XI. ORTHODONTICS (Orthodontics are not covered services for residents of ICF-IID facilities) LIMITED ORTHODONTIC TREATMENT D8010 Limited Orthodontic Treatment of The Primary Yes No Yes $332.50 Dentition D8020 Limited Orthodontic Treatment of The Transitional Yes No Yes $332.50 Dentition D8030 Limited Orthodontic Treatment of The Adolescent Yes No Yes $332.50 Dentition D8040 Limited Orthodontic Treatment of The Adult Dentition No No Not Covered INTERCEPTIVE ORTHODONTIC TREATMENT D8050 Interceptive Orthodontic Treatment of The Primary Yes No Yes $592.00 Dentition 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 when allowed ICF-IID allowed residents* under residents under 25.04 25.04 Interceptive Orthodontic Treatment of The Transitional Yes No Yes $592.00 Dentition COMPREHENSIVE ORTHODONTIC TREATMENT Comprehensive Orthodontic Treatment of The Yes No Yes The Department will reimburse $2,725.00 Transitional Dentition for one comprehensive orthodontic treatment per member per lifetime. D8070,
XI. ORTHODONTICS (Orthodontics are not covered services for residents of ICF-IID facilities) LIMITED ORTHODONTIC TREATMENT D8010 Limited Orthodontic Treatment of The Primary Dentition Yes No Yes $332.50 D8020 Limited Orthodontic Treatment of The Transitional Dentition Yes No Yes $332.50 D8030 Limited Orthodontic Treatment of The Adolescent Dentition Yes No Yes $332.50 D8040 Limited Orthodontic Treatment of The Adult Dentition No No Not Covered INTERCEPTIVE ORTHODONTIC TREATMENT D8050 Interceptive Orthodontic Treatment of The Primary Dentition Yes No Yes $592.00 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 Interceptive Orthodontic Treatment of The Transitional Dentition Yes No Yes $592.00 COMPREHENSIVE ORTHODONTIC TREATMENT Comprehensive Orthodontic Treatment of The Transitional Dentition Yes No Yes The Department will reimburse for one comprehensive orthodontic treatment per member per lifetime. D8070, $2,725.00