Prosthodontic Services Sample Clauses
The Prosthodontic Services clause defines the scope and terms under which prosthodontic dental treatments—such as the design, creation, and fitting of artificial teeth and dental prostheses—are provided or covered. This clause typically outlines which specific procedures are included, any limitations or exclusions, and the conditions for eligibility or reimbursement. By clearly specifying the extent of prosthodontic coverage, the clause helps prevent misunderstandings between patients, providers, and insurers, ensuring that all parties understand what services are available and under what circumstances.
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Prosthodontic Services. All dentures, fixed prosthodontics (fixed bridges) and maxillofacial prosthetics require prior authorization. New dentures or replacement dentures may be considered every 7 ½ years unless dentures become obsolete due to additional extractions or are damaged beyond repair. All needed dental treatment must be completed prior to denture fabrication. Patient identification must be placed in dentures in accordance with State Board regulation. Insertion of dentures includes adjustments for 6 months post insertion. Prefabricated dentures or transitional dentures that are temporary in nature are not covered. Prosthodontic services to include: Complete dentures and immediate complete dentures – maxillary and mandibular to address masticatory deficiencies. Excludes prefabricated dentures or dentures that are temporary in nature Partial denture – maxillary and mandibular to replace missing anterior tooth/teeth (central incisor(s), lateral incisor(s) and cuspid(s)) and posterior teeth where masticatory deficiencies exist due to fewer than eight posterior teeth (natural or prosthetic) resulting in balanced occlusion. Resin base and cast frame dentures including any conventional clasps, rests and teeth Flexible base denture including any clasps, rests and teeth Removable unilateral partial dentures or dentures without clasps are not considered Overdenture – complete and partial Denture adjustments –6 months after insertion or repair Denture repairs – includes adjustments for first 6 months following service Denture rebase – following 12 months post denture insertion and subject to prior authorization denture rebase is covered and includes adjustments for first 6 months following service Denture relines – following 12 months post denture insertion denture relines are covered once a year without prior authorization and includes adjustments for first 6 months following service Precision attachment, by report Maxillofacial prosthetics - includes adjustments for first 6 months following service Facial moulage, nasal, auricular, orbital, ocular, facial, nasal septal, cranial, speech aid, palatal augmentation, palatal lift prosthesis – initial, interim and replacement Obturator prosthesis: surgical, definitive and modifications Mandibular resection prosthesis with and without guide flange Feeding aid Surgical stents Radiation carrier Fluoride gel carrier Commissure splint Surgical splint Topical medicament carrier Adjustments, modification and repair to a maxillofacial prosthe...
Prosthodontic Services. Repair or rebasing of an existing full or partial denture; Initial installation of fixed bridgework; Implants; Initial installation of partial or full removable dentures (including adjustments for six [6] months following installation); Construction and replacement of dentures and bridges (replacement of existing dentures or bridges is payable when five [5] years or more have elapsed since the date of the initial installation).
Prosthodontic Services. 13 Repair or rebasing of an existing full or partial denture; 14 Initial installation of fixed bridgework;
Prosthodontic Services. Services and appliances that replace missing natural teeth (such as bridges, endosteal implants, partial dentures, and complete dentures).
Prosthodontic Services. A. DENTURES - Construction and insertion of dentures. Limited until after the person has been insured continuously under this benefit for a period of 12 consecutive months, unless a tooth is extracted.
(a) Full Dentures - Replacements must be separated by an interval of at least 5 years.
(i) Standard denture - Includes treatment plan, initial and final impressions, jaw relations records, try-in insertion, occlusal equilibration, and follow-up care and adjustments for 6 months following insertion.
(ii) Standard immediate denture - Includes treatment plan, impressions, jaw relations records, tissue conditioner, insertion, occlusal equilibration, and follow-up care and adjustments for 6 months following insertion.
(b) Partial Dentures - Includes treatment plan, mouth preparation, initial and final impressions, jaw relations records, connectors, rests, clasps, and bases, framework try-in, try-in evaluation, insertion, occlusal equilibration, and follow-up care and adjustments for 6 months following insertion. Replacements must be separated by an interval of at least 5 years.
▇. ▇▇▇▇▇▇▇ - Construction and insertion of bridges. For initial bridges, limited to teeth extracted while insured under this benefit. For replacement bridges: (1) if teeth are extracted in the period until the person has been insured under this benefit for 12 consecutive months, limited to teeth extracted while insured under this benefit; (2) if teeth are not extracted, only after the person has been insured under this benefit for a period of 12 months, and replacements must be separated by an interval of at least 10 years.
(a) Fixed bridges - Includes treatment planning, occlusal records, local anaesthesia, subgingival preparation of the tooth and supporting structures, removal of decay and/or old restoration, tooth preparation, pulp protection, impressions, temporary services, splinting and intraoral indexing for soldering purposes, insertion, occlusal adjustments and cementation. Does not include porcelain or porcelain fused to metal abutments or pontics for molar teeth.
(b) Recement fixed bridge.
(c) Repair fixed bridge. 8. DENTURE ADJUSTMENTS - Includes 6 month follow-up care.
Prosthodontic Services. Procedures for construction of fixed bridges, partial dentures, complete dentures, and/or adjustment or repair of an existing prosthodontic device.
Prosthodontic Services. To include bridges, partials and complete dentures.
Prosthodontic Services a) Removable
i) Denture adjustments and repairs (ODA 54201, 54202, 54209, 54301- 54303, 54401-54403, 54501-54503, 55101, 55102, 55201-55203, 55301, 55302, 55401-55403, 55501, 55509)
ii) Denture duplication, rebasing, relining (ODA 56111-56113, 56121-56123, 56211-56213, 56221-56223, 56231-56233, 56241-56243, 56251-56253, 56261-56263, 56311- 56313, 56321-56323, 56331-56333, 56341-56343, 56411-56413, 56511-56513, 56521-56523)
iii) Diagnostic procedures, impressions, jaw relation records, try-in, insertion, adjustments (ODA 51101-51104, 51301-51303, 51601-51603, 51701- 51703, 51801-51803, 52101-52103, 52111-52113, 52201-52203, 52211- 52213, 52301-52303, 52311-52313, 52401-52403, 52411-52413, 52501-
Prosthodontic Services a) Crowns (refer to ▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇);
b) Removable complete upper and/or lower dentures will be approved if the patient can tolerate and is expected to use them on a daily basis.
c) Removable partial upper and/or lower dentures will be approved if the patient can tolerate them and is expected to use them on a daily basis. There must less than eight posterior teeth in occlusion with missing anterior teeth.
d) Replacement of existing complete or partial dentures, may be reconstructed in any five (5) year period. Prior authorization must be requested with a documented need of medical necessity if the removable complete or partial denture(s) must be remade or replaced for any reason within the date of delivery of the initial prosthesis.
e) Relining or rebasing of existing complete or partial dentures may be performed one time in a two year period.
f) Denture labeling may be performed for patients residing in long term care facilities.
Prosthodontic Services i. Cosmetic dentistry;
ii. Dentures (partial) where there are more than 8 posterior teeth in occlusion and no missing anterior teeth;
iii. Fixed Partial Dentures (Bridges);
iv. Implants and associated abutments and /or attachments;