Section 140.TABLE D   Schedule of Dental Procedures

 

Effective January 1, 2018.  Additional dental services may be approved based on medical necessity.

 

a)         Diagnostic Services

 

1)         Clinical Oral Evaluations

 

A)      Oral Exams

 

i)          For ages 0-20 – Limited to two every 12 months per patient in an office setting and one per school year in a school setting; and

 

ii)         For ages 21 and over – Limited to one every 12 months per patient

 

B)        Limited Exam

 

C)        Comprehensive Exam

 

2)         X-rays

 

b)         Preventive Services

 

1)         Prophylaxis

 

A)        For ages 0-20 – Limited to one every 6 months per patient in an office setting and one per school year in a school setting; and

 

B)        For ages 21 and over – Limited to one every 12 months per patient

 

2)         Topical Application of Fluoride (ages 0-20) − limited to one every 6 months per patient in an office setting and one per school year in a school setting

 

3)         Fluoride Varnish (ages 0-2) − limited to three per 12 months per patient ages 0-2 years in an office setting

 

4)         Sealants (ages 0-20) − limited to one per two years per tooth regardless of place of service

 

5)         Space Maintenance (ages 0-20) – limited to one per lifetime per quadrant 

 

c)         Restorative Services

 

1)         Amalgams

 

2)         Resins

 

3)         Crowns

 

4)         Other Restorative Services

 

d)         Endodontic Services

 

1)         Pulpotomy – limited to ages 0-20

 

2)         Endodontic Therapy (ages 21 and over; limited to anterior teeth only)

 

3)         Apexification/Recalcification Procedures limited to ages 0-20

 

4)         Apicoectomy/Periradicular Services limited to ages 0-20

 

e)         Periodontal Services

 

1)         Surgical Services

 

2)         Non-Surgical Periodontal Services

 

3)         Other Periodontal Services

 

f)         Removable Prosthodontic Services

 

1)         Complete Denture

 

2)         Partial Denture – limited to ages 0-20

 

3)         Repairs to Complete Denture

 

4)         Repairs to Partial Denture

 

5)         Denture Reline Procedures

 

g)         Maxillofacial Prosthetics

 

h)         Prosthodontics Fixed limited to ages 0-20

 

1)         Fixed Partial Denture Pontics

 

2)         Fixed Partial Denture Retainers – Crowns

 

3)         Other Fixed Partial Denture Services

 

i)          Oral and Maxillofacial Services

 

1)         Extractions

 

2)         Surgical Extractions

 

3)         Other Surgical Procedures

 

4)         Alveoloplasty

 

5)         Surgical Excision of Intra-osseous Lesions

 

6)         Surgical Incision

 

7)         Treatment of Fractures – Simple

 

8)         Treatment of Fractures – Compound

 

9)         Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions

 

10)        Other Repair Procedures

 

j)          Orthodontic Services limited to ages 0-20

 

1)         Comprehensive Orthodontic

 

2)         Other Orthodontic Services

 

k)         Adjunctive General Services

 

1)         Unclassified Treatment

 

2)         Anesthesia

 

3)         Professional Consultation

 

4)         Drugs

 

(Source:  Amended at 47 Ill. Reg. 16385, effective November 3, 2023)