2019 Dental Plan...D0477 Special Stains, Not For Microorganisms $0 D0478 Immunohistochemical Stains...

© 2018 Allwell of 25

2019 Dental Plan Schedule of Benefits

Allwell from Sunshine Health has teamed up with Envolve Benefit Options to provide dental benefits under your Allwell Medicare plan. This document describes your covered dental benefits and services. Note that some services are either limited or excluded. For questions about your dental benefits, or to find a network dentist in your area, visit AllwellFlorida.com or call the Member Services number on your Allwell member ID card.

Deductible

There is no deductible under this dental plan. Maximum

There is a $3,000 maximum benefit under this plan. This is the maximum dollar amount this dental plan will cover toward the cost of your dental care. You are responsible for paying all costs above the annual maximum amount. Schedule of Benefits

The copayments listed in the table below only apply when you’re treated by a general dentist or dental specialist in our network. If you get a service not listed in the schedule of benefits, or from a dentist or other provider not in our network, you’ll have to pay the full cost. You should discuss all treatment options with your network dentist and request a written treatment plan before getting work done.

Code Description Limitation You Pay

Diagnostic (exams and x-rays)

D0120 Periodic Oral Evaluation 1 per 6 months $0

D0140 Limited Oral Evaluation - Problem Focused $0

D0145 Oral Evaluation For A Patient Under Three Years Of Age And Counseling With Primary Caregiver

1 per 6 months $0

D0150 Comprehensive Oral Evaluation - New Or Established Patient

1 per 6 months $0

D0160 Detailed And Extensive Oral Evaluation - Problem-Focused, By Report

$0

D0170 Re-Evaluation, Limited, Problem Focused $0

D0180 Comprehensive Periodontal Evaluation - New Or Established Patient

$0



D0270 Bitewing - Single Radiographic Image Up to 4 of any

combination of bitewings per calendar year

$0

D0272 Bitewings - Two Radiographic Images Up to 4 of any


$0

D0273 Bitewings - Three Radiographic Images Up to 4 of any


$0

D0274 Bitewings - Four Radiographic Images Up to 4 of any


$0

D0330 Panoramic Radiographic Image 1 per calendar year $0

D0411 Hba1c In-Office Point Of Service Testing $0

D0415 Collection Of Microorganisms For Culture And Sensitivity

$0

D0416 Viral Culture $0

D0425 Caries Susceptibility Tests $0

D0431

Adjunctive Pre-Diagnostic Test That Aids In Detection Of Mucosal Abnormalities Including Premalignant And Malignant Lesion

$0

D0460 Pulp Vitality Tests 1 per calendar year $0

D0470 Diagnostic Casts $0

D0472 Accession Of Tissue, Gross Examination $0

D0473 Accession Of Tissue, Gross And Microscopic Exam

$0

D0474 Accession Of Tissue, Gross And Microscopic Exam (Surgical)

$0

D0475 Decalcification Procedure $0

D0476 Special Stains For Microorganisms $0

D0477 Special Stains, Not For Microorganisms $0

D0478 Immunohistochemical Stains $0

D0479 Tissue In-Situ Hybridization, Including Interpretation

$0

D0480 Processing And Interpretation Of Cytologic Smears

$0

D0481 Electron Microscopy $0

D0482 Direct Immunofluorescence $0

D0483 Indirect Immunofluorescence $0

D0484 Consultation On Slides Prepared Elsewhere $0

D0485 Consultation, Including Preparation Of Slides From Biopsy Material Supplied By Referring Source

$0

D0486

Accession Of Exfoliative Cytological Smears, Microscopic Examination, Preparation And Transmission Of Written Report

$0



D0502 Other Oral Pathology Procedures, By Report

$0

D0999 Unspecified Diagnostic Procedure, By Report

$0

Preventive (cleanings)

D1110 Prophylaxis (Cleaning) - Adult 1 per 6 months $0

D1120 Prophylaxis (Cleaning) - Child 1 per 6 months $0

D1208 Topical Application of Fluoride 1 per calendar year $0

D1351 Sealant - Per Tooth $0

D1352 Preventive Resin Restoration - Permanent Tooth

$0

D1510 Space Maintainer - Fixed - Unilateral $0

D1516 Space Maintainer – Fixed – Bilateral, Maxillary

$0

D1517 Space Maintainer – Fixed – Bilateral, Mandibular

$0

D1520 Space Maintainer - Removable - Unilateral $0

D1526 Space Maintainer – Removable – Bilateral, Maxillary

$0

D1527 Space Maintainer – Removable – Bilateral, Mandibular

$0

D1550 Recement Or Re-Bond Of Space Maintainer $0

D1555 Removal Of Fixed Space Maintainer $0

Restorative (fillings)

D2140 Amalgam - One Surface, Primary Or Permanent

6 of any combination of filling per calendar year

$0

D2150 Amalgam - Two Surfaces, Primary Or Permanent


$0

D2160 Amalgam - Three Surfaces, Primary Or Permanent


$0

D2161 Amalgam - Four Or More Surfaces, Primary Or Permanent


$0

D2330 Resin-Based Composite - One Surface, Anterior


$0

D2331 Resin-Based Composite - Two Surfaces, Anterior


$0

D2332 Resin-Based Composite - Three Surfaces, Anterior


$0

D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)


