Prior authorization request form Form

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D0120 periodic oral evaluation, established patient N/A 1) One (1) per six (6) months in a dental office 2) One (1) per school year in a school setting for ages 0-20. 3) Completion of a mandated school form is part of the oral evaluation One (1) per six (6) months No None D0140 limited oral evaluation - problem focused N/A 1) One (1) per day per dentist or dental group 2) Payable when emergency services are medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury 3) Not payable if billed with D9110 on same date of service 1) One (1) per day per dentist or dental group 2) Payable when emergency services are medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury 3) Not payable if billed with D9110 on same date of service No None D0150 comprehensive oral evaluation, new or established patient N/A One (1) per lifetime per dentist or dental group One (1) per lifetime per dentist or dental group No None D0210 intraoral - complete series of radiographic images N/A 1) One (1) per 36 months, either D0210, D0277 or D0330 2) Limited to ages 6-20 One (1) per 36 months, either D0210, D0277 or D0330 No None D0220 intraoral - periapical first radiographic image A-T, 1-32 1) One (1) per day per dentist or dental group 2) Tooth letter/number must be submitted on claim 3) See Diagnostic Imaging Note #4 1) One (1) per day per dentist or dental group 2) Tooth letter/number must be submitted on claim 3) See Diagnostic Imaging Note #4 No None D0230 intraoral - periapical each additional radiographic image A-T, 1-32 1) One (1) per tooth per date of service, per dentist or dental group 2) Tooth letter/number must be submitted on claim 3) See Diagnostic Imaging Note #4 1) One (1) per tooth per date of service, per dentist or dental group 2) Tooth letter/number must be submitted on claim 3) See Diagnostic Imaging Note #4 No None D0270 bitewing - single radiographic image N/A See Diagnostic Imaging Note #4 See Diagnostic Imaging Note #4 No None D0272 bitewings - two radiographic images N/A 1) One (1) per 12 months, either D0272 or D0274 2) Limited to ages 2-20 3) See Diagnostic Imaging Note #4 1) One (1) per 12 months, either D0272 or D0274 2) See Diagnostic Imaging Note #4 No None DIAGNOSTIC GENERAL NOTES 1) All benefits are based on the calendar year. 2) If a CDT code is not listed on this Schedule of Covered Services the service is not covered; the member is responsible for the full fee charged by the dentist. 3) Services are only payable when provided by an affiliated dentist in the Avēsis network; there are no out-of-network benefits. 4) N/A refers to "Not Applicable." 5) Effective for dates of service on or after May 1, 2021, the Illinois Department of Healthcare and Family Services (HFS) will be temporarily amending children benefit limitations for certain dental services. Please note the following CDT code benefit changes to the dental benefit grid are effective for children until the public health emergency no longer exists. Claims Processing Notes 1) Services that require an arch should be reported with "01" (upper) or "02" (lower). 2) Services that require a quadrant should be reported with "10" (UR), "20" (UL), "30" (LL) and "40" (LR). 3) Supernumerary primary teeth are identified by adding "S" after the tooth letter. 4) Supernumerary permanent teeth are identified by adding "50' to the tooth number. 5) Service(s) on a primary tooth is not payable if exfoliation is imminent. Clinical Oral Evaluations 1) The collection and recording of some data and components by the dental examination may be delegated; however, the evaluation, which includes diagnosis and treatment planning is the responsibility of the dentist. 2) There is no distinction made between the evaluations provided by general practitioners and specialists. Diagnostic Imaging 1) Diagnostic imaging is for clinical reasons determined by the dentist. 2) Should be of diagnostic quality and properly identified and dated, and is part of the patient's clinical record. 3) Original images should be retained by the dentist and not used to fulfill requests from patients or third-parties for copies of records. 4) Reimbursement for radiographs is limited to the fee for a complete series (D0210). Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 1

