Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE89. SOCIAL SERVICES |
PART140. MEDICAL PAYMENT |
SUBPARTL. UNAUTHORIZED USE OF MEDICAL ASSISTANCE |
§140.TABLE D. Schedule of Dental Procedures
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Effective January 1, 2018. Additional dental services may be approved based on medical necessity.
a) Diagnostic Services
1) Clinical Oral Evaluations
A) Oral Exams
i) For ages 0-20 – Limited to two every 12 months per patient in an office setting and one per school year in a school setting; and
ii) For ages 21 and over – Limited to one every 12 months per patient
B) Limited Exam
C) Comprehensive Exam
2) X-rays
b) Preventive Services
1) Prophylaxis
A) For ages 0-20 – Limited to one every 6 months per patient in an office setting and one per school year in a school setting; and
B) For ages 21 and over – Limited to one every 12 months per patient
2) Topical Application of Fluoride (ages 0-20) − limited to one every 6 months per patient in an office setting and one per school year in a school setting
3) Fluoride Varnish (ages 0-2) − limited to three per 12 months per patient ages 0-2 years in an office setting
4) Sealants (ages 0-20) − limited to one per two years per tooth regardless of place of service
5) Space Maintenance (ages 0-20) – limited to one per lifetime per quadrant
c) Restorative Services
1) Amalgams
2) Resins
3) Crowns
4) Other Restorative Services
d) Endodontic Services
1) Pulpotomy – limited to ages 0-20
2) Endodontic Therapy (ages 21 and over; limited to anterior teeth only)
3) Apexification/Recalcification Procedures limited to ages 0-20
4) Apicoectomy/Periradicular Services limited to ages 0-20
e) Periodontal Services
1) Surgical Services
2) Non-Surgical Periodontal Services
3) Other Periodontal Services
f) Removable Prosthodontic Services
1) Complete Denture
2) Partial Denture – limited to ages 0-20
3) Repairs to Complete Denture
4) Repairs to Partial Denture
5) Denture Reline Procedures
g) Maxillofacial Prosthetics
h) Prosthodontics Fixed limited to ages 0-20
1) Fixed Partial Denture Pontics
2) Fixed Partial Denture Retainers – Crowns
3) Other Fixed Partial Denture Services
i) Oral and Maxillofacial Services
1) Extractions
2) Surgical Extractions
3) Other Surgical Procedures
4) Alveoloplasty
5) Surgical Excision of Intra-osseous Lesions
6) Surgical Incision
7) Treatment of Fractures – Simple
8) Treatment of Fractures – Compound
9) Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions
10) Other Repair Procedures
j) Orthodontic Services limited to ages 0-20
1) Comprehensive Orthodontic
2) Other Orthodontic Services
k) Adjunctive General Services
1) Unclassified Treatment
2) Anesthesia
3) Professional Consultation
4) Drugs
(Source: Amended at 47 Ill. Reg. 16385, effective November 3, 2023)