicoectomy/periradicular surgery- molar (first root) D3426 S apicoectomy/periradicular surgery (each additional root) D3430 S retrograde filling - per root D3450 S root amputation - per root D3460 N endodontic endosseous implant D3470 S intentional reimplantation (including necessary splinting)

OTHER ENDODONTIC PROCEDURES

D3950 S canal preparation and fitting of preformed dowel or post D3999 N unspecified endodontic procedure, by report

D4000-D4999 V. PERIODONTICS

Benefits and Limitations for Periodontal Services

1. All periodontal treatment requires written authorization prior to initiating treatment. The exception is emergency treatment required to repair defects caused by traumatic injury and is provided at the time of the initial treatment for that trauma.

2. Gingivectomies, gingival flap procedure, guided tissue regeneration and osseous surgery provided within 24 months of the same surgical periodontal procedure, in the same area of the mouth, are not covered.

3. Gingivectomies or gingivoplasties performed in conjunction with the placement of crowns, onlays, crown buildups, or posts and cores are considered integral to the restorative procedure.

4. Payment for gingivectomy/gingivoplasty will be made as follows:

a) one or two teeth will be paid at the per tooth allowance

b) three or four teeth will be paid at 50 percent of the full quadrant allowance.

5. Soft tissue grafts are processed according to the number of separate sites involved. Separate sites generally must be separated by two or more teeth.

6. Subepithelial connective tissue grafts are payable at the level of free soft tissue grafts.

7. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of teeth (e.g., crater) or surfaces involved. Another site on the same tooth is considered integral to the first site reported. Noncontiguous areas involving different teeth may be reported as additional sites.

8. Bone replacement grafts are eligible for payment or reimbursement when provided to treat periodontal defects. They are not eligible when provided for other reasons such as filling in an extraction site or a defect resulting from an apicoectomy or cyst removal.

9. Periodontal bone grafts are subject to the same limitations and requirements as bone replacement grafts using natural bone

10. Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of the mouth.

11. Osseous surgery performed in a limited area and in conjunction with crown lengthening on the same date of service, by the same dental provider/facility and in the same area of the mouth, will be processed for payment as a crown lengthening.

12. One crown lengthening per tooth, per lifetime, is covered.

13. Periodontal scaling and root planing is indicated to treat periodontal disease, which generally does not occur with frequency in younger patients. Periodontal scaling and root planing submitted for members under the age of 19 should be accompanied by x-rays and periodontal charting. If this information is not available, please provide an explanation regarding the need for periodontal care.

14. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing, or periodontal surgical procedures, in the same area of the mouth requires authorization.

15. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomies, gingival flap procedures, osseous surgery, or curettage.

16. Up to four periodontal maintenance procedures or any combination of routine prophylaxes and periodontal maintenance procedures totaling four may be paid within a 12 consecutive month period.

17. Payment for multiple periodontal surgical procedures (except soft tissue grafts, osseous grafts and guided tissue regeneration) provided in the same area of the mouth during the same course of treatment is based on the fee for the greater surgical procedure. The lesser procedure is considered integral and its allowance is included in the allowance for the greater procedure.

18. Full mouth debridement to enable comprehensive periodontal evaluation (D4355) is covered only once in a 24 month time frame and must be at least 2 years since the last dental prophylaxis. When full mouth debridement is performed on the same date of service as scaling and root planing, periodontal maintenance procedures, or a routine prophylaxis, it is considered integral to these services.

19. Implantology and related services are considered on a case-by case basis and require authorization. Implant services must meet all protocol(s) established by the service member’s branch of Service Dental Corps Chief or designated representative.

20. When covered, all procedures related to the placement of an implant (e.g., bone re-contouring and excision of gingival tissue) are considered integral to the implant placement procedure.

SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE CARE)

D4210 S gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant D4211 S gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant D4212 N gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth D4240 S gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant D4241 S gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant

D4245 S apically positioned flap D4249 S clinical crown lengthening - hard tissue

D4260 S osseous surgery (including flap entry and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant D4261 S osseous surgery (including flap entry and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant D4263 S bone replacement graft - first site in quadrant D4264 S bone replacement graft - each additional site in quadrant

D4266 S guided tissue regeneration - resorbable barrier, per site D4267 S guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) D4268 S surgical revision procedure, per tooth D4270 S pedicle soft tissue graft procedure D4273 S subepithelial connective tissue graft procedures, per tooth D4274 S distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) D4275 N soft tissue allograft

D4276 S combined connective tissue and double pedicle graft, per tooth

D4277 S free soft tissue graft procedure (including donor site surgery), first tooth or dentulous tooth position in a graft

