Periodontic Services. Periodontal surgery to remove diseased gum tissue surrounding the tooth; Adjunctive periodontal services, including provisional splinting to stabilize teeth, occlusal adjustments to correct the biting surface of a tooth and periodontal scaling to remove tartar from the root of the tooth; Treatment of gingivitis and periodontitis-diseases of the gums and gum tissue.
Periodontic Services. Procedures performed by properly licensed Dentists for the treatment of diseases of the gums and supporting structures of the teeth, excluding periodontal maintenance procedures following active therapy and scaling in the presence of moderate or severe gingival inflammation – full mouth, after oral evaluation which are payable as Class I services.
Periodontic Services. Periodontists specialize in the diagnosis, treatment and prevention of gum disease, the placement of implants and the treatment of certain jaw problems, most notably tempero- mandibular joint disorders. Your coverage for periodontic services include: Scaling and root planing limited to a combined maximum of 4 time units a year. Periodontal surgery. Occlugal adjustments and equillbration limited to a combined maximum of 4 time units a year.
Periodontic Services. The treatment of diseases of the gums and supporting structures of the teeth, including periodontal maintenance following periodontal therapy (periodontal cleanings).
Periodontic Services. ▪ Application of displacement dressings ▪ Management of oral infections ▪ Desensitization ▪ Gingival curettage ▪ Gingivoplasty ▪ Gingivectomy ▪ Flap approach surgery ▪ Soft tissue grafts with flaps ▪ Coronally positioned grafts ▪ Distal wedge procedure ▪ Post surgical treatment ▪ Provisional periodontal splinting or ligation ▪ Occlusal adjustment (8 units of time in any Calendar Year) ▪ Scaling or root planing ▪ Periodontal appliances ▪ Periodontal appliance maintenance, adjustment, reline or repairs Oral and Maxillofacial Surgery: ▪ Removal erupted teeth, uncomplicated ▪ Removal, erupted teeth, complicated ▪ Removal, impacted teeth ▪ Removal, residual roots ▪ Surgical exposure of teeth ▪ Transplantation ▪ Surgical repositioning ▪ Enucleation ▪ Alveoloplasty ▪ Removal of bone ▪ Tuberosity/Tuberoplasty ▪ Gingivoplasty and/or stomatoplasty ▪ Exicision of vestibular hyperplasia ▪ Shaving of papillary hyperplasia ▪ Vestibuloplasty, sub-mucous ▪ Surgical excision, benign tumors ▪ Surgical incision, intra oral ▪ Surgical exploration or trephination, intra oral ▪ Reduction of fractures, closed reduction ▪ Reduction of fractures, open reduction ▪ Replantation of avulsed tooth or teeth ▪ Repositioning of displaced teeth, repairs-lacerations (under 2cm.) ▪ Repairs-lacerations (2cm. or over) ▪ Frenectomy ▪ Temporomandibular joint (TMJ) dislocation treatment, closed reduction ▪ Treatment of salivary glands ▪ Antral surgery ▪ Control of hemorrhage ▪ Post surgical care Orthodontic Services: ▪ Cephalometric X-rays, films ▪ Cephalometric X-rays, tracing and interpretation ▪ Surgical exposure of tooth for orthodontic treatment Adjunctive General Services: ▪ Local anesthesia ▪ Anaesthesia of any kind is not payable unless used in conjunction with:
Periodontic Services. Procedures usually employed by dentists for the treatment of diseases of the gums and supporting structures of the teeth. CLASS II BENEFITS: Prosthodontic services defined as bridges and partial and complete dentures. In other words, appliances that replace missing natural teeth. CLASS III BENEFITS: Orthodontic services defined as treatment and procedures required for the correction of malposed teeth. APPENDIX B MILEAGE ALLOWABLE MILEAGE REIMBURSEMENT FOR TRANSACTING AGENCY RELATED BUSINESS
