Md. Code Regs. 10.09.05.05

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.05.05 - Limitations

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.

B. The Program does not cover:

(1) Resin crowns without a metal superstructure;

(2) Porcelain crowns without a metal superstructure;

(3) Fixed bridge work;

(4) Cosmetic procedures;

(5) Inpatient hospital dental or oral health care services rendered during an admission;

(6) Services which are investigational or experimental;

(7) Local anesthesia as a separate charge;

(8) Duplication of dentures;

(9) Drugs and supplies dispensed by the dentist which are acquired by the dentist at no cost;

(10) Referrals;

(11) Diagnostic models as a separate charge;

(12) Office visits as a separate service;

(13) Immediate dentures;

(14) Consultant payments when a member of the house staff of a hospital either requests or provides the consultations or, in the case of a group practice, to any partner or associate of that practice who either requests or provides the consultation;

(15) Aftercare services as a separate charge to a provider or, in the case of a group practice, to any partner or associate of that practice;

(16) Services when reimbursement is included under another segment of the Program;

(17) Unilateral partial dentures replacing fewer than three teeth, excluding third molars;

(18) Implants;

(19) More than one, per participant per lifetime, of the following services:

(a) Traditional comprehensive orthodontic treatment; or

(b) Self-ligating braces; and

(20) Services rendered without the required preauthorization.

Md. Code Regs. 10.09.05.05

Regulations .05 amended effective October 13, 1976 (3:21 Md. R. 1206)
Regulations .05 amended as an emergency provision effective February 1, 1982 (9:2 Md. R. 110); emergency status extended at 9:11 Md. R. 1122 and 9:17 Md. R. 1697 (Emergency provisions are temporary and are not printed in COMAR)
Regulations .05A amended as an emergency provision effective February 1, 1989 (16:3 Md. R. 336); adopted permanently effective June 1, 1989 (16:10 Md. R. 1108)
Regulation .05 amended effective October 1, 1985(12:19 Md. R. 1848); May 19, 2008 (35:10 Md. R. 972)
Regulation .05 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858); amended effective 44:16 Md. R. 808, eff. 8/14/2017; amended effective 46:10 Md. R. 485, eff. 5/20/2019; amended effective 48:22 Md. R. 938, eff. 11/1/2021; amended effective 48:23 Md. R. 979, eff. 11/15/2021; amended effective 50:13 Md. R. 512, eff. 7/10/2023