$0

D2390 Resin-Based Composite Crown, Anterior 6 of any combination of filling per calendar year

$0

D2391 Resin-Based Composite - One Surface, Posterior


$0

D2392 Resin-Based Composite - Two Surfaces, Posterior


$0



D2393 Resin-Based Composite - Three Surfaces, Posterior


$0

D2394 Resin-Based Composite - Four Or More Surfaces, Posterior


$0

D2510 Inlay - Metallic - One Surface 6 of any

inlay/onlay/crown/pontic per calendar year

$0

D2520 Inlay - Metallic - Two Surfaces 6 of any


$0

D2530 Inlay - Metallic - Three Or More Surfaces 6 of any


$0

D2542 Onlay Metallic, Two Surfaces 6 of any


$0

D2543 Onlay-Metallic-Three Surfaces 6 of any


$0

D2544 Onlay-Metallic-Four Or More Surfaces 6 of any


$0

D2610 Inlay - Porcelain/Ceramic - One Surface 6 of any


$0

D2620 Inlay - Porcelain/Ceramic - Two Surfaces 6 of any


$0

D2630 Inlay - Porcelain/Ceramic - Three Or More Surfaces

6 of any inlay/onlay/crown/pontic

per calendar year $0

D2642 Onlay - Porcelain/Ceramic - Two Surfaces 6 of any


$0

D2643 Onlay - Porcelain/Ceramic - Three Surfaces 6 of any


$0

D2644 Onlay - Porcelain/Ceramic - Four Or More Surfaces



D2650 Inlay - Composite/Resin - One Surface 6 of any


$0

D2651 Inlay - Composite/Resin - Two Surfaces 6 of any


$0

D2652 Inlay - Composite/Resin - Three Or More Surfaces


$0



per calendar year

D2662 Onlay - Composite/Resin - Two Surfaces 6 of any


$0

D2663 Onlay - Composite/Resin - Three Surfaces 6 of any


$0

D2664 Onlay - Composite/Resin - Four Or More Surfaces



D2710 Crown,Resin-Based Composite (Indirect) 6 of any


$0

D2712 Crown - 3/4 Resin-Based Composite (Indirect)



D2721 Crown - Resin With Predominantly Base Metal



D2722 Crown - Resin With Noble Metal 6 of any


$0

D2740 Crown - Porcelain/Ceramic Substrate 6 of any


$0

D2751 Crown - Porcelain Fused To Predominantly Base Metal



D2752 Crown - Porcelain Fused To Noble Metal 6 of any


$0

D2781 Crown, 3/4 Cast Predominately Base Metal 6 of any


$0

D2782 Crown, 3/4 Cast Noble Metal 6 of any


$0

D2783 Crown, 3/4 Porcelain/Ceramic 6 of any


$0

D2791 Crown - Full Cast Predominantly Base Metal 6 of any


$0

D2792 Crown - Full Cast Noble Metal 6 of any


$0

D2910 Recement Or Re-Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration


$0



per calendar year

D2915 Recement Or Re-Bond Cast Indirectlty Fabricated Or Prefabricated Post And Core



D2920 Recement Or Re-Bond Crown 6 of any


$0

D2930 Prefabricated Stainless Steel Crown - Primary Tooth



D2931 Prefabricated Stainless Steel Crown - Permanent Tooth



D2932 Prefabricated Resin Crown 6 of any


$0

D2933 Prefabricated Stainless Steel Crown With Resin Window



D2934 Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth



D2940 Protective Restoration $0

D2950 Core Buildup, Including Any Pins When Required

$0

D2951 Pin Retention - Per Tooth, In Addition To Restoration

$0

D2952 Cast Post And Core In Addition To Crown $0

D2953 Each Additional Indirectly Fabricated Post, Same Tooth

$0

D2954 Prefabricated Post And Core In Addition To Crown

$0

D2955 Post Removal (Not In Conjunction With Endodontic Therapy)

$0

D2957 Each Additional Prefabricated Post, Same Tooth

$0

D2971 Additional Procedures To Construct New Crown Under Partial Denture Framework

$0

D2975 Coping $0

D2980 Crown Repair Necessitated By Restorative Material Failure

$0

D2999 Unspecified Restorative Procedure, By Report

$0

Endodontics (root canals)

D3110 Pulp Cap - Direct (Excluding Final Restoration)

$0

D3120 Pulp Cap - Indirect (Excluding Final Restoration)

$0



D3220 Therapeutic Pulpotomy (Excluding Final Restoration)

$0

D3221 Pulpal Debridement, Primary And Permanent Teeth

$0

D3230 Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth (Excluding Final Restoration)

$0

D3240 Pulpal Therapy (Resorbable Filling) - Posterior, Primary Tooth (Excluding Final Restoration)

$0

D3310 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)

