restorations are placed on the same tooth. Reimbursement for an occlusal restoration includes any extensions onto the occlusal one-third of the buccal, facial or lingual surface(s) of the tooth. Extension of interproximal restorations into self-cleansing areas will not be considered as additional surfaces. Extension of any restoration into less than 1/3 of an adjacent surface is not considered an additional surface and will not be reimbursable (or if paid will be recovered). Restorative service to include: Restorations (fillings) – amalgam or resin based composite for anterior and posterior teeth. Service includes local anesthesia, pulp cap (direct or indirect) polishing and adjusting occlusion. Gold foil - . Service includes local anesthesia, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Inlay/onlay restorations – metallic, service includes local anesthesia, cementation, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Service requires prior authorization and will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor long term prognosis Service includes local anesthesia, temporary crown placement, insertion with cementation, polishing and adjusting occlusion. Provisional crowns are not covered. Recement of inlay, onlay, custom fabricated/cast or prefabricated post and core and crown, Prefabricated stainless steel, stainless steel crown with resin window and resin crowns. Service includes local anesthesia, insertion with cementation and adjusting occlusion. Core buildup including pins Pin retention Indirectly fabricated (custom fabricated/cast) and prefabricated post and core Additional fabricated ( custom fabricated/cast) and prefabricated post Post removal Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture Coping Crown repair Protective restoration/sedative filling Endodontic Services
restorations are placed on the same tooth. Reimbursement for an occlusal restoration includes any extensions onto the occlusal one-third of the buccal, facial or lingual surface(s) of the tooth. Extension of interproximal restorations into self-cleansing areas will not be considered as additional surfaces. Extension of any restoration into less than 1/3 of an adjacent surface is not considered an additional surface and will not be reimbursable (or if paid will be recovered). Restorative service to include: Restorations (fillings) – amalgam or resin based composite for anterior and posterior teeth. Service includes local anesthesia, pulp cap (direct or indirect) polishing and adjusting occlusion. Gold foil - . Service includes local anesthesia, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Inlay/onlay restorations – metallic, service includes local anesthesia, cementation, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Service requires prior authorization and will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor long term prognosis Service includes local anesthesia, temporary crown placement, insertion with cementation, polishing and adjusting occlusion. Provisional crowns are not covered. Recement of inlay, onlay, custom fabricated/cast or prefabricated post and core and crown, Prefabricated stainless steel, stainless steel crown with resin window and resin crowns. Service includes local anesthesia, insertion with cementation and adjusting occlusion. Core buildup including pins Pin retention Indirectly fabricated (custom fabricated/cast) and prefabricated post and core Additional fabricated ( custom fabricated/cast) and prefabricated post Post removal Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture Coping Crown repair Protective restoration/sedative filling Endodontic Services