For those plans with a pediatric
dental benefit, the following services will be covered:
Two screening exams every six months
dental x-rays every five years, and bitewings every six months
(cleaning) and fluoride treatment every six months
first and second permanent molars (once per lifetime)
Authorization will only be provided when a deciduous tooth is lost earlier than
expected, where there is likely to be a significant shift in tooth spacing as a
result, and where a permanent tooth is going to fill the space.
restorations are covered for all teeth
restorations are only covered for anterior teeth. Composites posterior to the
cuspids will be paid at the same rate as amalgam.
are not covered on teeth with crowns within one year of crown placement.
Prefabricated stainless steel crowns are covered for deciduous teeth.
All of the
following are subject to prepayment review:
Prefabricated stainless steel crowns are only covered for posterior permanent
teeth for loss of cuspal function.
Prefabricated stainless steel or resin crowns may be covered for anterior teeth
in members below 14 for:
dental caries where a significant amount of tooth structure has been destroyed
by decay and cannot be reasonably restored with a direct restorative material;
fractured off or broken off tooth structure that is not presently replaced with
an existing restoration and cannot be reasonably restored with a direct
restorative material; OR
a fractured or broken existing restoration that cannot reasonably be replaced
with a direct restoration.
are covered for deciduous teeth.
debridement for pain control, without completion of endodontic treatment on the
same day, is subject to pre-payment review. Such therapy will be covered only
if there is documentation of clinical reasons for delaying definitive therapy.
are covered one per tooth per lifetime.
therapy is subject to prepayment review. Coverage will require a report, a
perio-chart, and a complete series of radiographs that reflects evidence of bone
loss, numerous 4-5 mm pockets and obvious calculus.
dentures, including repairs, are subject to prepayment review.
series of x-rays and a complete treatment plan, including tooth numbers to be
replaced by partial dentures, must be submitted with the claim.
must be manufactured by a QualChoice contracted dental lab.
extractions and simple surgical extractions are covered.
surgical extractions (with unusual surgical complications or cutting procedure
to remove residual roots) require submission of records prior to payment.
will rarely be covered. Coverage will only be provided in documented cases
where the frenum causes significant, objective functional problems.
anesthesia requires preauthorization for members over age 6, and is only covered
when provided by an anesthesiologist or a certified registered nurse
anesthetist. Codes D9220 and D9221 are not accepted by QualChoice; the
appropriate billing code is 00170, anesthesia for intra-oral procedures.
conscious sedation is covered when medically necessary. Preauthorization is not
required, but post payment review may be performed.
inhaled nitrous oxide for analgesia is covered, one unit per day.