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D0274 bitewings - four radiographic images N/A 1) One (1) per 12 months, either D0272 or D0274 2) Limited to ages 10-20 3) See Diagnostic Imaging Note #4 1) One (1) per 12 months, either D0272 or D0274 2) See Diagnostic Imaging Note #4 No None D0277 vertical bitewings - 7 to 8 films N/A 1) One (1) per 36 months, either D0210, D0277 or D0330 2) Limited to ages 6-20 3) See Diagnostic Imaging Note #4 1) One (1) per 36 months, either D0210, D0277 or D0330 2) See Diagnostic Imaging Note #4 No None D0330 panoramic radiographic image N/A 1) One (1) per 36 months, either D0210, D0277 or D0330 2) Limited to ages 6-20 3) See Diagnostic Imaging Note #4 1) One (1) per 36 months, either D0210, D0277 or D0330 2) See Diagnostic Imaging Note #4 No None D0601 caries risk assessment and documentation, with a finding of low risk N/A 1) Must be submitted with any oral evaluation performed in a school or mobile setting 2) Limited to ages 0-18 in a school setting Not a plan benefit No None D0602 caries risk assessment and documentation, with a finding of moderate risk N/A 1) Must be submitted with any oral evaluation performed in a school or mobile setting 2) Limited to ages 0-18 in a school setting Not a plan benefit No None D0603 caries risk assessment and documentation, with a finding of high risk N/A 1) Must be submitted with any oral evaluation performed in a school or mobile setting 2) Limited to ages 0-18 in a school setting Not a plan benefit No None D1110 prophylaxis - adult N/A Not a plan benefit One (1) per six (6) months, either D1110 or D4355 No None D1120 prophylaxis - child N/A 1) One (1) per six (6) months, either D1120 or D4355 in a dental office/mobile setting 2) One per six (6) months in a school setting for ages 0-20 3) See General Note #5 Not a plan benefit No None D1206 topical application of fluoride varnish N/A 1) One (1) per six (6) months in a dental office for ages 3-20, either D1206 or D1208 2) Three (3) per 12 months in a dental office for ages 0-2, either D1206 or D1208 3) One (1) per 6 months in a school setting for ages 3-20. 4) See General Note #5 Not a plan benefit No None D1208 topical application of fluoride (ages 0-20) N/A 1) One (1) per six (6) months in a dental office for ages 3-20, either D1206 or D1208 2) Three (3) per 12 months in a dental office for ages 0-2, either D1206 or D1208 3) One (1) per 6 months in a school setting for ages 3-20. 4) See General Note #5 Not a plan benefit No None D1351 sealant - per tooth 2-3, 14-15, 18-19, 30-31 1) One (1) per two (2) years per tooth 2) Service can be provided in a school setting or dental office for ages 5-17 3) See General Note #5 Not a plan benefit No None 1) Removal of plaque, calculus and stains from the tooth structures. 2) It is intended to control local irrational factors. 3) Prescription strength fluoride product designed solely for use in the dental office, delivered to the dentition under the direct supervision of a dental professional. 4) Fluoride must be applied separately from prophylaxis paste. 5) Sealant must be placed on occlusal surfaces only. Teeth must be caries free. Sealant will not be covered when placed over restorations. PREVENTIVE Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 2

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D1354 interim caries arresting medicament application - per tooth A-T, 1-32 1) One (1) application per tooth to a maximum of four (4) teeth per day 2) Two (2) applications per tooth per year with a lifetime maximum of 6 applications per tooth 3) Not payable with any D2000 or D3000 code on the same tooth on the same date of service 4) Not payable for application on exposed pulps 5) Must be performed in dental office setting 1) One (1) application per tooth to a maximum of four (4) teeth per day 2) Two (2) applications per tooth per year with a lifetime maximum of 6 applications per tooth 3) Not payable with any D2000 or D3000 code on the same tooth on the same date of service 4) Not payable for application on exposed pulps 5) Must be performed in dental office setting No Silver Diamine Consent form must be completed and signed. This documentation must be retained in the patient’s chart. D1510 space maintainer - fixed - unilateral 10, 20, 30, 40 One (1) per lifetime per quadrant per dentist or dental group Not a plan benefit No None D1516 space maintainer - fixed - bilateral, maxillary 01, 02 One (1) per lifetime per arch per dentist or dental group Not a plan benefit No None D1517 space maintainer - fixed - bilateral, mandibular 01, 02 One (1) per lifetime per arch per dentist or dental group Not a plan benefit No None D1520 space maintainer - removable - unilateral 10, 20, 30, 40 One (1) per lifetime per quadrant per dentist or dental group Not a plan benefit No None D1526 space maintainer - removable - bilateral, maxillary 01, 02 One (1) per lifetime per arch per dentist or dental group Not a plan benefit No None D1527 space maintainer - removable - bilateral, mandibular 01, 02 One (1) per lifetime per arch per dentist or dental group Not a plan benefit No None D1551 re-cement or re-bond bilateral space maintainer - maxillary 01 1) One (1) per 24 months per arch 2) Not payable within six (6) months to dentist or dental group that initially placed the appliance Not a plan benefit No None D1552 re-cement or re-bond bilateral space maintainer - mandibular 02 1) One (1) per 24 months per arch 2) Not payable within six (6) months to dentist or dental group that initially placed the appliance Not a plan benefit No None D1553 re-cement or re-bond unilateral space maintainer - per quadrant 10, 20, 30, 40 