DentaQuest of Illinois, LLC
Attachment AA
Covered Services Comparison for Children and Adults
| Children (< age 21) |
Adults (> age 20) |
Requires Prior Approval |
|
|---|---|---|---|
| Diagnostic Services | |||
| Oral Exams (For children, limited to one every 6 months per dentist in an office setting, and one every 12 months in a school setting. For adults, limited to 1st visit per dentist.) | X | X | |
| X-rays | X | X | |
| Preventive Services | |||
| Prophylaxis – Cleanings (Once every 6 months) | X | ||
| Topical Fluoride (Annual) | X | ||
| Sealants | X | ||
| Space Maintenance | X | ||
| Restorative Services | |||
| Amalgams | X | X | |
| Resins | X | X | |
| Crowns | X | X | Y |
| Sedative Fillings | X | X | |
| Endodontic Services | |||
| Pulpotomy | X | ||
| Root Canals (For adults, limited to facial front teeth only.) | X | X | |
| Periodontal Services | |||
| Gingivectomy | X | Y | |
| Scaling and Root Planing | X | X | |
| Removable Prosthodontic Services | |||
| Complete Denture (upper and lower) | X | X | Y |
| Partial Denture (upper and lower) | X | Y | |
| Denture Relines | X | X | Y |
| Maxillofacial Prosthetics | X | X | Y |
| Fixed Prosthetic Services | |||
| Bridge | X | Y | |
| Oral and Maxillofacial Services | |||
| Extractions | X | X | |
| Surgical Extractions | X | X | Y |
| Alveoloplasty | X | Y | |
| Orthodontic Services | |||
| Orthodontia (Coverage limited to children meeting or exceeding a score of 42 from the Modified Salzmann Index or meeting criteria for medical necessity) | X | Y | |
| Adjunctive General Services | |||
| General Anesthesia | X | X | Y |
| IV Sedation | X | X | Y |
| Nitrous Oxide | X | X | |
| Conscious Sedation | X | X | Y |
| Therapeutic Drug Injection | X | X | Y |
DentaQuest of Illinois, LLC September 1, 2011
Current Dental Terminology © 2011 American Dental Association. All Rights Reserved.
Current Dental Terminology © 2011 American Dental Association. All Rights Reserved.