1. (1) Dental services shall only be available through a Medicaid-enrolled dental provider that complies with relevant laws and policy.
2. (2) Dental services shall only be provided within the parameters of generally accepted standards of dental practice and may be subject to any limitation or exclusion established by Medicaid.
3. (3) Dental services may be subject to any limitation or exclusion of medical necessity and utilization control considerations or conditions.
4. (4) Medicaid shall reimburse up to one evaluation for each member each day, even if more than one provider is involved from the same office or clinic. Medicaid may not cover multiple exams for the same date of service.
5. (5) Medicaid includes in the global payment, and may not reimburse separately, any denture adjustment performed by the original provider within six months of a member receiving a denture.
6. (6) Medicaid may cover third-molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove any remaining third molar during the same procedure.
7. (7) Medicaid shall cover the treatment of a temporomandibular joint fracture but may not cover other temporomandibular joint treatments.
8. (8) A laboratory or pathologist must submit a claim directly to Medicaid for payment of laboratory services.

9. (9) Medicaid may not cover the following dental services:

   1. (a) cast crowns, porcelain fused to metal, on posterior permanent teeth or on primary teeth;
   2. (b) consultation or second opinions not requested by Medicaid;
   3. (c) dental implants;
   4. (d) extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth;
   5. (e) fixed bridges or pontics;
   6. (f) general anesthesia for removal of an erupted tooth;
   7. (g) house calls;

   8. (h) limited orthodontic treatment, including removable appliance therapies;

      1. (i) nitrous oxide analgesia;
   9. (j) occlusal appliances, habit control appliances, or interceptive orthodontic treatment;

   10. (k) oral sedation for behavior management;

       1. (l) osteotomies;
   11. (m) procedures such as arthrostomy, meniscectomy, or condylectomy;
   12. (n) pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;
   13. (o) removable appliances in conjunction with fixed banded treatment;
   14. (p) ridge augmentation;
   15. (q) temporary dentures or temporary stayplate partial dentures;
   16. (r) tooth transplantation;
   17. (s) treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies; and
   18. (t) services provided without prior authorization.
10. (10) A Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes responsibility for the difference in fees for covered anterior stainless steel crowns that are deciduous to non-covered anterior stainless steel crowns with composite facings added or commercial or lab-prepared facings.

This section defines the scope of dental services available to a member who is eligible under the EPSDT program and includes comprehensive and preventive health care services.

KEY: Medicaid

Date of Last Change: April 1, 2025

Notice of Continuation: May 29, 2024

Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108; 26B-3-208