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Dental Coverage Limitations By ProgramProcedure orServicePeriodic Oral ExamCommon ADA CodesD0120Program CoverageIf you are less than 21 you may have an exam every 6 months.If you are 21 or older, you may have one exam each calendar year.Note: If you have a medical condition that makes it necessary foryou to have more frequent exams your dentist can requestadditional services for you.-No HUSKY B CopayEmergency or LimitedOral ExamInitial Oral ExamD0140D0150No Limits.-No HUSKY B CopayIf you are less than 21 you may have one new patient exam every 3years.If you are 21 or older, you are limited to one new patient exam inyour lifetime.Note: If you change dentists your new dentist can request thisadditional service for you.Detailed & ExtensiveOral EvaluationX-Ray-Intraoral,complete series (FMX,Full Mouth icDental Benefit LimitationsRev. 1.6 06/2013D0160D0210-Full MouthSeries-No HUSKY B CopayThis service does not have a limit-No HUSKY B CopayA complete set of X-rays of your mouth is covered once every 36months.D0220-1st FilmD0230-Each AdditionalFilm-No HUSKY B CopayIf you are under 21, there is no restriction to the number ofindividual x-rays that are covered.If you are 21 or older, individual x-rays are limited to four in 365days.D0270-SingleD0272-TwoD0274-four-No HUSKY B CopayIf you are under 21 bitewing procedures are covered once every 6monthsIf you are 21 or older bitewing procedures are covered once in acalendar yearD0330-PanoramicRadiograph-No HUSKY B CopayDentists other than oral and maxillofacial surgeons andorthodontists must ask for prior authorization to do a panoramic X-

ray.Note: Under the HUSKY dental plan, either a panoramic X-ray or afull mouth series is covered under the plan one time per 36 months.Dental Prophylaxis“Cleaning”D1110 AdultD1120 Pediatric-No HUSKY B CopayIf you are less than 21 you may have a cleaning every 6 months.If you are 21 or older, you may have one cleaning each calendaryear.Note: If you have a medical condition that makes it necessary foryou to have more frequent cleanings your dentist can requestadditional services for you.Topical Application ofFluoride-Adult &ChildrenPit & Fissure SealantsSpace MaintainersD1208-Topical FluorideapplicationIf you are 21 or older fluoride treatment is covered only undercertain conditions and requires prior authorization.D1351D1510-Fixed UnilateralD1515-Fixed BilateralRecementation ofSpace MaintainerRemoval of Fixed SpaceMaintainerRestorations “Fillings”Amalgams (Metal)Covered for permanentand “baby” teethRestorations-FillingsComposite ResinDental Benefit LimitationsRev. 1.6 06/2013-No HUSKY B Copay -No HUSKY B CopayIf you are less than 21 fluoride treatment is covered twice a yearD1525-RemovableBilateralD1550D1555D2140 – 1 surfaceD2150 – 2 surfaceD2160 – 3 surfaceD2161 – 4 surfaceAnterior (Front) Teeth:D2330 – 1 surface-No HUSKY B CopayCovered for children ages 5 through 16Sealants are covered once every 5 years per toothSealants are covered for permanent molars and pre-molarsTeeth to be sealed must be free of decay-No HUSKY B CopayD1510 – limit of 4 coveredD1515 – limit of 2 coveredD1525 – limit of 2 coveredHUSKY B Copay-33%Covered serviceHUSKY B Copay-20%Covered serviceHUSKY B Copay-33%Once per year to same surface. Not covered for “baby” teeth whichare about to fall out.HUSKY B Copay-20%Once per year to same surface. Not covered for “baby” which areabout to fall out.

