Current through Register Vol. 50, No. 9, September 20, 2024
A. The dental
services covered under the EPSDT Dental Program are organized in accordance
with the following 11 categories:
1.
diagnostic services which include oral examinations, radiographs and
oral/facial images, diagnostic casts and accession of tissue - gross and
microscopic examinations;
2.
preventive services which include prophylaxis, topical fluoride treatments,
sealants, fixed space maintainers and re-cementation of space
maintainers;
3. restorative
services which include amalgam restorations, composite restorations, stainless
steel and polycarbonate crowns, pins, core build-ups, pre-fabricated posts and
cores and unspecified restorative procedures;
4. endodontic services which include pulp
capping, pulpotomy, endodontic therapy on primary and permanent teeth
(including treatment plan, clinical procedures and follow-up care),
apexification/recalcification, apicoectomy/periradicular services and
unspecified endodontic procedures;
5. periodontal services which include
gingivectomy, periodontal scaling and root planning, full mouth debridement,
and unspecified periodontal procedures;
6. removable prosthodontics services which
include complete dentures, partial dentures, denture repairs, denture relines
and unspecified prosthodontics procedures;
7. maxillofacial prosthetics service, which
is a fluoride gel carrier;
8. fixed
prosthodontics services which include fixed partial denture pontic, fixed
partial denture retainer and other unspecified fixed partial denture
services;
9. oral and maxillofacial
surgery services which include non-surgical extractions, surgical extractions,
other surgical procedures, alveoloplasty, surgical incision, temporomandibular
joint (TMJ) procedure and other unspecified repair procedures;
10. orthodontic services which include
interceptive and comprehensive orthodontic treatments, minor treatment to
control harmful habits and other orthodontic services; and
11. adjunctive general services which include
palliative (emergency) treatment, anesthesia, professional visits,
miscellaneous services, and unspecified adjunctive procedures.
B. Effective November 1, 2006, the
following dental procedures are included in the service package for coverage
under the EPSDT Dental Program:
1.
prefabricated stainless steel crown with resin window; and
2. appliance removal (not by the dentist who
placed the appliance), including removal of archbar.
C. Effective December 24, 2008, the following
dental procedures are included in the service package for coverage under the
EPSDT Dental Program:
1. resin-based
composite restorations (1-4 or more surfaces), posterior; and
2. extraction, coronal remnants deciduous
tooth.
D. Effective
December 24, 2008, the service limit of six root canals per lifetime is
discontinued.
E. Effective August
1, 2010, the prefabricated esthetic coated stainless steel crown-primary tooth
dental procedure shall be included in the service package for coverage under
the EPSDT Dental Program.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
