Benefits for replacement within 24 months of initial placement by a different

Benefits for replacement within 24 months of initial

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participating dentist. Benefits for replacement within 24 months of initial placement by a different dentist/dental office are DENIED and the approved amount is chargeable to the patient. D2940 Protective restoration CDT: Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, or prevent further deterioration. Not to be used for endodontic access closure, or as a base or liner under a restoration. A protective restoration is a benefit as long as no other definitive treatment (i.e.: filling, RCT) is rendered to the tooth on the same date. Subject to 60 month time limitation; deny within that time period. a. Protective restorations are covered benefits for emergency relief of pain. The fee for a protective restoration filling is not billable to the patient by a participating dentist when performed in conjunction with a definitive restoration by the same dentist/dental office on the same date of service. b. Pulp cap - direct (excluding final restoration) (D3110) or pulp cap - indirect (excluding final restoration) (D3120) are not billable to the patient by a participating dentist when billed in conjunction with D2940. c. No payment is made for protective restorations and the fees are not billable to the patient by a participating dentist with any restorative codes D2000-D2999, bridge codes (D6200 - D6699), D3220 - D3330, D3346-D3353, D3410 - D3450. D2941 Interim therapeutic dentition CDT: Placement of an adhesive restorative material following caries debridement by hand or other method for the management of early childhood caries. Not considered a definitive restoration. 1. Allow once per primary tooth. 2. D2941 is not billable to the patient by a participating dentist when submitted by the same dentist/dental office in conjunction with definitive restoration within 24 months. D2949 Restorative foundation for an indirect restoration CDT: Placement of restorative material to yield a more ideal form, including elimination of undercuts. This procedure is a component of the definitive indirect restoration. Fees are not billable to the patient by a participating dentist. D2950 Core buildup, including any pins when required CDT: Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form or concave irregularity in a preparation. Tooth number and pre- operative periapical x-ray A core buildup is a benefit once per tooth in 60 months. Pins are not separately reimbursed. A core buildup only qualifies for benefits when it is necessary to retain a cast restoration due to extensive loss of tooth structure from caries or fracture. If the procedure does not qualify, no payment is made and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist.

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