Bitewing x-rays once a year, unless already covered by Medicaid
Comprehensive exam once every three years, but not within three years of a comprehensive exam covered by Medicaid
Full mouth series once every four years
Panoramic x-ray once every three years but not within three years of a panoramic x-ray covered by Medicaid, except if provided in conjunction with a scheduled outpatient facility procedure or as medically necessary for the diagnosis and follow-up of oral and maxillofacial pathology and trauma.
Panoramic x-ray once every two years for patients who cannot cooperate for intra-oral film due to a developmental disability or medical condition that does not allow for intra-oral film placement
Periapical x-rays
Periodic exam once every six months, but not within six months of a periodic exam covered by Medicaid.
Removable appliances - once per arch every three years but not within three years of a removable appliance provided by MA. Partial dentures must meet utilization criteria and be prior authorized
Reline, rebase and repair of removable appliance - may not exceed the cost of new appliance.
Limited to children through age 20
Must meet utilization criteria and be prior authorized:
