Service Category 1: Diagnostic and Preventive |
Dental exams (complete, routine, specific, emergency) |
No |
X-rays |
No |
Cleaning (scaling) |
No |
Fluoride applications |
No |
Sealants |
No |
Service Category 2: Basic Services |
|
Specific Services |
Preauthorization Required |
Restorative |
Permanent fillings |
No |
Temporary fillings |
No |
Pain control for diseased teeth |
No |
Other treatments for cavities |
No |
Endodontic |
Root canal treatments |
No |
Pulpectomies (first step of a root canal treatment) |
No |
Procedures to reduce infection and relieve pain |
No |
Re-treatment of previously completed root canal treatment |
Yes |
Periodontal |
Cleaning under the gumline |
No |
Treating abscesses |
No |
Bonding for mobile teeth |
Yes |
Post-surgical evaluations |
Yes |
Non-surgical gum disease management |
No |
Service Category 3: Major Services |
|
Specific Services |
Preauthorization Required |
Restorative |
Posts and post removal |
No |
Repairs to crowns and re-bonding of crowns and posts |
No |
Crowns |
Yes |
Cores (to support crowns) |
Yes |
Posts for crowns |
Yes |
Removable Prosthodontic |
Complete dentures (standard and temporary |
No |
Denture repairs, relines, and rebases |
No |
Placing lining in dentures to condition oral tissues |
No |
Complete immediate and overdentures |
Yes |
Partial dentures |
Yes |
Oral Surgey |
Removal of teeth and roots |
No |
Surgical removal of tumors and cysts |
No |
Surgical incisions (including draining |
No |
Treatments for broken jaw bones |
No |
Service Category 4: Anesthesia or Sedation |
|
Specific Services |
Preauthorization Required |
Minimal sedation (conscious) |
No |
Moderate sedation |
Yes |
Deep sedation |
Yes |
General anesthesia |
Yes |
Service Category 5: Orthodontic Services |
|
Specific Services |
Preauthorization Required |
Available in 2025, only in cases of medical need with strict criteria |
Yes |