6 of any combination of root canal or retreatment

of previous root canal per calendar year

$0

D3320 Endodontic Therapy, Premolar Tooth (Excluding Final Restoration)



$0

D3330 Endodontic Therapy, Molar (Excluding Final Restoration)



$0

D3331 Treatment Of Root Canal Obstruction, Non-Surgical Access

$0

D3332 Incomplete Endodontic Therapy; Inoperable, Unrestorable Or Fractured Tooth

$0

D3333 Internal Tooth Repair Of Performation Defects

$0

D3346 Retreatment Of Previous Root Canal Therapy - Anterior



$0

D3347 Retreatment Of Previous Root Canal Therapy - Premolar



$0

D3348 Retreatment Of Previous Root Canal Therapy - Molar



$0

D3351 Apexification/Recalcification-Initial Visit (Apical Closure/Calcific Repair Of Perforations, Root Resorption, Etc



$0

D3352 Apexification/Recalcification/Pulpal Regeneration - Interim Medication Replacement



$0



D3353 Apexification/Recalcification - Final Visit (Includes Completed Root



$0

D3355 Pupal Regeneration-Initial Visit $0

D3356 Pulpal Regeneration-Interim Medicament Replacement

$0

D3357 Pulpal Regeneration-Completion Of Treatment

$0

D3410 Apicoectomy - Anterior $0

D3421 Apicoectomy - Premolar (First Root) $0

D3425 Apicoectomy - Molar (First Root) $0

D3426 Apicoectomy (Each Additional Root) $0

D3430 Retrograde Filling - Per Root $0

D3450 Root Amputation - Per Root $0

D3460 Endodontic Endosseous Implant $0

D3470 Intentional Reimplantation (Including Necessary Splinting)

$0

D3910 Surgical Procedure For Isolation Of Tooth With Rubber Dam

$0

D3920 Hemisection (Including Any Root Removal), Not Including Root Canal Therapy

$0

D3950 Canal Preparation And Fitting Of Preformed Dowel Or Post

$0

D3999 Unspecified Endodontic Procedure, By Report

$0

Periodontics (gum and bone treatment)

D4210 Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

1 of either D4210 or D4211 per quadrant per

24 months $0

D4211 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant


24 months $0

D4230 Anatomical Crown Exposure - Four Or More Contiguous Teeth Or Tooth Bounded Tooth Spaces Per Quadrant

$0

D4231 Anatomical Crown Exposure - One To Three Teeth Or Tooth Bounded Tooth Spaces Per Quadrant

$0

D4240 Gingival Flap Procedure, Including Root Planning - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

$0

D4241 Gingival Flap Procedure - Including Root Planing -One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

$0

D4245 Apically Positioned Flap $0

D4249 Clinical Crown Lengthening - Hard Tissue $0



D4260 Osseous Surgery (Including Flap Entry And Closure) - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant


24 months $0

D4261 Osseous Surgery (Including Flap Entry And Closure) - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant


24 months $0

D4263 Bone Replacement Graft - First Site In Quadrant

$0

D4264 Bone Replacement Graft - Each Additional Site In Quadrant

$0

D4265 Biologic Materials To Aid In Soft And Osseous Tissue Regeneration

$0

D4266 Guided Tissue Regeneration - Resorbable Barrier, Per Site

$0

D4267 Guided Tissue Regeneration - Nonresorbable Barrier, Per Site (Includes Membrane Removal)

$0

D4268 Surgical Revision Procedure, Per Tooth $0

D4270 Pedicle Soft Tissue Graft Procedure $0

D4273 Autogenous Connective Tissue Graft Procedure, Per First Tooth, Implant Or Endentulous Tooth Position In Graft

$0

D4274 Distal Or Proximal Wedge Procedure (When Not Performed In Conjunction With Surgical Procedures In The Same Anatomical Ar

$0

D4275 Non-Autogenous Connective Tissue Graft (Including Recipient Site And Donor Material) First Tooth Implant

$0

D4276 Combined Connective Tissue And Double Pedicle Graft, Per Tooth

$0

D4277 Free Soft Tissue Graft Procedure Each Additional Contiguous Tooth, Implant Or Edentulous Tooth

$0

D4320 Provisional Splinting - Intracoronal $0

D4321 Provisional Splinting - Extracoronal $0

D4341 Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant


calendar year $0

D4342 Periodontal Scaling And Root Planing - One - Three Teeth, Per Quadrant


calendar year $0

D4355 Full Mouth Debridement To Enable Comprehensive Evaluation And Diagnosis On A Subsequent Visit

1 per 24 months $0

D4381 Localized Delivery Of Antimicrobial Agents Via A Controlled Release Vehicle Into Diseased Crevicular Tissue, Per Tooth

$0

D4910 Periodontal Maintenance 1 per 6 months $0



D4920 Unscheduled Dressing Change (By Someone Other Than Treating Dentist Or Their Staff)

$0

D4999 Unspecified Periodontal Procedure, By Report

$0

Removable Prosthodontics (dentures)