D4278 S free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site

NON-SURGICAL PERIODONTAL SERVICE

D4320 S provisional splinting - intracoronal D4321 S provisional splinting - extracoronal D4341 S periodontal scaling and root planing – four or more teeth per quadrant D4342 S periodontal scaling and root planing – one to three teeth per quadrant D4355 R full mouth debridement to enable comprehensive evaluation and diagnosis D4381 N localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

OTHER PERIODONTAL SERVICES

D4910 R periodontal maintenance D4920 R unscheduled dressing change (by someone other than treating dentist) D4999 N unspecified periodontal procedure, by report D5000-D5899 VI. PROSTHODONTICS (Removable) Benefits and Limitations for Prosthodontic Services

1. All prosthodontic treatment requires written authorization prior to initiating treatment. The exception is emergency treatment required to repair defects caused by traumatic injury and is provided at the time of the initial treatment for that trauma.

2. For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the preparation date. The completion date for removable prosthodontic procedures is the insertion date.

3. Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after the cancellation date of coverage are not eligible for payment or reimbursement.

4. The fee for diagnostic casts (study models) fabricated in conjunction with prosthetic and restorative procedures is considered integral and is included in the fee for these procedures.

5. Tissue conditioning is considered integral when performed on the same day as the delivery of a denture or a reline/rebase.

6. Adjustments provided within six months of the insertion of an initial or replacement denture are integral to the denture.

7. The relining or rebasing of a denture is considered integral when performed within six months following the insertion of that denture.

8. A reline/rebase is covered once in any 36 months.

9. Payment for a denture or an overdenture made with precious metals is based on the allowance for a conventional denture

10. Specialized procedures performed in conjunction with an overdenture are not covered.

11. A fixed partial denture and removable partial denture are not covered benefits in the same arch. Payment will be made for a removable partial denture to replace all missing teeth in the arch.

12. Cast unilateral removable partial dentures are not covered benefits.

13. Precision attachments, personalization, precious metal bases and other specialized techniques are not covered benefits.

14. Temporary fixed partial dentures are not a covered service if provided independently and are considered integral to the allowance for the fixed partial denture procedure when provided in conjunction with a permanent fixed partial denture procedure. They will not be considered for payment or reimbursement.

15. Recementation of crowns, fixed partial dentures, inlays, onlays, or cast posts within six months of their placement by the same dental provider/facility is considered integral to the original procedure.

16. All placement/replacement of removable prostheses (D5110 through D5214) and fixed prostheses (D6210 through D6792) requires approval by a DSPOC.

17. Implantology and related services require authorization for the complete procedure and are considered on a case by case basis. Implant services must meet all protocol(s) established by the service member’s branch of Service Dental Corps Chief or designated representative.

18. Posts are only eligible when provided as part of a core buildup and are considered integral to the buildup procedure. A separate charge for a post as an independent procedure is not a covered benefit.

COMPLETE DENTURES (Including Routine Post-Deliver Care) D5110 S complete denture - maxillary

D5120 S complete denture - mandibular

D5130 S immediate denture - maxillary D5140 S immediate denture - mandibular PARTIAL DENTURES (Including Routine Post-Delivery Care) D5211 S maxillary partial denture - resin base (including any conventional clasps, rests and teeth)

D5212 S mandibular partial denture - resin base (including any conventional clasps, rests and teeth)

D5213 S maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

D5214 S mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5225 S maxillary partial denture – flexible base (including any clasps, rests and teeth)

D5226 S mandibular partial denture – flexible base (including any clasps, rests and teeth) D5281 N removable unilateral partial denture – one piece cast metal (including clasps and teeth)

ADJUSTMENTS TO DENTURES

D5410 R adjust complete denture - maxillary

D5411 R adjust complete denture - mandibular

D5421 R adjust partial denture - maxillary

D5422 R adjust partial denture - mandibular

REPAIRS TO COMPLETE DENTURES

D5510 R repair broken complete denture base

D5520 R replace missing or broken teeth - complete denture (each tooth)

REPAIRS TO PARTIAL DENTURES

D5610 R repair resin denture base

D5620 R repair cast framework

D5630 R repair or replace broken clasp

D5640 R replace broken teeth - per tooth

D5650 S add tooth to existing partial denture

D5660 S add clasp to existing partial denture

D5670 S replace all teeth and acrylic on cast metal framework (maxillary)

D5671 S replace all teeth and acrylic on cast metal framework (mandibular)

DENTURE REBASE PROCEDURES

D5710 S rebase complete maxillary denture

D5711 S rebase complete mandibular denture

D5720 S rebase maxillary partial denture

D5721 S rebase mandibular partial denture

DENTURE RELINE PROCEDURES

D5730 S reline complete maxillary denture (chairside)

D5731 S reline complete mandibular denture (chairside)

