R414-49-5. Service Coverage

(1) A dental provider shall provide each dental service within generally accepted standards of dental practice and subject to limitations of medical necessity and utilization control. (2) The following limitations apply to coverage of dental services. (a) Medicaid covers up to one evaluation for one member each day. (b) A denture adjustment by the original furnishing provider within six months of delivery is included in the global payment. (c) Third-molar extractions are covered when at least one third molar has documented pathology requiring extraction. (d) Coverage of a dental service to the temporomandibular joint (TMJ) is limited to the treatment of TMJ fractures. (e) Medicaid covers alveoloplasty and vestibuloplasty procedures for eligible adult populations effective January 1, 2025. (3) Medicaid may cover an otherwise excluded dental service for an EPSDT eligible member if the department determines the service is medically necessary to correct or ameliorate a condition discovered as part of a screening. (4) Unless authorized under Subsection (3), Medicaid does not cover a dental implant, fixed bridge, ridge augmentation, tooth transplantation, nitrous oxide, or oral sedation for behavior management. (5) Emergency dental coverage is restricted to treating a sudden and acute onset of a condition where delay would jeopardize health, specifically: (a) tooth eruption; or (b) drainage of an abscess. (6) A member may upgrade a covered service to a non-covered service, such as anterior stainless-steel crowns with facings, by assuming financial responsibility for the fee difference. The fee difference is determined by subtracting the provider's usual and customary charges of the base version from the usual and customary charges of the upgraded version.