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Exhibit E Benefits Covered for
FL - Better Health Adult Medicaid (MMA)
Reimbursement includes local anesthesia and routine post-operative care.
The 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.
The incidental removal of a cyst or 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.
NOTE: MEDICAID GUIDELINES- Extractions:
For recipients 21 years and older, Medicaid covers extractions and other surgical procedures essential to the preparation of the mouth for dentures. Acute
emergency services for the alleviation of pain or infection are also covered and are limited to extractions and the incision and drainage of an abscess.
Surgical extractions of erupted teeth are defined as extractions requiring elevation of a mucoperiosteal flap and removal of bone and/or section of the tooth
and closure. Includes incidental removal of a cyst or lesion attached to the root(s). Removal of asymptomatic tooth not covered. Includes incidental removal
of a cyst or lesion attached to the root(s). Extraction codes D7210, D7220, D7230, D7240, D7241, D7250.
Please note that D7310 is not payable in the same quadrant on the same day with codes D7210, D7220, D7230, D7240, D7241 and D7250.
Member copayment is $0 for all covered procedures.
Oral and Maxillofacial Surgery
Code
Brief Description
Age Limitation
Teeth Covered
Review
Required
Benefit Limitations
D7140
extraction, erupted tooth or
exposed root (elevation and/or
forceps removal)
21 and older
Teeth 1 - 32, 51 - 82, A - T,
AS, BS, CS, DS, ES, FS,
GS, HS, IS, JS, KS, LS,
MS, NS, OS, PS, QS, RS,
SS, TS
No
Includes incidental removal of a cyst or
lesion attached to the root(s)
D7210
surgical removal of erupted tooth
requiring removal of bone and/or
sectioning of tooth, and including
elevation of mucoperiosteal flap if
indicated
21 and older
Teeth 1 - 32, 51 - 82, A - T,
AS, BS, CS, DS, ES, FS,
GS, HS, IS, JS, KS, LS,
MS, NS, OS, PS, QS, RS,
SS, TS
Yes
Please note that D7310 is not payable in
the same quadrant on the same day with
codes D7210, D7220, D7230, D7240,
D7241 and D7250.
Please refer to NOTE: Medicaid
Guidelines-Extractions located at the top
of this exhibit.
Current Dental Terminology © American Dental Association. All rights reserved.
CPT® codes, descriptions and other data only are copyright 2010 American Medical Association.
DentaQuest of Florida, Inc. March 18, 2015
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Documentation
Required
pre-operative x-ray(s)