Periodontal Services. Services require prior authorization with submission of diagnostic materials and documentation of need.
Periodontal Services i) Full mouth debridement - one (1) per lifetime.
Periodontal Services. 1. Periodontal surgery.
Periodontal Services. E. CONTRACTOR will provide dental treatment in accordance with the guidelines set forth by DEPARTMENT in ANNEX 1 (MSP Health Care Services Procedure documents PE 06.01-09, ANNEX 2 (MT DOC Guide to the Dental Chart) and ANNEX 4 (MT DOC Dental Services Guidelines).
Periodontal Services. Nonsurgical services, excluding training in personal therapeutic periodontal care. Surgical services. Post-surgical visits 4 visits per year. adjustments -for periodontal purposes only.
Periodontal Services i) Non-surgical, surgical and adjunctive services (ODA 41101-41104, 41109, 41211-41214, 41219, 41221-41224, 41229, 41231-41234, 41239, 41301, 41302, 41309, 42111, 42201, 42311, 42321, 42331, 42339, 42411, 42421, 43431, 42441, 42511, 42521, 42531, 42611, 42711, 42811, 42819, 42821-42823, 42829, 43111, 43211, 43231, 43241, 43261, 43311-43314, 43319, 43421-43427, 43429). Perio- dontal appliances (ODA 43611, 43612, 43621-43623, 43629, 43631) (grinding habit) TMJ appliance (ODA 43711, 43712, 43721, 43722, 43731-43733, 43739, 43741) Periodontal Reevaluation (ODA 49101, 49102, 49109) Periodontal Xxxxxx- xxxx (XXX 00000, 49219)
Periodontal Services. Periodontal maintenance: Limited to a total of one periodontal maintenance or prophylaxis in any six consecutive month period. Allowance includes periodontal charting, scaling and polishing. Also see Prophylaxis under Prophylaxis And Fluorides in Group I Services. Periodontal Services: Allowance includes the treatment plan, local anesthetic and post- treatment care. Requires documentation of periodontal disease confirmed by both radiographs and pocket depth probings of each tooth involved. Scaling and root planing, per quadrant: Limited to once per quadrant in any 24 consecutive month period. Covered when there is radiographic and pocket charting evidence of bone loss. Full mouth debridement: Limited to once in any 36 consecutive month period. Considered only when no diagnostic preventive, periodontal maintenance procedure, periodontal service or periodontal surgery procedure has been performed in the previous 36 consecutive month period. Periodontal Surgery Allowance includes the treatment plan, local anesthetic and post-surgical care. Requires documentation of periodontal disease confirmed by both radiographs and pocket depth probings of each tooth involved. Considered when performed to retain teeth. Treatment performed for a tooth or teeth with a guarded, questionable or poor prognosis is not covered. The treatment listed below is limited to a total of one of following, once per tooth in any 12 consecutive month period. • Gingivectomy or gingivoplasty, per tooth (less than three teeth). • Crown lengthening, hard tissue. The treatment listed below is limited to a total of one of the following, once per quadrant, in any 36 consecutive month period. • Gingivectomy or gingivoplasty, per quadrant. • Osseous surgery, including scaling and root planing, flap entry and closure, per quadrant. • Gingival flap procedure, including scaling and root planing, per quadrant. • Distal or proximal wedge procedure, not in conjunction with osseous surgery. • Surgical revision procedure, per tooth. The treatment listed below is limited to a total of one of the following, once per quadrant in any 36 consecutive month period, when the tooth is present, or when dentally necessary as part of a covered surgical placement of an implant. • Pedicle or free soft tissue grafts, including donor site. • Subepithelial connective tissue graft procedure. The treatment listed below is limited to a total of one of the following, once per area or tooth, per lifetime, when the tooth is presen...
Periodontal Services. Nonsurgical services, excluding training in personal therapeutic periodontal care. Surgical services. Post-surgical visits visits per year. Occlusal adjustments for periodontal purposes only. Subgingival root planing maximum of time units OR one full month per year. Special periodontal appliance for only. DENTURE SERVICES Repairs. Additions. Relines. ORAL SURGERY Extractions uncomplicated and complicated. Removal of residual roots. Surgical exposure of teeth. Alveoloplasty, gingivoplasty, stomatoplasty and osteoplasty. Surgical excisions. Surgical incisions. Treatment of fractures. Miscellaneous surgical services excluding a surcharge for immediate insertion of dentures. ADJUNCTIVE SERVICES House and hospital visit. Office visit after regularly scheduled hours and no operative services performed. Injection of drugs. Anaesthesia and sedation only when performed in conjunction with oral surgery. MAJOR SERVICES SINGLE RESTORATIONS Inlays, crowns only if the tooth cannot be restored with a Basic Restoration. transitional (temporary) crowns are considered part of the final restoration. limited to full metal crowns on molar teeth. Porcelain repairs. Retentive pins, post and cores. Recementation. Removal of crown or inlay. PROSTHODONTICS FIXED Retainer Abutment crowns limited to full metal crowns and for molars.
Periodontal Services. Nonsurgical services, excluding training in personal therapeutic periodontal care. Surgical services. Post-surgical visits four visits per year. Occlusal adjustments for periodontal purposes only. Occlusal equilibration maximum of eight time units per lifetime. Subgingival scaling and/or root planning maximum of eight time units OR one f u l l month per year. Special periodontal appliance €or bruxism only. DENTURE SERVICES
Periodontal Services. Osseous surgery.. ...................................................................................... Osseous grafts ............................................................................... Soft tissue grafts.. ...................................................................... Post surgical treatment.. ............................................................................ Provisional splinting ..................................................................... equilibration.. ........................................................................... Periodontal scaling and root planing.. ..................................................... Special periodontal appliances (including guards) .................. Anaesthesia.. .................. ............................................................................... Consultation . With another Dentist .......................
