Covered Dental Services2019-11-25T15:31:34-05:00

Covered Dental Services

All supplemental benefits purchased with the Prominence+ Card (dental, vision, hearing) are covered if they are medically necessary and in addition to the benefit covered by original Medicare.

Covered dental services must be obtained from Providers in the Prominence DenteMax Dental Network .

Dental services

For preventive dental services, the following are covered services:

    • D1110 Cleaning — Adult
  • Oral exam, once a year for the following dental codes:
    • D0120 Periodic Oral Evaluation — Established Patient
  • X-rays, once a year for the following dental codes:
    • D0270 Bitewing — Single Radiographic Image
    • D0272 Bitewings — Two Radiographic Images
    • D0274 Bitewings — Four Radiographic Images
    • D0277 Vertical Bitewings — 7 to 8 Radiographic Images
  • Fluoride treatment, twice a year for the following dental codes:
    • D1208 Topical Application of Fluoride — Excluding Varnish

For comprehensive dental services, the following are covered services:

  • Non-routine services for the following dental codes:
    • D9110 Palliative (Emergency) Treatment of Dental Pain — Minor Procedure
    • D9223 Deep Sedation/General Anesthesia — Each Subsequent 15 Minute Increment
    • D9243 Intravenous Moderate (Conscious) Sedation/Analgesia — Each Subsequent 15 Minute Increment
  • Diagnostic services for the following dental codes:
    • D0150 Comprehensive Oral Evaluation — New or Established Patient
  • Restorative services for the following dental codes:
    • D2140 Amalgam — One Surface, Primary or Permanent
    • D2150 Amalgam — Two Surfaces, Primary or Permanent
    • D2160 Amalgam — Three Surfaces, Primary or Permanent
    • D2330 Resin-Based Composite — One Surface, Anterior
    • D2331 Resin-Based Composite — Two Surfaces, Anterior
  • Endodontics services for the following dental codes:
    • D3110 Pulp Cap — Direct (Excluding Final Restoration)
    • D3120 Pulp Cap — Indirect (Excluding Final Restoration)
  • Periodontics services for the following dental codes:
    • D4342 Periodontal Scaling and Root Planing — One to Three Teeth per Quadrant
    • D4910 Periodontal Maintenance
  • Prosthodontics services for the following dental codes:
    • D5410 Adjust Complete Denture — Maxillary
    • D5411 Adjust Complete Denture — Mandibular
    • D5421 Adjust Partial Denture — Maxillary
    • D5422 Adjust Partial Denture — Mandibular
  • Extractions services for the following dental codes:
    • D7140 Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Removal)
    • D7210 Extraction, Erupted Tooth Requiring Removal of Bone and/or Sectioning of Tooth, and Elevation of Mucoperiosteal Flap if Indicated
  • Oral/maxillofacial surgery services for the following dental codes:
    • D7220 Removal of Impacted Tooth — Soft Tissue

Supported Dental Services

Following is a list of services that Prominence may pay a portion of through the Prominence+ Card. To determine if a service is eligible for partial funding, contact member services at 855-969-5882 (TTY: 711).

  • Diagnostic Services
    • D0140 Diagnostic limited oral evaluation — problem focused
    • D0150 Diagnostic comprehensive oral evaluation — new or established patient
    • D0180 Diagnostic comprehensive periodontal evaluation — new or established patient
    • D0210 Diagnostic intraoral — complete series of radiographic images
    • D0220 Diagnostic intraoral — periapical first radiographic image
    • D0230 Diagnostic intraoral — periapical each additional radiographic image
    • D0240 Diagnostic intraoral — occlusal radiographic image
    • D0330 Diagnostic panoramic radiographic image
    • D0460 Diagnostic pulp vitality tests
    • D1206 Preventive topical application of fluoride varnish
    • D1208 Preventive topical application of fluoride — excluding varnish
  • Restorative Services
    • D2391 Restorative resin-based composite — one surface, posterior
    • D2392 Restorative resin-based composite — two surfaces, posterior
    • D2393 Restorative resin-based composite — three surfaces, posterior
    • D2394 Restorative resin-based composite — four or more surfaces, posterior
    • D2740 Restorative crown — porcelain/ceramic
    • D2750 Restorative crown — porcelain fused to high noble metal
    • D2751 Restorative crown — porcelain fused to predominantly base metal
    • D2752 Restorative crown — porcelain fused to noble metal
    • D2790 Restorative crown — full cast high noble metal
    • D2920 Restorative re-cement or re-bond crown
    • D2940 Restorative protective restoration
    • D2950 Restorative core buildup, including any pins when required
    • D2954 Restorative prefabricated post and core in addition to crown
  • Endodontics
    • D3220 Endodontics therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal
    • D3310 Endodontics endodontic therapy, anterior tooth (excluding final restoration)
    • D3320 Endodontics endodontic therapy, premolar tooth (excluding final restoration)
    • D3330 Endodontics endodontic therapy, molar tooth (excluding final restoration)
    • D3348 Endodontics retreatment of previous root canal therapy — molar
    • D4260 Periodontics osseous surgery (including elevation of a full thickness flap and closure)
    • D4273 Periodontics autogenous connective tissue graft procedure (including donor and recipient
    • D4341 Periodontics periodontal scaling and root planing — four or more teeth per quadrant
    • D4346 Periodontics scaling in presence of generalized moderate or severe gingival inflammation
    • D4355 Periodontics full mouth debridement to enable a comprehensive oral evaluation and diag
    • D5110 Prosthodonotics, removable complete denture — maxillary
    • D5120 Prosthodonotics, removable complete denture — mandibular
    • D5130 Prosthodonotics, removable immediate denture — maxillary
    • D5140 Prosthodonotics, removable immediate denture — mandibular
    • D5213 Prosthodonotics, removable maxillary partial denture — cast metal framework with resin denture bases
    • D5214 Prosthodonotics, removable mandibular partial denture — cast metal framework with resin denture bases
    • D7220 Oral & Maxillofacial Surgery removal of impacted tooth — soft tissue
    • D7230 Oral & Maxillofacial Surgery removal of impacted tooth — partially bony
    • D7240 Oral & Maxillofacial Surgery removal of impacted tooth — completely bony
    • D7250 Oral & Maxillofacial Surgery removal of residual tooth roots (cutting procedure)
    • D7953 Oral & Maxillofacial Surgery bone replacement graft for ridge preservation — per site

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Last update 11/25/2019