D5110 Complete Denture - Maxillary

1 set of any combination of maxillary and

mandibular full/partial dentures per 5 calendar

years

$0

D5120 Complete Denture - Mandibular



years

$0

D5130 Immediate Denture - Maxillary



years

$0

D5140 Immediate Denture - Mandibular



years

$0

D5211 Maxillary Partial Denture - Resin Base (Including Retentive/Clasping Materials, Rests And Teeth)



years

$0

D5212 Mandibular Partial Denture - Resin Base (Including Retentive/Clasping Materials, Rests And Teeth)



years

$0

D5213

Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And



years

$0

D5214

Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And



years

$0

D5225 Maxillary Partial Denture - Flexible Base (Including Any Clasps, Rests And Teeth)


$0




years

D5226 Mandibular Partial Denture - Flexible Base (Including Any Clasps, Rests And Teeth)



years

$0

D5282 Removable Unilateral Partial Denture – One Piece Cast Metal (Including Clasps And Teeth), Maxillary



years

$0

D5283 Removable Unilateral Partial Denture – One Piece Cast Metal (Including Clasps And Teeth), Mandibular



years

$0

D5410 Adjust Complete Denture - Maxillary 2 of any combination of adjustments or relines


D5411 Adjust Complete Denture - Mandibular 2 of any combination of adjustments or relines


D5421 Adjust Partial Denture - Maxillary 2 of any combination of adjustments or relines


D5422 Adjust Partial Denture - Mandibular 2 of any combination of adjustments or relines


D5511 Repair Broken Complete Denture Base - Mandibular

2 of any combination of repair/addition/replacement codes per calendar

year

$0

D5512 Repair Broken Complete Denture Base - Maxillary


year

$0

D5520 Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)


year

$0

D5611 Repair Resin Partial Denture Base - Mandibular


year

$0

D5612 Repair Resin Partial Denture Base - Maxillary

2 of any combination of repair/addition/replacem

$0



ent codes per calendar year

D5621 Repair Cast Partial Denture Base - Mandibular


year

$0

D5622 Repair Cast Partial Denture Base - Maxillary


year

$0

D5630 Repair Or Replace Broken Retentive Clasping Materials - Per Tooth


year

$0

D5640 Replace Broken Teeth - Per Tooth


year

$0

D5650 Add Tooth To Existing Partial Denture


year

$0

D5660 Add Clasp To Existing Partial Denture - Per Tooth


year

$0

D5670 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary)


year

$0

D5671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular)


year

$0

D5710 Rebase Complete Maxillary Denture 2 of any combination of adjustments or relines


D5711 Rebase Complete Mandibular Denture 2 of any combination of adjustments or relines


D5720 Rebase Maxillary Partial Denture 2 of any combination of adjustments or relines


D5721 Rebase Mandibular Partial Denture 2 of any combination of adjustments or relines


D5730 Reline Complete Maxillary Denture (Chairside)

2 of any combination of adjustments or relines

$0



per calendar year

D5731 Reline Complete Mandibular Denture (Chairside)



D5740 Reline Maxillary Partial Denture (Chairside) 2 of any combination of adjustments or relines


D5741 Reline Mandibular Partial Denture (Chairside)



D5750 Reline Complete Maxillary Denture (Laboratory)



D5751 Reline Complete Mandibular Denture (Laboratory)



D5760 Reline Maxillary Partial Denture (Laboratory)



D5761 Reline Mandibular Partial Denture (Laboratory)



D5810 Interim Complete Denture (Maxillary) $0

D5811 Interim Complete Denture (Mandibular) $0

D5820 Interim Partial Denture (Maxillary) $0

D5821 Interim Partial Denture (Mandibular) $0

D5850 Tissue Conditioning, Maxillary $0

D5851 Tissue Conditioning, Mandibular $0

D5862 Precision Attachment, By Report $0

D5863 Overdenture-Complete Maxillary



years

$0

D5864 Overdenture-Partial Maxillary



years

$0

D5865 Overdenture - Complete Mandibular



years

$0

D5866 Overdenture-Partial Mandibular



$0



years

D5867 Replacement Of Replaceable Part Of Semi-Precision Attachment


year

$0

D5875 Modification Of Removable Prosthesis Following Implant Surgery

$0

D5899 Unspecified Removable Prosthodontic Procedure, By Report

$0

D5992 Adjust Maxillofacial Prosthetic Appliance, By Report

$0

D5993 Maintenance And Cleaning Of A Maxillofacial Prosthesis (Extra Or Intraoral) Other Than Required Adjustments.

