Ind. Admin. Code tit. 405, r. 5-14-2 – Covered services

Sec. 2. The following are covered dental services under Medicaid:

(1) Evaluations.
(2) Radiographs.
(3) Prophylaxis.
(4) Topical fluoride for members twenty (20) years of age and younger.
(5) Sealant for permanent molars and premolars for members twenty (20) years of age and younger.
(6) Amalgam.
(7) Unilateral and bilateral space maintainers for members twenty (20) years of age and younger.
(8) Resin anteriors and posteriors.
(9) Recement crowns.
(10) Steel crown primary.
(11) Stainless steel crown permanent.
(12) Therapeutic pulpotomy.
(13) Extractions.
(14) Oral biopsies.
(15) Alveoplasty.
(16) Excision of lesions.
(17) Excision of benign tumor.
(18) Odontogenic cyst removal.
(19) Nonodontogenic cyst removal.
(20) Incise and drain abscess.
(21) Fracture simple stabilize.
(22) Compound fracture of the mandible.
(23) Compound fracture of the maxilla.
(24) Repair of wounds.
(25) Suturing.
(26) Emergency treatment dental pain.
(27) Analgesia for members twenty (20) years of age and younger.
(28) Drugs and medicaments.
(29) Periodontic procedures.
(30) Other dental services as medically necessary to treat members eligible for the EPSDT program.
(31) General anesthesia.
(32) Intravenous (IV) sedation covered only for oral surgical services.
(33) Dentures and partials.
(34) Orthodontic services for members twenty (20) years of age and under only.
(35) Physician fluoride varnish services for members younger than four (4) years of age.

(Office of the Secretary of Family and Social Services; 405 IAC 5-14-2; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3319; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Apr 16, 2003, 10:50 a.m.: 26 IR 2862; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; filed Sep 2, 2016, 12:26 p.m.: 20160928-IR-405150450FRA; readopted filed Jul 28, 2022, 2:21 p.m.: 20220824-IR-405220205RFA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)