(White)D2331 – 2 surfaceD2332 – 3 surfaceD2335 – 4 surfacePosterior (Back) Teeth:D2391 – 1 surfaceD2392 – 2 surfaceD2393 – 3 surfaceD2394 – 4 surface(Wisdom teeth are notcovered.)Crown –Porcelain fused D2751to predominantly basemetalFront permanent teethFor clients 21 or older resin (white) fillings are not covered for firstmolar teeth and second molar teethNot a covered service for wisdom teethHUSKY B-20% CopayCovered for permanent front teeth onlyLimited to once per five yearsPrior authorization requiredHUSKY B Copay 33%Crown-Full castpredominantly basemetalRe-cement CrownD2791D2910D2920Covered for all permanent teethLimited to once per five yearsPrior authorization requiredHUSKY B Copay 33%Covered serviceHUSKY B Copay 20%Crowns-Stainless Steelwith Resin Window(Primarily used ry orPermanentRestorative TemporarySedative fillingD2940Core BuildupD2950Pin Retention-perToothEndodontic Therapy(Root Canal Therapy)–Front TeethD2951Endodontic Therapy(Root Canal Therapy) –Back TeethDental Benefit LimitationsRev. 1.6 06/2013D3310D3320 - BicuspidD3330 - MolarCovered only when breakdown of tooth structure is excessiveD2933 Covered for “baby” or permanent teeth, front or back teethCrowns are not covered for “baby” teeth which are about to comeout.Prior authorization requiredHUSKY B Copay 33%Covered ServiceHUSKY B Copay 20%Prior Authorization requiredHUSKY B Copay 33%HUSKY B Copay 33%Once per tooth per Client per lifetime limitationPrior authorization is required for clients 21 and olderHUSKY B Copay 20%Once per tooth per Client per lifetime limitation.Prior authorization is required for clients 21 and older

HUSKY B Copay 20%Retreatment RootCanal TherapyApicoectomy/Periraduclar SurgeryApexificationGingevectomy orGingivoplasty(Reposition formingtooth bud to anothersocket)Full larD3351D4210-Four or MoreTeethD4211-One to ThreeTeeth5110 Full Upper5120 Full LowerCovered for ages 0-20. Prior authorization required for all providersexcept endodontistsHUSKY B Copay 20%Prior authorization is required for under age 21 for all providersexcept endodontistsHUSKY B Copay 20%Not including root canal treatment but includes all visits to completethe service.Restricted up to age 20 – Prior authorization is required for allspecialties except endodontists.HUSKY B Copay 20%PA required for clients age 21 and over. Covered for severe effectscaused by medication.HUSKY B Copay 50%Covered once every 7 years.Note: When you pick up your new denture, you will be required tosign a form stating that you understand the replacement policy andthat your denture is acceptable.If you need a replacement denture before the 7 year period is up,your dentist can request the additional service for you. Dentureswill only be replaced if it is medically necessary. If your denture wasstolen or destroyed in an accident or natural disaster you shouldgive a copy of the accident or police report to your dentist.Dentures will not be replaced for cosmetic reasons.Removable Prosthetic – 5211 Partial UpperPartial DentureResin Based(Requires PA)5212 Partial LowerResin Based5213-Partial Upper Castmetal5214-Partial Lower CastmetalDental Benefit LimitationsRev. 1.6 06/2013HUSKY B Copay 50%Covered once every 7 years.Note: When you pick up your new denture, you will be required tosign a form stating that you understand the replacement policy andthat your denture is acceptable.If you need a replacement denture before the 7 year period is up,your dentist can request the additional service for you. Dentureswill only be replaced if it is medically necessary. If your denture wasstolen or destroyed in an accident or natural disaster you shouldgive a copy of the accident or police report to your dentist.Dentures will not be replaced for cosmetic reasons.

HUSKY B Copay 50%Denture RepairsD5510-Repair ofBroken CompleteDenture BaseCovered ServiceHUSKY B Copay 20%D5520-Replace Missingor Broken TeethCompleteD5610-Repair ResinDenture BaseD5620-Repair CastFrameworkD5640-Repair orReplace Broken ClaspD5650-Add Tooth toExisting Partial DentureReline Dentures ChairsideReline Dentures LaboratoryDental Benefit LimitationsRev. 1.6 06/2013D5660-Add Clasp toExisting Partial DentureD5730-Reline CompleteMaxillary Denture-ChairsideD5731-Reline CompleteMandibular DentureChairsideD5740-Reline MaxillaryPartial Denture-ChairsideD5741-RelineMandibular PartialDenture – ChairsideD5750- RelineComplete MaxillaryDentureD5751- RelineComplete MandibularDentureD5760- Reline MaxillaryPartial DentureD5761- RelineOnce per 2 year period limitationPrior authorization required for some dental specialtiesHUSKY B Copay-20%Once per 2 year period limitationPrior authorization required for some dental specialtiesHUSKY B Copay 20%

