D2999 Unspecified Restorative Procedure, by Report YES YES YES YES Ex: Temp. fractured By Report – tooth IV. ENDODONTICS PULP CAPPING Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under age 21 age 21 & under age age 21 & & all over when 21 & all over allowed ICF-IID when residents* under residents allowed 25.04 under 25.04 D3110 Pulp Cap - Direct (excluding final restoration) YES YES NO NO Not covered on primary teeth $7.00 with more than 2/3 of root structure reabsorbed D3120 Pulp Cap Indirect (excluding final restoration) YES YES NO NO $19.00 – PULPOTOMY D3220 Therapeutic Pulpotomy (excluding final restoration) YES YES NO NO Not separately reimbursable to $50.00 – Removal of Pulp Coronal to the Dentinocemental same provider as part of root Junction and Application of Medicament in same period of treatment D3221 Pulpal Debridement, Primary and Permanent Teeth NO NO Not Covered D3222 Partial pulpotomy for apexogenesis-permanent tooth YES YES Not separately reimbursable to $50.00 with incomplete root development same provider as part of root canal in same period of treatment
D2999 Unspecified Restorative Procedure, by Report YES YES YES YES Ex: Temp. – fractured tooth By Report IV. ENDODONTICS PULP CAPPING Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D3110 Pulp Cap - Direct (excluding final restoration) YES YES NO NO Not covered on primary teeth with more than 2/3 of root structure reabsorbed $7.00 D3120 Pulp Cap – Indirect (excluding final restoration) YES YES NO NO $19.00 PULPOTOMY D3220 Therapeutic Pulpotomy (excluding final restoration) – Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament YES YES NO NO Not separately reimbursable to same provider as part of root in same period of treatment $50.00 D3221 Pulpal Debridement, Primary and Permanent Teeth NO NO Not Covered D3222 Partial pulpotomy for apexogenesis-permanent tooth with incomplete root development YES YES Not separately reimbursable to same provider as part of root canal in same period of treatment $50.00