405 IAC 5-14-2
405 IAC 5-14-2 Covered services
Cite as Ind. Admin. Code tit. 405, r. 5-14-2
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) Periodontic procedures.
(30) Other dental services as medically necessary to treat members eligible for the EPSDT program.
(31) General anesthesia.
(32) Intravenous (IV) sedation covered only for oral surgical services.
(33) Dentures and partials.
(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.