$0

Fixed Prosthodontics (crowns and pontics)

D6205 Pontic - Indirect Resin Based Composite 6 of any


$0

D6210 Pontic - Cast High Noble Metal 6 of any


$0

D6211 Pontic - Cast Predominantly Base Metal 6 of any


$0

D6212 Pontic - Cast Noble Metal 6 of any


$0

D6241 Pontic - Porcelain Fused To Predominantly Base Metal



D6242 Pontic - Porcelain Fused To Noble Metal 6 of any


$0

D6245 Pontic-Porcelain/Ceramic 6 of any


$0

D6251 Pontic - Resin With Predominantly Base Metal



D6252 Pontic - Resin With Noble Metal 6 of any


$0

D6253 Provisional Pontic - Further Treatment Or Completion Of Diagnosis Necessary Prior To Final Impression



D6545 Retainer - Cast Metal For Resin Bonded Fixed Prosthesis





D6548 Retainer-Porcelain/Ceramic For Resin Bonded Fixed Prosthesis



D6600 Retainer Inlay-Porcelain/Ceramic, Two Surfaces



D6601 Retainer Inlay - Porcelain/Ceramic, Three Or More Surfaces



D6602 Retainer Inlay - Cast High Noble Metal, Two Surfaces



D6603 Retainer Inlay - Cast High Noble Metal, Three Or More Surfaces



D6604 Retainer Inlay - Cast Predominantly Base Metal, Two Surfaces



D6605 Retainer Inlay - Cast Predominantly Base Metal, Three Or More Surfaces



D6606 Retainer Inlay - Cast Noble Metal, Two Surfaces



D6607 Retainer Inlay - Cast Noble Metal, Three Or More Surfaces



D6608 Retainer Onlay - Porcelain/Ceramic, Two Surfaces



D6609 Retainer Onlay - Porcelain/Ceramic, Three Or More Surfaces



D6612 Retainer Onlay - Cast Predominantly Base Metal, Two Surfaces



D6613 Retainer Onlay - Cast Predominantly Base Metal, Three Or More Surfaces



D6614 Retainer Onlay - Cast Noble Metal, Two Surfaces



D6615 Retainer Onlay - Cast Noble Metal, Three Or More Surfaces



D6710 Retainer Crown - Indirect Resin Based Composite (Not To Be Used As A Temporary Or Provisional Crown)





D6721 Retainer Crown - Resin With Predominantly Base Metal



D6722 Retainer Crown - Resin With Noble Metal 6 of any


$0

D6740 Retainer Crown-Porcelain/Ceramic 6 of any


$0

D6751 Retainer Crown - Porcelain Fused To Predominantly Base Metal



D6752 Retainer Crown - Porcelain Fused To Noble Metal



D6781 Retainer Crown-3/4 Cast Predominately Based Metal



D6782 Retainer Crown-3/4 Cast Noble Metal 6 of any


$0

D6783 Retainer Crown-3/4 Porcelain/Ceramic 6 of any


$0

D6791 Retainer Crown - Full Cast Predominantly Base Metal



D6792 Retainer Crown - Full Cast Noble Metal 6 of any


$0

D6793 Provisional Retainer Crown-Further Treatment Or Completion Of Diagnosis Necessary Prior To Final Impression

$0

D6920 Connector Bar $0

D6930 Recement Or Re-Bond Fixed Partial Denture

$0

D6940 Stress Breaker $0

D6950 Precision Attachment $0

D6980 Fixed Partial Denture Repair $0

D6999 Fixed Prosthodontic Procedure $0

Oral and Maxillofacial Surgery (extractions and removals)

D7111 Extraction, Coronal Remnants - Primary Tooth

6 of any combination of extractions per calendar

year $0

D7140 Extraction, Erupted Tooth Or Exposed Root (Elevation And/Or Forceps Removal)


year $0

D7210 Surgical Removal Of Erupted Tooth Req 6 of any combination of $0



Removal Of Bone,Sectioning Of Tooth And Including Elevation Of Mucoperiosteal Flap

extractions per calendar year

D7220 Removal Of Impacted Tooth - Soft Tissue 6 of any combination of extractions per calendar

year $0

D7230 Removal Of Impacted Tooth - Partially Bony 6 of any combination of extractions per calendar

year $0

D7240 Removal Of Impacted Tooth - Completely Bony


year $0

D7241 Removal Of Impacted Tooth - Completely Bony, With Unusual Surgical


year $0

D7250 Surgical Removal Of Residual Tooth Roots (Cutting Procedure)


year $0

D7251

Coronectomy-Intentional Partial Tooth Removal Is Performed When A Neurovascular Complication Is Likely If The Entire Impacted Tooth Is Removed.

$0

D7260 Oroantral Fistula Closure $0

D7261 Primary Closure Of A Sinus Perforation $0

D7270 Tooth Reimplantation And/Or Stabilization Of Accidentally Evulsed Or Displaced Tooth

$0

D7272 Tooth Transplantation (Includes Reimplantation From One Site To Another And Splinting And/Or Stabilization)

$0

D7280 Surgical Access Of An Unerupted Tooth $0

D7282 Mobilization Of Erupted Or Malpositioned Tooth To Aid Eruption

$0

D7283 Placement Of Device To Facilitate Eruption Of Impacted Tooth

$0

D7285 Incisional Biopsy Of Oral Tissue - Hard (Bone, Tooth)

$0

D7286 Incisional Biopsy Of Oral Tissue - Soft (All Others)