1) One (1) per 24 months per quadrant 2) Not payable within six (6) months to dentist or dental group that initially placed the appliance Not a plan benefit No None D2140 amalgam - one surface, primary or permanent A-T, 1-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2150 amalgam - two surfaces, primary or permanent A-T, 1-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2160 amalgam - three surfaces, primary or permanent A-T, 1-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2161 amalgam - three surfaces, primary or permanent A-T, 1-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2330 resin-based composite - one surface, anterior C-H, M-R, 6-11, 22-27 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2331 resin-based composite - two surfaces, anterior C-H, M-R, 6-11, 22-27 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2332 resin-based composite - three surfaces, anterior C-H, M-R, 6-11, 22-27 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None 1) Local anesthesia is usually considered to be part of restorative procedures. 2) Restorations on primary teeth are not payable if exfoliation is imminent. 3) Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of restoration. 4) If pins are used, they should be reported separately (see D2951). 5) Reimbursement for any restoration on a tooth will be the total number of surfaces restored on that date of service. 6) Tooth preparation, acid etching, adhesives (including resin bonding agents), glass ionomers, liners and bases and curing are included as part of the restoration. RESTORATIVE Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 3

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D2335 resin-based composite - four or more surfaces, anterior C-H, M-R, 6-11, 22-27 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2391 resin-based composite - one surface, posterior A-B, I-J, K-L, S-T 1-5, 12-16, 17-21, 28-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2392 resin-based composite - two surfaces, posterior A-B, I-J, K-L, S-T 1-5, 12-16, 17-21, 28-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2393 resin-based composite - three surfaces, posterior A-B, I-J, K-L, S-T 1-5, 12-16, 17-21, 28-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2394 resin-based composite - four or more surfaces, posterior A-B, I-J, K-L, S-T 1-5, 12-16, 17-21, 28-32 One (1) restoration per 12 months per tooth per surface One (1) restoration per 12 months per tooth per surface No None D2542 onlay - metallic - two surfaces 1-32 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2543 onlay - metallic - three surfaces 1-32 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2544 onlay - metallic - four or more surfaces 1-32 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2642 onlay - porcelain/ceramic - two surfaces 1-32 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2643 onlay - porcelain/ceramic - three surfaces 1-32 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2644 onlay - porcelain/ceramic - four or more surfaces 1-32 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes 1) One (1) per 60 months per tooth 2) See Inlay/Onlay notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2740 crown - porcelain/ceramic 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2750 crown - porcelain fused to high noble metal 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2751 crown - porcelain fused to predominantly base metal 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2752 crown - porcelain fused to noble metal 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image Crowns - Single Restorations Only 1) The date of delivery for the crown is the date of service (billing date). 2) One (1) per 60 months per tooth, either D2740, D2750, D2751, D2752, D2753, D2790, D2791 or D2792, D2542, D2543, D2544, D2642, D2643 or D2644. 3) One (1) per lifetime per tooth, either D2930, D2933 or D2934. 4) One (1) per 60 months per tooth, either D2931 or D2932. 5) One (1) per 60 months per tooth, either D2950, D2951 or D2954. 6) All radiographs submitted for documentation must show entire tooth (crown to apex). Inlays/Onlay Restorations 1) The date of delivery for the inlay/onlay is the date of service (billing date). 2) One (1) per 60 months per tooth, either D2740, D2750, D2751, D2752, D2753, D2790, D2791, D2792, D2542, D2543, D2544, D2642, D2643 or D2644. 3) All radiographs submitted for documentation must show entire tooth (crown to apex). Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 4

