Section 2699.6201 - Scope of Dental Benefits(a) The basic scope of benefits offered by a participating dental carrier as a dental benefit plan shall include all of the benefits and services listed in this section, subject to the exclusions listed in Section 2699.6205. No other dental benefits shall be permitted to be offered by a participating dental carrier. The basic scope of dental benefits shall be as follows: (1) Diagnostic and Preventive Benefits (A) Initial, periodic and emergency oral examinations, limited as follows:1. Routine oral examinations: one every six months per enrollee.(B) Palliative treatment.(C) Consultations, including specialist consultations.(D) Roentgenology, limited as follows:1. Bitewing x-rays in conjunction with period examinations are limited to one series of four films in any 12 consecutive month period.2. Full mouth x-rays in conjunction with period examinations are limited to once every 60 consecutive months.3. Panoramic film x-rays are limited to once every 60 consecutive months.4. Isolated bitewing or periapical films are allowed on an emergency or episodic basis.(E) Prophylaxis services, limited as follows:1. Not to exceed once in a six month period.(F) Fluoride treatment, limited as follows: 1. Only for dental benefit plan enrollees under the age of 18.(G) Dental sealant treatments, limited as follows:1. Only for dental plan enrollees under the age of 14.2. Permanent first and second molars only.3. One treatment per tooth in a 36 consecutive month period.(H) Space maintainers, limited as follows: 1. Only for dental plan enrollees under the age of 14.(I) Preventive dental education and oral hygiene instruction(2) Restorative Dentistry (A) Restorations, limited as follows: 1. The covered dental benefit is limited to the benefit level for the least costly dentally appropriate alternative. If a more costly alternative is chosen by the patient, the patient will be responsible for all additional charges.2. Replacement of a restoration is covered only when it is defective, as evidenced by conditions such as recurrent caries or fracture, and replacement is necessary for the enrollee's dental health.(B) Use of pins in conjunction with a restoration.(3) Oral Surgery (A) Extractions, including surgical extractions(B) Removal of impacted teeth, limited as follows:1. Surgical removal of impacted teeth is a covered benefit only when evidence of pathology exists.(C) Biopsy of oral tissues(E) Excision of cysts and neoplasms(F) Treatment of palatal torus if interfering with a prosthesis(G) Treatment of mandibular torus if interfering with a prosthesis(I) Incision and drainage of abscesses(J) Post-operative services including exams, suture removal and treatment of complications.(4) Endodontics(B) Therapeutic pulpotomy(C) Apexification filling with calcium hydroxide(E) Root amputation and Hemisection(5) Periodontics (A) Periodontal scaling performed in the presence of gingival inflammation(B) Periodontal scaling and root planing, gingival flap procedure, and subgingival curettage, limited as follows: 1. Four quadrant treatments in any 12 consecutive months.(C) Gingivectomy or gingivoplasty(D) Osseous or muco-gingival surgery(E) Correction of occlusion, limited to occlusal adjustment.(6) Crowns and Fixed Bridges(A) Crowns, limited as follows:1. Replacement of each unit is limited to once every 60 consecutive months, with the exception of prefabricated stainless steel crowns.(B) Fixed bridges, limited as follows: 1. Fixed bridges are a covered benefit when there are one or two missing teeth in any one quadrant.2. Other than in one (1) above, fixed bridges will be covered only when a partial denture cannot satisfactorily restore the case. If a fixed bridge is used when a partial could satisfactorily restore the case, coverage will be provided at the level it would have been for a partial denture.3. Replacement of an existing fixed bridge is covered only when it cannot be made satisfactory by repair.4. Replacement of bridge pontic and bridge abutment units is limited to once every 60 consecutive months.(C) Recementation of crowns or bridges(D) Inlays and onlays, limited as follows: 1. Replacement of each unit is limited to once every 60 consecutive months.(E) Prefabricated, cast or laboratory posts and cores for crowns or bridges(F) Repair or replacement of crowns, abutments or pontics.(7) Removable Prosthetics (A) Dentures, full or partials, teeth, and clasps, limited as follows:1. Partial dentures are not to be replaced within 60 consecutive months, unless: a. it is necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible, orb. the denture is unsatisfactory and cannot be made satisfactory.2. Full upper and/or lower dentures are not to be replaced within 60 consecutive months unless the existing denture is unsatisfactory and cannot be made satisfactory.3. The covered dental benefit for complete dentures will be limited to the benefit level for a standard procedure. If a more personalized or specialized treatment is chosen by the patient and the dentist, the patient will be responsible for all additional charges.4. The covered dental benefit for partial dentures will be limited to the charges for a cast chrome or acrylic denture if this would satisfactorily restore an arch. If a more elaborate or precision appliance is chosen by the patient and the dentist, and is not necessary to satisfactorily restore an arch, the patient will be responsible for all additional charges.(B) Office or laboratory relines or rebases, limited as follows: 1. One per arch in any 24 consecutive months for a standard procedure.2. One per arch may be performed during the 6 consecutive months after an immediate procedure. After this initial period, this benefit is limited to one per arch in any 24 consecutive months.(8) Orthodontia (A) The basic benefit shall cover a treatment program and shall include:1. Start-up records, examination, consultation, x-rays, study models, photographs.2. Final exam, x-rays, study models, photographs.3. Post-treatment retention(B) Interceptive orthodontic treatment shall be a benefit if, in the opinion of the dental professional and the dental carrier, alternative interceptive orthodontic treatment would be a more appropriate course of treatment for an enrollee under the age of 18 than the customary orthodontic program described in (A) above.(9) Other Dental Benefits (B) Injection of antibiotic drugs.(10) This part shall not be construed to prohibit a dental plan's ability to impose cost-control mechanisms. Such mechanisms may include but are not limited to requiring prior authorization for benefits or providing alternative treatments or services.(11) The level of benefits covered under a fee-for-service dental benefit plan shall be limited to usual, customary or reasonable (UCR) charges.Cal. Code Regs. Tit. 10, § 2699.6201
1. New section filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 5-23-94 order transmitted to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
3. Editorial correction of subsection (a)(7)(A)4 (Register 94, No. 43). Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.
1. New section filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 5-23-94 order transmitted to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
3. Editorial correction of subsection (a)(7)(A)4 (Register 94, No. 43).