J-2 Benefits Exclusions and Limitations v2.docx

Attachment J-2 Benefits, Limitations and Exclusions

These ADSM benefits, exclusions and limitations currently conform to the American Dental Association’s (ADA) Current Dental Terminology (CDT) 2020 Dental Procedure Codes.

1.0. GENERAL POLICIES

1.1. Purchased care dental benefits are intended to be an adjunct, not a replacement for Dental Treatment Facility (DTF) dental care provided to Active Duty Service Members (ADSMs). Treatment and services not immediately required to establish or maintain dental health to meet dental readiness or world-wide deployability standards may be delayed by the DTF or Dental Service Point of Contact (DSPOC) until this treatment can be provided at a DTF. All treatment and procedures should be reported following the guidelines and definitions of the most current version of the ADA’s CDT.

1.2. The following services, supplies, or charges are not covered for purchased care dental benefits unless specifically authorized by the Services' Dental Corps Chief(s) or designated representative(s) (e.g., DSPOCs if remote care and DTF if referred care):

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

1.2.2. Any dental service or treatment determined by the Services' Dental Corps specialty consultants or DSPOC to be unnecessary or which does not meet accepted standards of dental practice.

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

1.2.4. 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.

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

1.2.6. 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.

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

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

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

1.2.10. 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.

1.2.11. 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.

1.2.12. 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 further treatment for crowns, inlays, onlays, cast post and cores, or dentures/bridges that were 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 for all claims.

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

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

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

1.2.16. Telephone consultations.

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

1.2.18. Network providers may not bill patients for the completion of claim forms.

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

1.2.20. Duplicate and temporary devices, appliances and services.

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

1.2.22. 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.

1.2.23. Services applicable to a “per site” payment as defined in the effective ADA CDT Dental Procedure Codes will not be paid as separate charges even if referred multiple times.

1.2.24. 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 mal-alignment of teeth.

1.2.25. Gold foil restorations.

1.2.26. 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.

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

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

1.2.29. 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.

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

1.2.31. Any request for payment of a Continental United States (CONUS) claim more than 12 months after the month the service was provided is not eligible for payment. Any request for payment of an Outside the Continental United States (OCONUS) claim more than 3 years after the month the service was provided is not eligible for payment. A network dentist may not bill the member for services that are denied for this reason.

1.2.32. For remote ADSMs seeking services that include time and frequency limitations, if a service is provided within 30 days of the expiration of the time period, the service shall be considered authorized.

1.2.33. DTFs will not refer elective dental procedures to private sector care.

1.2.34. DTFs shall consult with the DSPOCs prior to referring out an ADSM for implants and the following related services: D6010, D6190, D7950, D7951, and D7952.

2.0. 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 acute pain or treat an acute exacerbation of a periradicular 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.

3.0. COVERED SERVICES

3.1. To be considered a covered service, a procedure or treatment must be appropriate and necessary to establish and maintain dental health to meet military worldwide readiness/deployment status.

3.2. 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 was 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.

3.3. For each CDT Code listed, there is a letter code defined in the table below. All four codes are only applicable to remote ADSM utilization. The code “N” only applies for DTF referred care; that is the DSPOCs may authorize care that is not typically covered care.

4.0. DIAGNOSTIC – D0100-D0999

Clinical Oral Evaluations

Pre-Diagnostic Services

Diagnostic Imaging

Tests Examinations

Oral Pathology Laboratory

4.1. Benefits and Limitations for Diagnostic Services:

4.1.1. For Remote ADSMs, two routine examinations per consecutive 12-month period 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. Radiographic images completed during the third exam on the same day, by the same provider, in support of a second opinion are covered for payment.

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

4.1.3. 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.

4.1.4. Re-evaluations are considered integral procedures.

4.1.5. Radiographic images which are not of diagnostic quality are not covered and may not be charged to the patient when provided by a network dentist. The contractor or DSPOC may determine the diagnostic quality of the radiograph; however, the DSPOC has final determination of the level of quality.

4.1.6. Unless approved by DSPOC, one complete series of radiographic images or one panoramic radiographic image is covered in a 36-month period for Remote ADSMs.

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

4.1.8. Vertical bitewings (D0277) will be paid at the same allowance as four bitewings and are subject to the same benefit limitations as four bitewing radiographic images.

4.1.9. Periapical radiographic images are covered, when necessary.

4.1.10. Radiographic images are not a covered benefit when taken by an x-ray laboratory, unless billed by a licensed dental provider.

4.1.11. If the total allowance for individually reported periapical and/or bitewing radiographic images equals or exceeds the allowance for a complete series, the individually reported radiographic images 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 network dentist.

4.1.12. Periapical and/or bitewing radiographic images are considered integral when performed on the same date of service, by the same dental provider, as a complete series of radiographic images.

4.1.13. Bitewing radiographic images are not considered integral when performed on the same date of service as a panoramic radiographic image; they may be paid as a separate service.

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

4.1.15. 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.

4.1.16. Caries susceptibility tests are not payable on a routine basis, for patients with unrestored carious lesions, or when performed for patient education.

4.1.17. 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.

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

4.1.19. 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).

4.1.20. 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.

4.1.21. HbA1c point of service testing (D0411) to be submitted in conjunction with or before surgical procedure for a known diabetic patient.