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D2753 crown - porcelain fused to titanium and titanium alloys 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2790 crown - full cast high noble metal 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2791 crown - full cast predominantly base metal 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2792 crown - full cast noble metal 1-32 1) One (1) per 60 months per tooth 2) See Crown notes 1) One (1) per 60 months per tooth 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2910 re-cement or re-bond inlay, onlay, veneer or partial coverage restoration 1-32 Not payable within 6 months of initial insert, re-cement or re- bond to dentist or dental group that delivered the restoration Not payable within 6 months of initial insert, re-cement or re- bond to dentist or dental group that delivered the restoration No None D2915 re-cement cast or prefabricated post and core 1-32 Not payable within 6 months of initial insert, re-cement or re- bond to dentist or dental group that delivered the post and core Not payable within 6 months of initial insert, re-cement or re- bond to dentist or dental group that delivered the post and core No None D2920 re-cement or re-bond crown A-T, 1-32 Not payable within 6 months of initial insert, re-cement or re- bond to dentist or dental group that delivered the crown Not payable within 6 months of initial insert, re-cement or re- bond to dentist or dental group that delivered the crown No None D2930 prefabricated stainless steel crown - primary tooth A-T One (1) per lifetime per tooth either D2930, D2933 or D2934 Not a plan benefit No None D2931 prefabricated stainless steel crown - permanent tooth 1-32 1) One (1) per 60 months per tooth either D2931 or D2932. 2) See Crown notes 1) One (1) per 60 months per tooth either D2931 or D2932 2) See Crown notes No None D2932 prefabricated resin crown C-H, M-R 6-11, 22-27 1) One (1) per 60 months per tooth either D2931 or D2932. 2) See Crown notes 1) One (1) per 60 months per tooth either D2931 or D2932. 2) See Crown notes Yes Eff. 1/1/2021 Pre-treatment radiographic image D2933 prefabricated stainless steel crown with resin window C-H, M-R
One (1) per lifetime per tooth either D2930, D2933 or D2934 Not a plan benefit No None D2934 prefabricated esthetic coated stainless steel crown - primary tooth A-T One (1) per lifetime per tooth either D2930, D2933 or D2934 Not a plan benefit No None D2940 protective restoration A-T, 1-32 1) One (1) per lifetime per tooth 2) Not payable with any other procedure billed on the same date for that tooth 1) One (1) per lifetime per tooth 2) Not payable with any other procedure billed on the same date for that tooth No None D2950 core buildup, including any pins 1-32 One (1) per 60 months, either D2950, D2951 or D2954 One (1) per 60 months, either D2950, D2951 or D2954 Yes Eff. 1/1/2021 Pre-treatment radiographic image effective July 23,2018 D2951 pin retention - per tooth, in addition to restoration 1-32 One (1) per 60 months, either D2950, D2951 or D2954 One (1) per 60 months, either D2950, D2951 or D2954 Yes Eff. 1/1/2021 Pre-treatment radiographic image effective July 23,2018 D2954 prefabricated post and core in addition to crown 1-32 One (1) per 60 months, either D2950, D2951 or D2954 One (1) per 60 months, either D2950, D2951 or D2954 Yes Eff. 1/1/2021 Pre-treatment radiographic image D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament A-T 1) One (1) per lifetime per tooth, either D3220 or D3222 2) Not payable if previously billed or billed on the same day with D3230, D3310, D3320 or D3330 Not a plan benefit No None D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development 6-11, 22-27 1) One (1) per lifetime per tooth either D3222, D3351 or D3353 2) Only payable for trauma Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity ENDODONTICS 1) Local anesthesia is usually considered to be part of Endodontic procedures. 2) All pre-treatment and post-treatment radiographs must show the entire tooth (crown to apex). 3) Pulpotomy on a permanent tooth is not to be construed as the first stage of a root canal. 4) Includes pulpectomy, cleaning and filing of canals with resorbable material. 5) Pulpectomy is part of root canal therapy. Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 5

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D3230 pulpal therapy (resorbable filling) - anterior, primary tooth C-H, M-R
One (1) per lifetime per tooth Not a plan benefit No None D3310 endodontic therapy, anterior tooth (excluding final restoration) 6-11, 22-27 One (1) per lifetime per tooth, either D3310, D3351, D3352 or D3353 One (1) per lifetime per tooth No None D3320 endodontic therapy, premolar tooth (excluding final restoration) 4-5, 12-13 20-21, 28-29 One (1) per lifetime per tooth, either D3320, D3351, D3352 or D3353 Not a plan benefit No None D3330 endodontic therapy, molar tooth (excluding final restoration) 1-3, 14-16 17-19, 30-32 One (1) per lifetime per tooth, either D3330, D3351, D3352 or D3353 Not a plan benefit No None D3351 apexification/ recalcification/ pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) 1-32 One (1) per lifetime per tooth Not a plan benefit Yes Eff. 1/1/2021 Pre-treatment radiographic image D3352 apexification/ recalcification/ pulpal regeneration - interim medication replacement 1-32 One (1) per lifetime per tooth Not a plan benefit Yes Eff. 1/1/2021 Pre-treatment