55 Pa. Code § 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.
Notes
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