$0

D7287 Exfolliative Cytological Sample Collection $0

D7288 Brush Biopsy - Transepithelial Sample Collection

$0

D7290 Surgical Repositioning Of Teeth $0

D7291 Transseptal Fiberotomy, By Report $0

D7292 Surgical Placement Of Temporary Anchorage Device [Screw Retained Plate] Requiring Flap; Includes Device Removal

$0

D7293 Surgical Placement Of Temporary Anchorage Device Requiring Flap; Includes Device Removal

$0



D7294 Surgical Placement Of Temporary Anchorage Device Without Flap; Includes Device Removal

$0

D7295 Harvest Of Bone For Use In Autogenous Grafting Procedure

$0

D7310 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant

$0

D7311 Alveoplasty In Conjunction With Extraction - One To Three Teeth Or Tooth Spaces, Per Quadrant

$0

D7320 Alveoloplasty Not In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant

$0

D7321 Alveoplasty Not In Conjunction With Extraction - One To Three Teeth Or Tooth Spaces, Per Quadrant

$0

D7340 Vestibuloplasty - Ridge Extension (Secondary Epithelialization)

$0

D7350 Vestibuloplasty - Ridge Extension (Including Soft Tissue Grafts, Muscle Reattachment, Revision Of Soft Tissue Attachment

$0

D7410 Excision Of Benign Lesion Up To 1.25 Cm $0

D7411 Excision Of Benign Lesion Greater Than 1.25 Cm

$0

D7412 Excision Of Benign Lesion, Complicated $0

D7413 Excision Of Malignant Lesion Up To 1.25 Cm

$0

D7414 Excision Of Malignant Lesion Greater Than 1.25 Cm

$0

D7415 Excision Of Malignant Lesion, Complicated $0

D7440 Excision Of Malignant Tumor – Lesion Diameter Up To 1.25 Cm

$0

D7441 Excision Of Malignant Tumor - Lesion Diameter Greater Than 1.25cm

$0

D7450 Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm

$0

D7451 Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Greater Than 1.25 Cm

$0

D7460 Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm

$0

D7461 Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Greater Than 1.25 Cm

$0

D7465 Destruction Of Lesion(s) By Physical Or Chemical Method, By Report

$0

D7471 Removal Of Exostosis - Per Site $0



D7472 Removal Of Torus Palatinus $0

D7473 Removal Of Torus Mandibularis $0

D7485 Surgical Reduction Of Osseous Tuberosity $0

D7490 Radical Resection Of Mandible With Bone Graft

$0

D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissue

$0

D7511

Incicion And Drainage Of Abscess - Intraoral Soft Tissue - Complicated (Includes Drainage Of Multiple Fascial Spaces)

$0

D7520 Incision And Drainage Of Abscess - Extraoral Soft Tissue

$0

D7521

Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated (Includes Drainage Of Multiple Fascial Spaces)

$0

D7530 Removal Of Foreign Body From Mucosa, Skin, Or Subcutaneous Alveolar Tissue

$0

D7540 Removal Of Reaction-Producing Foreign Bodies - Musculoskeletal System

$0

D7960 Frenulectomy (Frenectomy Or Frenotomy) - Separate Procedure Not Incidental To Another Procedure

$0

D7963 Frenuloplasty $0

D7970 Excision Of Hyperplastic Tissue - Per Arch $0

D7971 Excision Of Pericoronal Gingiva $0

D7972 Surgical Reduction Of Fibrous Tuberosity $0

D7997 Appliance Removal (Not By Dentist Who Placed Appliance), Includes Removal Of Archbar

$0

D7999 Unspecified Oral Surgery Procedure, By Report

$0

Non-Routine Services

D9120 Fixed Partial Denture Sectioning $0

D9210 Local Anesthesia Not In Conjunction With Operative Or Surgical Procedures

$0

D9211 Regional Block Anesthesia $0

D9212 Trigeminal Division Block Anesthesia $0

D9215 Local Anesthesia In Conjunction With Operative Or Surgical Procedures

$0

D9222 Deep Sedation/General Anesthesia – First 15 Minutes

$0

D9223 Deep Sedation/General Anesthesia-Each Subsequent 15 Minute Increment

$0

D9230 Inhalation Of Nitrous Oxide/Anxiolysis Analgesia

$0



D9239 Intravenous Moderate (Conscious) Sedation/Analgesia – First 15 Minutes

$0

D9243 Intravenous Moderate (Conscious) Sedation/Analgesia-Each Subsequent 15 Minute Increment

$0

D9248 Non-Intravenous Conscious Sedation. This Includes Non-Iv Minimal And Moderate Sedation.