radiographic image D3353 apexification/ recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) 1-32 One (1) per lifetime per tooth Not a plan benefit Yes Eff. 1/1/2021 Pre-treatment radiographic image D3410 apicoectomy/ periradicular surgery - anterior 6-11, 22-27 1) One (1) per lifetime per tooth 2) Not payable with D3310. Not a plan benefit Yes Eff. 1/1/2021 Pre-treatment radiographic image D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 Yes 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm 1) A root canal is not payable if a gross periapical or periodontal pathosis is demonstrated radiographically (caries to the furcation, or subcrestal deeming the tooth non-restorable); general oral condition does not justify root canal therapy due to loss of arch integrity; tooth does not demonstrate 50% bone support and/or tooth demonstrates active untreated periodontal disease. 2) Includes all appointment necessary to complete treatment. 3) Includes all intra-operative radiographs. 4) All radiographs submitted for documentation must show entire tooth (crown to apex). 5) Payment will be made if all roots in a multi-rooted tooth are treated. PERIODONTICS Local anesthesia is usually considered to be part of Periodontal procedures.1) The word "site" is frequently used to indicate an area of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions. 2) If two contiguous teeth have areas of soft tissue recession, each ear of recession is a single site. 3) If two contiguous teeth have adjacent but separate osseous defects, each defect is a single site. 4) If two contiguous teeth have a communicating interproximal osseous defect, it should be considered a single site. 5) If all non-communicating osseous defects are single sites. 6) All edentulous non-contiguous tooth positions are single sites. 7) Depending on the dimensions of the defect, up to two contiguous edentulous tooth positions may be considered a single site. 8) Either D4210, D4211, D4240, D4241, D4260 or D4261 9) Not payable within 90 days of active periodontal treatment; does not include D4355 Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 6

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4249 clinical crown lengthening - hard tissue 1-32 1) One (1) per per tooth per lifetime 2) Not payable if performed within 24 months of D4260 or D4261 in the same quadrant 1) One (1) per per tooth per lifetime 2) Not payable if performed within 24 months of D4260 or D4261 in the same quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months D4260 osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4261 osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 One (1) per 24 months per quadrant, either D4210, D4211, D4240, D4241, D4260 or D4261 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4263 bone replacement graft - retained natural tooth - first site in quadrant 10, 20, 30, 40 None One (1) per 24 months per quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4264 bone replacement graft - retained natural tooth - each additional site in quadrant 10, 20, 30, 40 None One (1) per 24 months per quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4270 pedicle soft tissue graft procedure 1-32 None One (1) per 24 months per quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4273 autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in graft 1-32 None One (1) per 24 months per quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4274 mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) 1-32 None One (1) per 24 months per quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4277 Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or edentulous tooth position in graft 1-32 None One (1) per 24 months per quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 7

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D4278 Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or edentulous tooth position in same graft site 1-32 None One (1) per 24 months per quadrant Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4322 splint - intra-coronal; natural teeth or prosthetic crowns 10, 20, 30, 40 None One (1) per 24 months per quadrant Yes Eff. 1/1/2022 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4323 splint - extra-coronal; natural teeth or prosthetic crowns 10, 20, 30, 40 None One (1) per 24 months per quadrant Yes Eff. 1/1/2022 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4341 periodontal scaling and root planing - four or more teeth per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant either D4341 or D4342 One (1) per 24 months per quadrant either D4341 or D4342 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image (for members who are pregnant a narrative can be submitted instead of the radiographic image) 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4342 periodontal scaling and root planing -one to three teeth per quadrant 10, 20, 30, 40 One (1) per 24 months per quadrant either D4341 or D4342 One (1) per 24 months per quadrant either D4341 or D4342 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image (for members who are pregnant a narrative can be submitted instead of the radiographic image) 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4355 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit N/A 1) One (1) D4355 per thirty-six (36) months. 