caresource dental program september 9, 2008 12:00 1:00

1. CareSource Dental Program September 9, 2008 12:00 – 1:00

8. The following services require prior authorization D0321 Other TMJ Films D2752 Crown Porcelain w Noble Metal D2952 Post & Core Cast + Crown D3320 Root Canal Therapy bicuspids D3330 Root Canal Therapy molars Note: Root Canals require PA if 3 or more root canal procedures are scheduled within 6 months. D3352 Apexification/ recalcificaiton interim visit D4210 Gingivectomy/Plasty Per Quad D7240 Impact Tooth Removal Comp Bony D7241 Impact Tooth Removal Bony w Comp D7250 Tooth Root Removal D7280 Surgical Access Unerupted Tooth

9. The following services require prior authorization D7471 Removal Exostosis Any Site D7899 TMJ Unspecified Therapy D7960 Frenulectomy/ Frenulotomy D7970 Excision Hyperplastic Tissue D8210 Orthodontic Removable Appliance Tx D8220 Fixed Appliance Therapy Habit Y7255 Remove Supernumary Tooth D5110 Complete Upper Denture - Maxillary D5210 Complete Lower Denture - Mandibular D5211 Maxillary Upper Partial Denture - Resin Base D5212 Mandibular Lower Partial Denture - Resin Base D5213 Maxillary Upper Denture Partial – Cast metal D5214 Mandibular Lower Denture Partial - Cast metal