Obturator ProsthesisMandibular PartialDentureD5931-SurgicalHUSKY B Copay 20%Obturator ProsthesisD5932-DefinitiveHUSKY B Copay 20%Oral SurgerySimple ExtractionsSurgical ExtractionsImpactionsTooth TransplantationSurgical Access ofUnerupted ToothOsteoplastyClosure of SalivaryFistulaOrthodontics(Required PA)Dental Benefit LimitationsRev. 1.6 06/2013D7140 – Extraction oferupted tooth orexposed rootCovered for all teethD7210 - Surgicalremoval of eruptedtooth requiringremoval of boneand/or sectioning oftoothCovered for all teethD7220-Soft TissueD7230-Partially BonyD7240-CompletelyBonyD7241-CompletelyBony, with unusualsurgical complicationsD7272Prior authorization % HUSKY B Copay33% HUSKY B Copay(Oral Surgeons are not required to submit Prior authorization forsurgical extractions)HUSKY B Copay 33%Restricted to ages 0-20HUSKY B Copay 20%Covered only for orthodontic reasons – not covered unlessorthodontia has been prior authorized.HUSKY B Copay 20%Requires prior authorizationHUSKY B Copay 20%HUSKY B Copay 20%HUSKY A, HUSKY C, HUSKY DOnce per client per lifetime.Work must be performed by aqualified OrthodontistLimited to clients under age 21.Therapy must be completed bythe age of 21.Prior authorization required.HUSKY BOnce per client per lifetime.Limited to clients under age 19No predetermination requiredBenefit limited to 725.00 per caseClient is responsible for balance upto the Medicaid allowed amount.

Coverage of braces is based ona scoring method. If your teethare not crooked enough toqualify you may still be eligibleif braces are consideredmedically necessary. Pleasetalk to your orthodontist or callour call center for moreinformation.Local AnesthesiaGeneral SurgicalAnesthesiaIt is not payable as a separate service and is included in otherprocedure codes.Covered for clients under the age of nine (Prior to ninth birthday) orclients with autism, cerebral palsy, hyperactivity disorder orsevere/profound developmental delay for behavior managementrelated to the dental procedures to be st 30minutesD9221- DeepSedation/ GeneralCovered for clients age nine and older when:Anesthesia-each Multiple oral surgical procedures are performed at the sameadditional 15 minutesvisit 5 or more extractions are performed Extraction of impacted wisdom teethNot covered for clients 21 or older for the extraction of less than 6single teeth (excluding wisdom teeth) or for general dental treatmentHUSKY B Copay is 20%Analgesia, Anxiolysis,Inhalation of NitrousOxide “Laughing Gas”D9230 –Analgesia,Anxiolysis InhalationNO2Covered for clients under the age of 9, or clients of any age who have adiagnosis such as autism, cerebral palsy hyperactivity disorder ordevelopmental delay with a demonstrated need for behaviormanagement related to the dental procedures to be performed.Not a covered benefit for clients age nine (9) or over for the extractionof a single tooth or general dental services.Not a covered benefit for clients twenty one or over for general dentalservices.Intravenous ConsciousSedationDental Benefit LimitationsRev. 1.6 06/2013D9241-IntravenousConscious Sedation/Analgesia -first 30minutesHUSKY B Copay 20%Covered for clients under the age of nine (Prior to ninth birthday) orclients with autism, cerebral palsy, hyperactivity disorder orsevere/profound developmental delay for behavior managementrelated to the dental procedures to be performed.D9242- IntravenousCovered for clients age nine and older when: