§ 1149.57. Noncompensable services and items.
No payment will be made to a dentist for the following services or items:
(1) Services or items not listed in the MA Program fee schedule.
(2) Silicate, acrylic or plastic restorations involving the occlusal surfaces of posterior teeth.
(3) Dental services for cosmetic purposes.
(4) Anesthesia services performed in a hospital short procedure unit, hospital emergency room or on an inpatient hospital basis.
(5) Diagnostic or pathological examinations of body fluids or tissues. Payment for these procedures is made only to hospital and independent laboratories approved for participation in the MA Program.
(6) Radiographs improperly identified as specified in § 1149.43(5) and (6) (relating to requirements for dental records) or not clearly readable or free from defects.
(7) Troches, lozenges, throat tablets, cough drops, chewing gum, mouth washes, and the like, prescribed for local treatment of disorders of the mouth and throat, even though the products are combined with antibiotic, antibacterial, analgesic, anesthetic or antitussive agents.
(8) Medications and supplies furnished by a dentist during the course of an examination or treatment.
(9) Initial oral examination or periodic oral examination when emergency treatment is provided.
(10) Fluoride treatment for persons 17 years of age or older.
(11) Self-curing dental materials.
(12) Crowns which are splinted for periodontal reasons.
(13) Crowns in conjunction with a bridge.
(14) Pontics in conjunction with a bridge.
(15) Fixed bridgework.
(16) Pulpotomy on fully developed permanent teeth.
(17) Root canal treatment, other than paste filling material, on primary teeth.
(18) Dental services other than those specified in § 1149.21 (relating to scope of benefits for the categorically needy), unless provided to MA recipients under 21 years of age.
Source The provisions of this § 1149.57 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995. Immediately preceding text appears at serial page (130981).
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