TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.TABLE D SCHEDULE OF DENTAL PROCEDURES



 

Section 140.TABLE D   Schedule of Dental Procedures

 

Effective January 1, 2018.  Additional dental services may be approved based on medical necessity.

 

a)         Diagnostic Services

 

1)         Clinical Oral Evaluations

 

A)      Oral Exams − in an office and school setting;

 

i)           For ages 0-20 – Limited to one every 6 months per patient; 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 in an office or school setting

 

A)        For ages 0-20 – Limited to one every 6 months per patient; 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 or 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 lifetime 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 43 Ill. Reg. 1014, effective December 31, 2018)