$0

D9310 Consultation (Diagnostic Service Provided By Dentist Or Physician Other Than Practitioner Providing Treatment)

$0

D9410 House/Extended Care Facility Call $0

D9420 Hospital Call $0

D9430 Office Visit For Observation - No Other Services Performed

$0

D9440 Office Visit After Regularly Scheduled Hours $0

D9450 Case Presentation, Detailed And Extensive Treatment Planning

$0

D9610 Therapeutic Parenteral Drug, Single Administration

$0

D9612 Therapeutic Parenteral Drugs, Two Or More Administrations, Different Medications

$0

D9630 Other Drugs And/Or Medicaments, By Report

$0

D9910 Application Of Desensitizing Medicament $0

D9911 Application Of Desensitizing Resin For Cervical And/Or Root Surface, Per Tooth

$0

D9920 Behavior Management $0

D9930 Treatment Of Complications (Post-Surgical) - Unusual Circumstances, By Report

$0

D9942 Repair And/Or Reline Of Occlusal Guards $0

D9944 Occlusal Guard – Hard Appliance, Full Arch $0

D9945 Occlusal Guard – Soft Appliance, Full Arch $0

D9946 Occlusal Guard – Hard Appliance, Partial Arch

$0

D9950 Occlusion Analysis - Mounted Case $0

D9951 Occlusal Adjustment - Limited $0

D9952 Occlusal Adjustment - Complete $0

D9999 Unspecified Adjunctive Procedure, By Report

$0

Non-covered Services

The plan does not cover the following:

Dental services not listed in this Schedule of Benefits

Dental services received from an out-of-network dentist

Services or items listed in the Exclusions section or dental services that exceed frequency limitations


You’re responsible for all charges related to any excluded services. You must also pay the costs of any services received greater than the limits specified.

LIMITATIONS AND EXCLUSIONS

EXCLUSIONS

1. Services which, in the opinion of the participating network general dentist or

specialist, are not necessary for the patient's dental health.

2. Cosmetic or experimental dental services, and/or procedures not generally

performed in a general dentist office.

3. Cost of hospitalization and/or pharmaceuticals.

4. Any services performed by a non-participating network general dentist or non-

participating network specialist.

5. Services that cannot be performed because of the general health of the patient.

6. Treatment which, in the opinion of the participating network general dentist,

must be performed by a non-participating network specialist.

7. Services which are not consistent with the usual and customary services

provided by a participating network general dentist or specialist.

8. Any dental treatment started prior to the member's effective date.

9. Services for injuries and/or conditions which are paid or payable under

Worker's Compensation or Employer Liability Laws.

10. Treatment for related to cysts, neoplasms and/or malignancies.

11. Services provided without cost to the Subscriber by the government or an

agency thereof, or any municipality, county and other subdivisions.

12. The cost of precious metal used in any form of dental benefits services.

13. Any procedure not specifically listed as a covered benefit in this Schedule of

Benefits.

14. Cost of dental care covered under any automobile, medical or no-fault or

similar type insurance.

15. Sealants applied to baby teeth are not covered.

LIMITATIONS

General

1. Services must be individualized, specific, and consistent with symptoms or

confirmed diagnosis of the illness or injury under treatment, and not in excess

of the recipient's need.

2. Services must reflect the level of services that can be safely furnished, and for

which no equally effective and more conservative or less costly treatment is


available statewide.

3. Services must be furnished in a manner not primarily intended for the

convenience of the member, the member's caretaker, or the provider.

4. Unspecified procedures are not covered without a report demonstrating

services provided are covered under the terms of the exclusions and

limitations.

5. Intravenous conscious sedation is limited to medically necessary covered oral

surgery.

Diagnostics (4 bitewing radiographs and 1 panoramic file per year)

1. Diagnostic services included the oral examination, and selected radiograph

needed to assess the oral health, diagnose oral pathology, and develop an

adequate treatment plan for the member' oral health. Reimbursement for some

radiographs of the same tooth or area may be denied if Envolve Dental

determines that the number to be redundant, excessive or not in keeping with

the federal guidelines relating to radiation exposure. The maximum amount

paid for individual radiographs taken on the same day will be limited to the

allowance for full mouth series. For example a panoramic x-ray and 4

Bitewings taken in a day will be considered as a full mouth x-ray (D0210).

2. Reimbursement for radiographs is limited to those films required for proper

treatment and/or diagnosis.

3. All radiographs must be of good diagnostic quality, properly mounted, dated

and identified with the recipient's name and date of birth. Substandard

radiographs will not be reimbursed for, or if already paid for, Envolve Dental

will recoup the funds previously paid.

4. Envolve Dental utilizes the guidelines published by the Department of Health

and Human Services for Devices and Radiological Health. However, please

consult the following benefit grid above for benefit limitations.

Restoratives (6 of any combination of fillings and 6 of any combination of

crowns/inlays/onlays/pontics per year)

1. Reimbursement includes local anesthesia.

2. Services are limited to essential services to restore and maintain dental health.

Restorations are not covered on primary teeth if loss is expected within six (6)

months.

3. Payment is made for restorative services based on the number of surfaces

restored (not on the number of restoratives per surface) per tooth per day. A

restoration is considered a two (2) or more surface restoration only when two

(2) or more actual tooth surfaces are involved, whether they are connected or


not.

4. Tooth preparation, all adhesives (including amalgam and resin bonding

agents), acid etching, copalite, liners, bases, direct and indirect pulp caps,

curing, and polishing are included as part of the fee for restoration .

5. Billing and reimbursement for cast crowns and post & cores or any other fixed

prosthetics shall be based on cementation date.