D5740 S reline maxillary partial denture (chairside)

D5741 S reline mandibular partial denture (chairside)

D5750 S reline complete maxillary denture (laboratory)

D5751 S reline complete mandibular denture (laboratory)

D5760 S reline maxillary partial denture (laboratory)

D5761 S reline mandibular partial denture (laboratory)

INTERIM PROSTHESIS

D5810 S interim complete denture (maxillary)

D5811 S interim complete denture (mandibular)

D5820 S interim partial denture (maxillary) D5821 S interim partial denture (mandibular)

OTHER REMOVABLE PROSTHETIC SERVICES

D5850 R tissue conditioning, maxillary

D5851 R tissue conditioning, mandibular

D5860 S overdenture - complete, by report D5861 S overdenture - partial, by report D5862 S precision attachment, by report

D5867 S replacement of replaceable part of semi-precision or precision attachment (male or female component)

D5875 S modification of removable prosthesis following implant surgery

D5899 N unspecified removable prosthodontics procedure, by report

D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS

D5911 S facial moulage (sectional) D5912 S facial moulage (complete)

D5913 S nasal prosthesis D5914 S auricular prosthesis D5915 S orbital prosthesis D5916 S ocular prosthesis D5919 S facial prosthesis D5922 S nasal septal prosthesis D5923 S ocular prosthesis, interim D5924 S cranial prosthesis D5925 S facial augmentation implant prosthesis

D5926 S nasal prosthesis, replacement D5927 S auricular prosthesis, replacement D5928 S orbital prosthesis, replacement D5929 S facial prosthesis, replacement D5931 S obturator prosthesis, surgical D5932 S obturator prosthesis, definitive D5933 S obturator prosthesis, modification D5934 S mandibular resection prosthesis with guide flange D5935 S mandibular resection prosthesis without guide flange D5936 S obturator prosthesis, interim D5937 S trismus appliance (not for TMD treatment) D5953 S speech aid prosthesis, adult D5954 S palatal augmentation prosthesis D5955 S palatal lift prosthesis, definitive D5958 S palatal lift prosthesis, interim D5959 S palatal lift prosthesis, modification D5960 S speech aid prosthesis, modification

D5982 S surgical stent D5983 S radiation carrier D5984 S radiation shield D5985 S radiation cone locator D5986 S fluoride gel carrier D5987 S commissure splint D5988 S surgical splint D5991 N topical medicament carrier

D5992 S adjust maxillofacial prosthetic appliance, by report D5993 S maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report

D5999 N unspecified maxillofacial prosthesis, by report

D6200-D6999 IX. PROSTHODONTICS (FIXED)

FIXED PARTIAL DENTURE PONTICS

D6205 N pontic – indirect resin based composite

D6210 S pontic - cast high noble metal

D6211 N pontic - cast predominantly base metal

D6212 S pontic - cast noble metal

D6214 S pontic - titanium

D6240 S pontic - porcelain fused to high noble metal

D6241 N pontic - porcelain fused to predominantly base metal

D6242 S pontic - porcelain fused to noble metal D6245 N pontic – porcelain / ceramic D6250 N pontic - resin with high noble metal

D6251 N pontic - resin with predominantly base metal

D6252 N pontic - resin with noble metal D6253 N provisional pontic – further treatment or completion of diagnosis necessary prior to final impression

FIXED PARTIAL DENTURE RETAINERS - INLAYS/ONLAYS

D6545 S retainer - cast metal for resin bonded fixed prosthesis

D6548 N retainer – porcelain / ceramic for resin bonded fixed prosthesis

D6600 N inlay – porcelain / ceramic, two surfaces

D6601 N inlay – porcelain / ceramic, three or more surfaces

D6602 N inlay - cast high noble metal, two surfaces

D6603 N inlay - cast high noble metal, three or more surfaces

D6604 N inlay – cast predominantly base metal, two surfaces

D6605 N inlay – cast predominantly base metal, three or more surfaces

D6606 N inlay – cast noble metal, two surfaces

D6607 N cast noble metal, three or more surfaces

D6608 N onlay – porcelain / ceramic, two surfaces

D6609 N onlay – porcelain / ceramic, three or more surfaces

D6610 N onlay – cast high noble metal, two surfaces

D6611 N onlay - cast high noble metal, three or more surfaces D6612 N onlay – cast predominantly base metal, two surfaces

D6613 N onlay – cast predominantly base metal, three or more surfaces

D6614 N onlay – cast noble metal, two surfaces

D6615 N onlay – cast noble metal, three or more surfaces

D6624 N inlay – titanium

D6634 N onlay - titanium

FIXED PARTIAL DENTURE RETAINERS - CROWNS

D6710 N crown – indirect resin based composite

D6720 N crown - resin…