Periodontic Services. Scaling and Root Planning: Limit 1 per quadrant per two years. • Maintenance (at least 30 days following periodontal therapy), unless a cleaning is performed on the same day. Limit 4 per year. Periodontal and osseous Surgical Procedures – Limit 1 per quadrant per 3 years. Coverage includes bone replacement, tissue regeneration, and/or graft procedures. The most inclusive procedure will be considered if more than one surgical procedure is administered on the same day. • Occlusal adjustments: Limit 1 per quadrant per 3 years when administered in combination with periodontal surgical procedure. • Separate pre/post-operative care and evaluation fees within 3 months are not considered a part of pediatric dental benefits. Prosthodontic Services • Denture adjustments covered once it has been 6 months since initial installation, or adjustment performed by dental Provider that is not the one who provided the denture. • Initial placement of Bridges, Complete Dentures, and Partial Dentures: Limit 1 per 5 years. o Includes pontics, inlays, onlays, and crowns: Limit 1 per tooth per 5 years • Replacement of bridges, complete dentures, and partial dentures. Treatment covered if: o 5 years have passed since initial placement and is not/cannot be made serviceable. o Accidental injury has caused damage beyond repair while restoration was in the oral cavity; or o Extraction of functioning teeth (with the exception of third molars or teeth not in full occlusion with an opposing tooth or prosthesis requires replacement). • Recementation of Bridge – Limit once per 5 years • Tissue Conditioning • Denture Relines or Rebases – Covered after 6 months of installation of permanent appliance. Limit 1 time per 3 years. • Post or core build-up in addition to partial denture retainers with or without core build up – Limit 1 per tooth per 5 years ORAL SURGERY SERVICES Extraction – Covered Services include: • Extraction of coronal remnants of a deciduous tooth • Extraction of erupted tooth or exposed root for permanent and primary teeth General Anesthesia, Intravenous Conscious Sedation and IV Sedation – Covered when administered with covered surgical service.
Periodontic Services. Periodontic: Certain Services for treatment of gum tissue and bone supporting teeth. PROCEDURE BENEFIT DESCRIPTION Periodontal Scaling and Root Planing - Per Quadrant Covered one time per quadrant of the mouth in any 24 month period. Periodontal Maintenance Procedures Following Active Therapy Covered if 3 months have passed since the completion of active periodontal therapy (gum surgery or scaling and root planing). Then one time in any 6 month period. Not covered if performed within 6 months of a routine cleaning. Gingivectomy One periodontal surgical procedure is covered per quadrant in any 36 month period. If less than a full quadrant is treated, benefits will be based on the fee for a partial quadrant. Local anesthesia and routine post-operative care are not separately allowed as benefits. Gingival Flap Procedure One periodontal surgical procedure is covered per quadrant in any 36 month period. If less than a full quadrant is treated, benefits will be based on the fee for a partial quadrant. Root planning, local anesthesia and routine post-operative care are not separately covered. Crown lengthening-hard tissue, by report Not covered if performed on the same date as surgery to bone structures, crown preparation or other restoration. Osseous Surgery, Guided Tissue Regeneration (includes surgery and reentry), Pedicle Soft Tissue Graft, Free Soft Tissue Graft (including donor site) One periodontal surgical procedure is covered per quadrant in any 36 month period. If less than a full quadrant is treated, benefits will be based on the fee for a partial quadrant. Local anesthesia and routine post-operative care are not separately allowed as benefits.
Periodontic Services. Diagnosis and Treatment of gum tissue. Dentures: Complete maxillary (upper) denture. Complete mandibular (lower) denture, partial maxillary (upper) or mandibular (lower) denture, denture relining processed (complete or partial denture), maxillary or mandibular partial denture additions, addition or replacement of clasp with new cast clasp.
Periodontic Services. Procedures necessary for the treatment of diseases of the soft tissue (gums) and the bones surrounding and supporting the teeth.
