CAPITULO V CONTROL TÉCNICO
5.1.3 PROCESOS CONSTRUCTIVOS
recalcification, prior authorization for the final root canal therapy shall be submitted along with the post-treatment radiograph to demonstrate sufficient apical formation.
PROCEDURE D3352
APEXIFICATION/ RECALCIFICATION/PULPAL REGENERATION - INTERIM MEDICATION REPLACEMENT 1. Prior authorization isrequired for D3351, which shall be completed before D3352 is payable.
2. Submission of radiographs, photographs or written documentation
demonstrating medical necessity is not required for payment.
3. Requires a tooth code. 4. A benefit:
a. only following apexification/
recalcification- initial visit (apical closure/ calcific repair of perforations, root resorption, etc.) (D3351).
b. once per permanent tooth.
c. for patients under the age of 21.
5. Not a benefit:
a. for primary teeth. b. for 3rd molars, unless
the 3rd molar occupies the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or removable partial denture with
cast clasps or rests. c. on the same date of
service as any other endodontic
procedures for the same tooth. 6. This procedure includes
reopening the tooth, placement of medications and all treatment and post treatment radiographs. 7. Upon completion of
apexification/ recalcification, prior authorization for the final root canal therapy shall be submitted along with the post treatment radiograph to demonstrate sufficient apical formation.
PROCEDURE D3353
APEXIFICATION/RECALCIFICATION - FINAL VISIT (INCLUDES COMPLETED ROOT CANAL THERAPY - APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT
RESORPTION, ETC.) This procedure is not a benefit. Upon completion of apexification/
recalcification, prior authorization for the final root canal therapy shall be submitted along with the post treatment radiograph to demonstrate sufficient apical formation.
PROCEDURE D3354
PULPAL REGENERATION - (COMPLETION OF REGENERATIVE TREATMENT IN AN IMMATURE PERMANENT TOOTH WITH A NECROTIC PULP); DOES NOT INCLUDE FINAL RESTORATIONThis procedure is not a benefit.
PROCEDURE D3410
APICOECTOMY/ PERIRADICULAR SURGERY - ANTERIOR 1. Prior authorization is required.2. Radiographs for prior authorization - submit arch and periapical radiographs demonstrating the medical necessity.
3. Written documentation for prior authorization - if the medical necessity is not evident on the radiographs, documentation shall include the rationale for treatment. 4. Requires a tooth code. 5. A benefit for permanent
anterior teeth only. 6. Not a benefit:
a. to the original provider within 90 days of root canal therapy except when a medical necessity is documented. b. to the original provider within 24 months of a prior apicoectomy/ periradicular surgery. 7. The fee for this procedure includes the placement of retrograde filling material and all treatment and post treatment radiographs.
PROCEDURE D3421
APICOECTOMY/PERIRADICULAR SURGERY - BICUSPID (FIRST ROOT) 1. Prior authorization is
required.
2. Radiographs for prior authorization - submit arch and periapical radiographs demonstrating the medical necessity.
3. Written documentation for prior authorization - if the medical necessity is not evident on the radiographs, documentation shall include the rationale and the identity of the root that requires treatment. 4. Requires a tooth code. 5. A benefit for permanent
bicuspid teeth only. 6. Not a benefit:
a. to the original provider within 90 days of root canal therapy except when a medical necessity is documented. b. to the original provider within 24 months of a prior apicoectomy/ periradicular surgery, same root.
7. The fee for this procedure includes the placement of retrograde filling material and all treatment and post treatment radiographs. 8. If more than one root is
treated, use apicoectomy/ periradicular surgery - each additional root (D3426).
PROCEDURE D3425
APICOECTOMY/PERIRADICULAR SURGERY - MOLAR (FIRST ROOT) 1. Prior authorization is
required.
2. Radiographs for prior authorization - submit arch and periapical radiographs demonstrating the medical necessity.
3. Written documentation for prior authorization - if the medical necessity is not evident on the radiographs, documentation shall include the rationale and the
identity of the root that requires treatment. 4. Requires a tooth code. 5. A benefit for permanent 1st
and 2nd molar teeth only. 6. Not a benefit:
a. to the original provider within 90 days of root canal therapy except when a medical necessity is documented. b. to the original provider within 24 months of a prior apicoectomy/ periradicular surgery, same root.
c. for 3rd molars, unless the 3rd molar
occupies the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or removable partial denture with cast clasps or rests. 7. The fee for this procedure
includes the placement of retrograde filling material and all treatment and post treatment radiographs. 8. If more than one root is
treated, use apicoectomy/ periradicular surgery - each additional root (D3426).
PROCEDURE D3426
APICOECTOMY/PERIRADICULAR SURGERY (EACH ADDITIONAL ROOT) 1. Prior authorization is
required.
2. Radiographs for prior authorization - submit arch and periapical radiographs demonstrating the medical necessity.
3. Written documentation for prior authorization - if the
medical necessity is not evident on the radiographs, documentation shall include the rationale and the identity of the root that requires treatment. 4. Requires a tooth code. 5. A benefit for permanent
teeth only. 6. Not a benefit:
a. to the original provider within 90 days of root canal therapy except when a medical necessity is documented. b. to the original provider within 24 months of a prior apicoectomy/ periradicular surgery, same root.
c. for 3rd molars, unless the 3rd molar
occupies the 1st or 2nd molar position or is an abutment for an existing fixed partial denture or removable partial denture with cast clasps or rests. 7. Only payable the same date
of service as procedures D3421 or D3425.
8. The fee for this procedure includes the placement of retrograde filling material and all treatment and post treatment radiographs.
PROCEDURE D3430
RETROGRADE FILLING - PER ROOTThis procedure is to be performed in conjunction with endodontic procedures and is not payable
separately.
PROCEDURE D3450
ROOT AMPUTATION – PER ROOT This procedure is not a benefit.