5101:3-5-08 Dental program: covered removable prosthodontic services and limitations.

The following removable prosthodontic services are covered under the dental care program subject to the specified limitations.

(A) Complete dentures (including routine post-delivery care).

(1) Complete denture - maxillary.

(2) Complete denture - mandibular.

(3) All dentures must be prior authorized. In cases where the recipient is not edentulous prior to requesting dentures, complete radiographs of the mouth, properly mounted and clearly readable, must be submitted with each denture request. Radiographs must be taken prior to extractions. Radiographs are not necessary for those individuals edentulous prior to requesting dentures.

(4) The diagnosis for dentures shall be based on the total condition of the mouth, ability to adjust to dentures, and the desire to wear dentures. Natural teeth that have healthy bone, are sound, and do not have to be extracted must not be removed.

(5) Complete extractions must be deferred until authorization to construct the denture has been given, except in absolute emergency situations.

(6) The dental care program shall not authorize immediate dentures except in very unusual circumstances which must be documented and approved by the department.

(7) A denture, complete, partial, or combination thereof, shall not be replaced or remade within eight years except for very unusual circumstances.

(8) The dentist shall be responsible for constructing a complete functional denture. The fee for dentures includes all necessary corrections and adjustments for a period of six months after seating the denture.

(9) A preformed denture with teeth already mounted (that is, teeth already set in acrylic prior to initial impressions), forming a denture module, is not a covered service.

(10) A denture shall not be authorized when dental history reveals that any or all dentures made in recent years have been unsatisfactory for reasons that are not remediable because of psychological or physiological reasons.

(B) Partial dentures.

(1) Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth).

(2) Mandibular partial denture - cast metal framework with resin denture bases

(including any coventional clasps, rests and teeth).

(3) Maxillary partial denture - resin base (including conventional clasps, rests and teeth). This procedure includes acrylic resin base denture with resin or wrought wire clasps. This procedure is a covered service for patients age eighteen and younger.

(4) Mandibular partial denture-resin base (including any conventional clasps, rests and teeth). This procedure includes acrylic resin base denture with resin or wrought wire clasps. This procedure is a covered service for patients age eighteen and younger.

(5) All partial dentures must be prior-authorized. Complete radiographs of the mouth, properly mounted and clearly readable, must be submitted with each request.

(6) Partial dentures cannot be replaced, remade, or exchanged for complete dentures for a minimum period of eight years except for unusual situations when justification for the new dentures can be established.

(7) Partial dentures are authorized when several teeth are missing in the arch and the masticatory function is severely impaired or when anterior teeth are missing in the arch which will affect the appearance of the patient.

(8) The dentist shall be responsible for constructing a complete functional partial denture. The fee for a partial denture includes all necessary corrections and adjustments for a period of six months after seating the partial denture.

(C) Repairs to dentures.

(1) Repairs to complete dentures.

(a) Repair broken complete denture base.

(b) Replace missing or broken teeth - complete denture (each tooth).

(2) Repairs to partial dentures.

(a) Repair resin denture base.

(b) Repair cast framework.

(c) Repair or replace broken clasp.

(d) Replace broken teeth - per tooth.

(e) Add tooth to existing partial denture.

(f) Add clasp to existing partial denture.

(D) Denture reline procedures.

(1) Reline complete maxillary denture.

(2) Reline complete mandibular denture.

(3) Reline partial maxillary denture.

(4) Reline partial mandibular denture.

(5) The reline must consist of the readaptation of the denture to the present oral tissues using accepted dental practice standards and procedures. The denture must be processed and finished with materials chemically compatible with the existing denture base. Chairside self-curing materials are not allowed.

(6) A complete or partial denture reline shall not occur more frequently than once every four years and not before four years after construction of the complete or partial denture except for unusual circumstances which must be documented.

(7) All complete and partial denture relining procedures include six months of post-delivery care.

Effective: 07/01/2008
R.C. 119.032 review dates: 10/16/2007 and 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.0112 , 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 1/4/88, 11/15/93, 12/29/95 (Emer), 3/21/96, 1/1/00, 10/01/03, 1/1/06