Surgical Placement: Temporary Anchorage Device NO NO Not Covered Requiring Surgical Flap D7294 Surgical Placement: Temporary Anchorage Device NO NO Not Covered Without Surgical Flap Harvest of Bone for use in Autogenous Grafing YES YES NO YES Only reimbursable when $225.00 Procedure necessary for bone graft for reconstruction of alveolar defect. Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code 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 ALVEOLOPLASTY - SURGICAL PREPARATION OF FOR DENTURES D7310 Alveoloplasty in Conjunction with Extractions - Four or Yes Yes NO NO $64.00 More or Tooth Spaces, Per Quadrant D7311 Alveoloplasty in Conjunction with Extractions - One to NO NO Not Covered Three Teeth or Tooth Spaces, Per Quadrant D7320 Alveoloplasty not in Conjunction with Extractions - Four Yes Yes NO NO Only reimbursable for $94.00 or More or Tooth Spaces, Per Quadrant members who have alveolar segment irregularity preventing denture placement. D7321 Alveoloplasty not in Conjunction with Extractions - One YES YES NO NO Only reimbursable for $47.00 to Three Teeth or Tooth Spaces, Per Quadrant members who have alveolar segment irregularity preventing denture placement.
Surgical Placement: Temporary Anchorage Device Requiring Surgical Flap NO NO Not Covered D7294 Surgical Placement: Temporary Anchorage Device Without Surgical Flap NO NO Not Covered Harvest of Bone for use in Autogenous Grafing Procedure YES YES NO YES Only reimbursable when necessary for bone graft for reconstruction of alveolar defect. $225.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow 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 ALVEOLOPLASTY - SURGICAL PREPARATION OF FOR DENTURES D7310 Alveoloplasty in Conjunction with Extractions - Four or More or Tooth Spaces, Per Quadrant Yes Yes NO NO $64.00 D7311 Alveoloplasty in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per Quadrant NO NO Not Covered D7320 Alveoloplasty not in Conjunction with Extractions - Four or More or Tooth Spaces, Per Quadrant Yes Yes NO NO Only reimbursable for members who have alveolar segment irregularity preventing denture placement. $94.00 D7321 Alveoloplasty not in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per Quadrant YES YES NO NO Only reimbursable for members who have alveolar segment irregularity preventing denture placement. $47.00
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