Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.05 - Dental Services › Section 10.09.05.05 - Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Program
				  places the following limitations upon covered services:
(1) Reimbursement for a complete radiographic
				  survey or full series of X-rays of the mouth may not be made more frequently
				  than once every 3 years to the same provider, or in the case of a group
				  practice, to any partner or associate of that practice, unless medically
				  necessary or specifically required or requested by the Program.
(2) For any traumatic injury case, a provider
				  may be reimbursed for a maximum of four panoramic or other extra-oral
				  radiographs. When services are rendered by members of a group practice or
				  association, reimbursement to the group practice or association shall also be
				  limited to a maximum of four panoramic or other extra-oral
				  radiographs.
(3) Endodontic
				  therapies and pulpectomies may not be covered when:
(a) Root resorption has started and
				  exfoliation is imminent;
(b) Gross
				  periapical or periodontal pathosis is demonstrated on the radiograph;
				  or
(c) The general oral condition
				  does not justify endodontic therapy.
(4) Reimbursement for crowns will be limited
				  to permanent resin fused to metal crowns, permanent porcelain fused to metal
				  crowns, permanent nonprecious metal (full cast), provisional resin crowns, and
				  stainless steel crowns.
(5)
				  Composite restorations will be covered for all teeth when necessary for the
				  particular conditions of the patient.
(6) Replacement dentures for participants who
				  meet the requirements of Regulation .04A(3) of this chapter will be covered
				  only when:
(a) Dentures have been lost,
				  broken, or stolen after 1 year of placement; or
(b) Adjustment, repair, relining, or rebasing
				  of the patient's present denture does not make it serviceable.
(7) Rebasing is included in the 6
				  months of aftercare following denture placement, and may not be provided more
				  frequently than once every 2 years after that.
(8) Reimbursement for endodontic therapy
				  includes all diagnostic tests, preoperative and postoperative radiographs,
				  preoperative and postoperative treatments, pulpotomies and
				  pulpectomies.
(9) Reimbursement for
				  a sinus closure will only be made when this service is rendered as a separate
				  procedure and not in conjunction with the removal of a tooth.
(10) Separate reimbursement will not be made
				  for cavity liners and office visits, as these procedures are considered to be
				  components of the necessary treatment. These services may not be billed to the
				  participant.
(11) The provider may
				  bill for emergency treatment or for the actual dental procedures rendered
				  during an emergency visit, but not for both.
(12) Gold restorations, gold crowns, and gold
				  replacement appliances are not covered services.
(13) The Program's fee for a complete series
				  of intra-oral radiographs including bitewings, represents the maximum payable
				  for any combination of periapical X-rays and bitewings.
(14) Assistant surgeons' services are covered
				  only:
(a) As specified in Regulation .07M of
				  this chapter;
(b) If the procedures
				  were rendered in a hospital or a Medicare-certified ambulatory surgery center;
				  and
(c) If the assistant surgeon is
				  a dentist.