Sec. 1. (a) Medicaid reimbursement is available only for those dental services listed in section 2 of this rule subject to the limitations set out in this rule.
(c) (b) For those members twenty-one (21) years of age and over, all covered services will require prior authorization except the following:
(1) Diagnostic and preventative services.
(2) Direct restorations.
(3) Treatment of lesions.
(4) Periodontal services for the following immuno-compromised individuals:
(A) Transplant patients.
(B) Pregnant women.
(C) Diabetic patients.
(5) Extractions.
(6) Emergency and trauma care.
Sec. 2. The following are covered dental services under Medicaid:
(1) Evaluations.
(2) Radiographs.
(3) Prophylaxis.
(4) Topical fluoride for members twenty (20) years of age and younger.
(5) Sealant for permanent molars and premolars for members twenty (20) years of age and younger.
(6) Amalgam.
(7) Unilateral and bilateral space maintainers for members twenty (20) years of age and younger.
(8) Resin anteriors and posteriors.
(9) Recement crowns.
(10) Steel crown primary.
(11) Stainless steel crown permanent.
(12) Therapeutic pulpotomy.
(13) Extractions.
(14) Oral biopsies.
(15) Alveoplasty.
(16) Excision of lesions.
(17) Excision of benign tumor.
(18) Odontogenic cyst removal.
(19) Nonodontogenic cyst removal.
(20) Incise and drain abscess.
(21) Fracture simple stabilize.
(22) Compound fracture of the mandible.
(23) Compound fracture of the maxilla.
(24) Repair of wounds.
(25) Suturing.
(26) Emergency treatment dental pain.
(27) Analgesia for members twenty (20) years of age and younger.
(28) Drugs and medicaments.
(29) Periodontal surgery limited to drug-induced periodontal hyperplasia. Periodontic procedures.
(30) Other dental services as medically necessary to treat members eligible for the EPSDT program.
(31) Periodontal root planing and scaling.
(32) (31) General anesthesia.
(33) (32) Intravenous (IV) sedation covered only for oral surgical services.
(34) (33) Dentures and partials.
(35) (34) Orthodontic services for members twenty (20) years of age and under only.
(35) Physician fluoride varnish services for members younger than four (4) years of age.
Sec. 4. Reimbursement is available for one (1) topical application of fluoride every six (6) months per member only for patients who are twelve (12) months of age or older but who are younger than twenty-one (21) years of age. from the time of first tooth eruption. Topical applications of fluoride are not covered for members twenty-one (21) years of age or older. Brush-in fluoride (topical application of fluoride phosphate) is not a covered service.