5.0. PREVENTIVE – D1000-D1999

Dental Prophylaxis D1110 R prophylaxis – adult

Topical Fluoride Treatment (Office Procedure)

Other Preventive Services

Space Maintenance (Passive Appliances) Services

5.1. Benefits and Limitations for Preventive Services

5.1.1. For remote ADSM, two routine prophylaxes are covered in a consecutive 12-month period. Additional prophylaxis in a 12-month period must be approved by the DSPOC. However, if a remote member requests or obtains care that exceeds the allowed quantity in a consecutive 12-month period, the care will be considered authorized if it occurs no more than one month prior to the expiration of the consecutive 12-month period.

5.1.2. Routine prophylaxis are considered integral when performed by the same dental provider/facility within 45 days as scaling and root planing, periodontal surgery and periodontal maintenance procedures.

5.1.3. 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.

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

5.1.5. 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.

5.1.6. 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.

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

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

6.0. RESTORATIVE – D2000-D2999

Amalgam Restorations (Including Polishing)

Resin-Based Composite Restorations – Direct

Gold Foil Restorations

Inlay/Onlay Restorations

Porcelain/Ceramic Restorations

Resin Based Restorations

Crowns – Single Restorations Only

Labial Veneer Services

Other Restorative Services

6.1. Benefits and Limitations for Restorative Services

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

6.1.2. 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.

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

6.1.4. 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).

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

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

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

6.1.8. 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.

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

6.1.10. 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.

6.1.11. 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 network 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 and is required to restore the tooth following root canal therapy.

6.1.12. 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.

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

6.1.14. 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.

6.1.15. Prefabricated stainless steel crowns (with or without resin windows for anterior and premolar teeth) are covered only when authorized in writing prior to initiating the procedure.

6.1.16 Restorative and removable and 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.

6.1.17. Based on Military Specialty Consultants' recommendation, all ceramic crowns D2740 on molars are required to be either lithium disilicate (i.e. IPS e.max CAD, Ivoclar Vivadent) or Full Contour Zirconia (i.e., Bruxir, Lava Plus, Zirlux) whether they are placed in DTFs or via private sector care. Civilian dental providers are required to provide a copy of the lab bill, for non DTF- referred care, with the dental claim providing evidence of the materials used for fabricating the crown. If the dental office has their own milling machine (Cerec, ProCad, Vitablocs, Paradigm, etc) the dentist shall indicate this and also confirm what brand and material type of block was used.

6.1.18. 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 5 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 5-year replacement period must be approved by a DSPOC. The 5-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 5-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.

6.1.19. Inlays typically require greater reduction of sound natural tooth structure compared to restorations utilizing direct restorative materials and are therefore not as cost effective nor as conservative for restoring intracoronal defects.

6.1.20. 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.

6.1.21. Recementation of prefabricated and cast crowns, bridges, onlays, inlays and posts within 6 months of placement by the same dental provider/facility is considered integral to the original procedure.

6.1.22. 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.

6.1.23. 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.

6.1.24. 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.

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

6.1.26. 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.

6.1.27. 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.

7.0. ENDODONTICS – D3000-D3999

Pulp Capping

Pulpotomy

Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care)

Endodontic Retreatment

Apexification/Recalcification and Pulpal Regeneration Procedures

Apicoectomy/Periradicular Services

Other Endodontic Procedures

7.1. Benefits and Limitations for Endodontic Services

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

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

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

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

7.1.5. 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.

7.1.6. Pulpal therapy (resorbable filling) is limited to primary teeth with unerupted succedaneous permanent teeth only and therefore not generally covered for ADSMs. 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.

7.1.7. 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.

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

7.1.9. 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.

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

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

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

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

8.0. PERIODONTICS – D4000-D4999

Surgical Services (Including Usual Postoperative Care)

Non-Surgical Periodontal Service

Other Periodontal Services

8.1. Benefits and Limitations for Periodontal Services

8.1.1. 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.

8.1.2. 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.

8.1.3. 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.

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

8.1.4.1. One or two teeth will be paid at the per tooth allowance.

8.1.4.2. Three or four teeth will be paid at 50 percent of the full quadrant allowance.

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

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

8.1.7. 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.

8.1.8. 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.

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

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

8.1.11. 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.

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

8.1.13. 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.

8.1.14. 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.

8.1.15. 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.

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

8.1.17. 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.

8.1.18. D4346 is allowed once per 36 months AND consider part of the routine prophylaxis limitation; the combination of routine prophylaxis and D4346 should not exceed one per six months or two per 12 months.

8.1.19. Periodontal scaling and root planing, periodontal maintenance, or periodontal surgery (D4240-D4278) is not covered when provided within six months following D4346.

8.1.20. D4346 is not covered when provided on the same day by same provider as a routine prophylaxis, periodontal maintenance, periodontal scaling and root planing, or full mouth debridement.

8.1.21. D4346 is considered integral when provided on the same day by same provider as periodontal surgery (4240-D4278).

8.1.22. D4346 is not covered if reported within 6 months following full mouth debridement, periodontal maintenance, periodontal scaling and root planing, or periodontal surgery.

8.1.23. Full mouth debridement to enable a comprehensive periodontal evaluation (D4355) is covered only once in a 24-month timeframe 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. Not to be completed on the same day as D0150, D0160, or D0180.

8.1.24. Implants and related services (i.e. D6010, D6190, D7950, D7951, and D7952) are considered on a case-by case basis and require DSPOC authorization. Implant services must meet all protocol(s) established by the service member’s branch of Service Dental Corps Chief or designated representative.

8.1.25. 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.

8.1.26. Repair or repeating a surgical procedure by the same…