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<regulation prefix="Regulation" num=".05" citation="COMAR 10.09.05.05" title_num="10" subtitle_num="09" chapter_num="05" heading="Limitations.">
  <paragraph num="A.">
    <text>The Program places the following limitations upon covered services:</text>
    <paragraph num="(1)">
      <text>Reimbursement for a complete radiographic survey or full series of X-rays of the mouth may not be made more frequently than once every 3 years to the same provider, or in the case of a group practice, to any partner or associate of that practice, unless medically necessary or specifically required or requested by the Program.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>For any traumatic injury case, a provider may be reimbursed for a maximum of four panoramic or other extra-oral radiographs. When services are rendered by members of a group practice or association, reimbursement to the group practice or association shall also be limited to a maximum of four panoramic or other extra-oral radiographs.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Endodontic therapies and pulpectomies may not be covered when:</text>
      <paragraph num="(a)">
        <text>Root resorption has started and exfoliation is imminent;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Gross periapical or periodontal pathosis is demonstrated on the radiograph; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The general oral condition does not justify endodontic therapy.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Reimbursement for crowns will be limited to permanent resin fused to metal crowns, permanent porcelain fused to metal crowns, permanent nonprecious metal (full cast), provisional resin crowns, prefabricated zirconia crowns, and stainless steel crowns.</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Composite restorations will be covered for all teeth when necessary for the particular conditions of the patient.</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Replacement dentures for participants who meet the requirements of Regulation .04A(3) of this chapter will be covered only when:</text>
      <paragraph num="(a)">
        <text>Dentures have been lost, broken, or stolen after 1 year of placement; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Adjustment, repair, relining, or rebasing of the patient's present denture does not make it serviceable.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(7)">
      <text>Rebasing is included in the 6 months of aftercare following denture placement, and may not be provided more frequently than once every 2 years after that.</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Reimbursement for endodontic therapy includes all diagnostic tests, preoperative and postoperative radiographs, preoperative and postoperative treatments, pulpotomies and pulpectomies.</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Reimbursement for a sinus closure will only be made when this service is rendered as a separate procedure and not in conjunction with the removal of a tooth.</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Separate reimbursement will not be made for cavity liners and office visits, as these procedures are considered to be components of the necessary treatment. These services may not be billed to the participant.</text>
    </paragraph>
    <paragraph num="(11)">
      <text>The provider may bill for emergency treatment or for the actual dental procedures rendered during an emergency visit, but not for both.</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Gold restorations, gold crowns, and gold replacement appliances are not covered services.</text>
    </paragraph>
    <paragraph num="(13)">
      <text>The Program's fee for a complete series of intra-oral radiographs including bitewings, represents the maximum payable for any combination of periapical X-rays and bitewings.</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Assistant surgeons' services are covered only:</text>
      <paragraph num="(a)">
        <text>As specified in Regulation .07M of this chapter;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>If the procedures were rendered in a hospital or a Medicare-certified ambulatory surgery center; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>If the assistant surgeon is a dentist.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>The Program does not cover:</text>
    <paragraph num="(1)">
      <text>Fixed bridge work;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Cosmetic procedures;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Inpatient hospital dental or oral health care services rendered during an admission;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Services which are investigational or experimental;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Local anesthesia as a separate charge;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Duplication of dentures;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Drugs and supplies dispensed by the dentist which are acquired by the dentist at no cost;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Referrals;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Diagnostic models as a separate charge;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Office visits as a separate service;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Immediate dentures;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Consultant payments when a member of the house staff of a hospital either requests or provides the consultations or, in the case of a group practice, to any partner or associate of that practice who either requests or provides the consultation;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Aftercare services as a separate charge to a provider or, in the case of a group practice, to any partner or associate of that practice;</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Services when reimbursement is included under another segment of the Program;</text>
    </paragraph>
    <paragraph num="(15)">
      <text>Unilateral partial dentures replacing fewer than three teeth, excluding third molars;</text>
    </paragraph>
    <paragraph num="(16)">
      <text>Implants;</text>
    </paragraph>
    <paragraph num="(17)">
      <text>More than one, per participant per lifetime, of the following services:</text>
      <paragraph num="(a)">
        <text>Traditional comprehensive orthodontic treatment; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Self-ligating braces; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(18)">
      <text>Services rendered without the required preauthorization.</text>
    </paragraph>
  </paragraph>
</regulation>