Section 17b-262-864 - Limitations on Coverage of Certain Non-emergency Dental ServicesThe limitations on coverage of certain non-emergency dental services in subsection (a) of this section apply to healthy adults. The limitations on non-emergency dental services in subsection (b) of this section apply to all adults twenty-one years of age and older and are subject to the prior authorization requirements in section 17b-262-866 of the Regulations of Connecticut State Agencies.
(a) Coverage of non-emergency dental services provided to healthy adults shall be limited as follows:(1) One comprehensive oral examination per client per lifetime. If a client changes dental providers, the new provider may request approval to conduct an additional comprehensive oral examination through the prior authorization process described in section 17b-262-866 of the Regulations of Connecticut State Agencies;(2) One periodic oral examination per client per year;(3) Four intraoral periapical x-rays per year;(4) One set of bitewing x-rays per year; and(5) One prophylaxis procedure per year.(b) Coverage of non-emergency dental services provided to all adults twenty-one years of age and older shall be limited as follows:(1) One topical fluoride treatment for clients who have xerostomia or have undergone head or neck radiation or chemotherapy.(2) Prosthodontics: (A) Coverage of complete and removable partial dentures for functional purposes when there are fewer than 8 posterior teeth in occlusion or missing anterior teeth is subject to prior authorization requirements in section 17b-262-866 of the Regulations of Connecticut State Agencies.(B) Coverage of removable partial dentures when there are more than 8 posterior teeth in occlusion and no missing anterior teeth is allowed on a case-by-case basis conditioned upon a demonstration of medical necessity and subject to prior authorization requirements in section 17b-262-866 of the Regulations of Connecticut State Agencies;(C) One complete and partial denture prosthesis construction is covered per seven-year period. Clients shall sign an acceptance form upon receipt of a new denture prosthesis acknowledging that the prosthesis is acceptable and that he or she understands the department's replacement policy as described in subsection (d) of this section; and(D) Replacement of denture prosthesis more than once in a seven-year period shall be limited to replacement for reasons of medical necessity. Replacement shall not be made for cosmetic reasons. Replacement shall not be made if the prosthesis was lost, stolen or destroyed as a result of misuse, abuse or negligence.(3) Coverage of periodontics is allowed on a case-by-case basis conditioned upon a demonstration of medical necessity and subject to prior authorization requirements in section 17b-262-866 of the Regulations of Connecticut State Agencies;(4) Coverage of implants and unilateral removable appliances is allowed on a case-by-case basis conditioned upon a demonstration of medical necessity and subject to prior authorization requirements in section 17b-262-866 of the Regulations of Connecticut State Agencies; and(5) Coverage of vestibuloplasty is allowed on a case-by-case basis conditioned upon a demonstration of medical necessity and subject to prior authorization requirements in section 17b-262-866 of the Regulations of Connecticut State Agencies.Conn. Agencies Regs. § 17b-262-864