6. When restorations involving multiple surfaces are requested or performed, that

are outside the usual anatomical expectation, the allowance is limited to that

of a one-surface restoration. Any fee charged in excess of the allowance for

the one-surface restoration is disallowed.

Endodontics (6 root canals or retreatment of root canals per calendar year)

1. Payment for conventional root canal therapy is limited to treatment of

permanent teeth or retained primary teeth with no succedaneous permanent

teeth. Endodontic therapy for primary teeth with succedaneous permanent

teeth is limited to pulpal therapy.

2. Root canal therapy is reimbursable: a) for teeth that has restorative crowns, b)

if the prognosis of the tooth is not questionable for periodontal reasons, and c)

if exfoliation of a deciduous tooth is not anticipated within eighteen (18)

months.

3. The standard acceptability employed for endodontic procedures requires that

the canal(s) be completely sealed apically and laterally. In cases where the

root canal filing does not meet Envolve Dental's treatment standards, Envolve

Dental can require the procedure to be redone at no additional cost. Any

reimbursement already made for an inadequate service may be recouped after

any post payment review. A pulpotomy or palliative treatment is not to be billed

in conjunction with a root canal treatment.

4. Pulpotomies will be limited to primary teeth or permanent teeth with incomplete

root development.

5. The fee for root canal therapy includes diagnosis, extirpation treatment,

temporary fillings, fillings and obturation of root canals, and progress

radiographs. A completed fill radiograph is also included.

6. Filling material not accepted by FDA (e.g. Sargent filling material) is not

covered.

Prosthodontics (One set of any combination of dentures per 5 years, 2 of any

combination of adjustments or relines per year, 2 of any

combination of repair/addition/replacement per year)

1. Provision for removable prostheses when masticatory function is impaired, or


when existing prostheses is unserviceable and when evidence is submitted

that indicates that the masticatory insufficiency are likely to impair the general

health of the member.

2. Partial dentures to replace posterior teeth will not be covered if there are in

each quadrant at least three (3) periodontal sound posterior teeth in each

quadrant in fairly good position and occlusion with opposing dentition.

3. Cast partial dentures for anterior teeth generally will not be given covered

unless one (1) or more teeth in the same arch are missing.

4. Dentures will not be covered when dental history reveals that any or all

dentures made in recent years have been unsatisfactory for reasons that are

not remediable because of physiological or psychological reasons, or repair,

relining or rebasing of the patient's present dentures will make them

serviceable.

5. Billing and reimbursement for dentures shall be based on delivery date, and

must include the signed and dated "Patient Acknowledgement of Treatment"

form.

6. Delivery of removable prostheses includes up to three (3) adjustments within

six (6) months of the delivery for a complete or partial denture and within three

(3) months of the delivery for immediate dentures.

7. No partial dentures for a single tooth will be covered unless replacing an

anterior tooth.

8. Relines include all necessary adjustments for a period of six (6) months from

the date of the reline. A reline using a “light-cured technique” is a chairside

reline. Any combination of relines and adjustments are limited to twice per

denture per year. Initial relines are limited to no earlier than three (3) months

after the date of insertion for immediate dentures and limited to no earlier than

six (6) months after seating for a complete denture.

9. Denture adjustments performed on the same date of service as relines or

repairs are not covered.

Oral Surgery (Any combination of up to 6 oral surgeries or extractions are allowed

per year)

1. Reimbursement includes local anesthesia and routine post-operative care .

2. Prophylactic extraction of asymptomatic impacted or erupted teeth is not a

covered benefit. Symptomatic conditions would include pain and/or infection or

demonstrated malocclusion causing a shifting of existing dentition.

3. Covered services for oral surgery are limited to alleviation of pain or infection

and are limited to extractions and the incision and drainage of an abscess,

unless essential to the preparation of the mouth for dentures.

4. The incidental removal of a cyst or a lesion attached to the root(s) of an


extraction is considered part of the extraction or surgical fee and should not be

billed as a separate procedure.

Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state

Medicaid programs. Enrollment in Allwell depends on contract renewal. This information is

not a complete description of benefits. Call 1-877-935-8022 (TTY: 711) for more information.

The provider network may change at any time. You will receive notice when necessary.

Allwell complies with applicable federal civil rights laws and does not discriminate on the

basis of race, color, national origin, age, disability, or sex. For assistance, please call: 1-877-

935-8022 (TTY: 711). Español (Spanish): Servicios de asistencia de idiomas, ayudas y

servicios auxiliares, y otros formatos alternativos están disponibles para usted sin ningún

costo. Para obtener esto, llame al número de arriba. Kreyòl (French Creole) W ap jwenn

gratis sèvis tradiksyon, èd ak sèvis siplemantè, ak lòt fòma altènatif san w pa peye pou yo.

Tanpri sonnen nan nimewo ki make anlè a pou w resevwa sa.

H5190-001, H5190-002, H5190-003, H5190-004

Y0020_19_9767DM_C_10042018

2019 Dental Plan...D0477 Special Stains, Not For Microorganisms $0 D0478 Immunohistochemical Stains...

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