2) One (1) per six (6) months, either D1120 or D4355 1) One (1) D4355 per thirty-six (36) months. 2) One (1) per six (6) months, either D1110 or D4355 No 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm D4910 periodontal maintenance N/A 1) Only payable after active periodontal therapy 2) One (1) per twelve (12) months, or a combination of D1120 and D4910 during a twelve (12) month period. 3) See Periodontics note #9 1) Only payable after active periodontal therapy 2) One (1) per twelve (12) months, or a combination of D1110 and D4910 during a twelve (12) month period. 3) See Periodontics note #9 Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Comprehensive periodontal evaluation, including charting, not older than twelve (12) months 3) For ages 21 and older, must exhibit bone loss and pocket depths greater than 4mm Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 8

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D5110 complete denture - maxillary N/A 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D5120 complete denture - mandibular N/A 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D5130 immediate denture - maxillary N/A 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D5140 immediate denture - mandibular N/A 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) N/A 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) N/A 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date D5213 maxillary partial denture - cast metal framework with resin denture bases (including conventional clasps, rests and teeth) N/A 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date D5214 mandibular partial denture - cast metal framework with resin denture bases (including conventional clasps, rests and teeth) N/A 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date D5221 immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth N/A 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date D5222 immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth N/A 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date PROSTHODONTICS (removable) 1) Local anesthesia is considered to be part of Removable Prosthodontic procedures. 2) Includes all adjustments, replacement of lost teeth (tooth), or relines for the first six (6) months following delivery. 3) The date of delivery for any denture is the date of service (billing date). 4) Reimbursement of an incomplete denture service will be limited to out-of-pocket costs documented by a copy of the lab bill. 5) Provisions for removable prosthesis include initial placement when masticatory function is impaired or when existing prosthesis is at least five (5) years old and unserviceable. All necessary restorative work must be completed before fabrication of a partial denture. Abutments for partial dentures must be free of active periodontal disease and have at least 50% bone support. 6) Dentures for patients with the following medical conditions will not be considered for coverage: a) patients on feeding tubes, b) post CVA patients with decreased facial muscle tone, c) patients in a coma, d) patients with diminished mental capacity that could not function with dentures, e) patients who do not desire dentures, f) advanced terminal patients. 7) Extractions and other procedures necessary prior to denture placement must be rendered and paid before dentures will be reimbursed. If immediate dentures, extractions must be rendered and billed with the same date of service as placement of the immediate dentures. 8) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221, or D5223. 9) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224. 10) Partial dentures that replace only posterior permanent teeth, must include three or more teeth on the denture that are anatomically correct (natural size, shape and color). Partial dentures must include one anterior tooth and/or 3 posterior teeth (including third molars). Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 9

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D5223 immediate maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth N/A 1) One (1) per 60 months per arch either D5110, D5130, D5211, D5213, D5221 or D5223 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date D5224 immediate mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth N/A 1) One (1) per 60 months per arch either D5120, D5140, D5212, D5214, D5222 or D5224 2) See Prosthodontics Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) RPD Worksheet 3) If applicable, prior placement date D5511 repair broken denture base, mandibular 02 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5512 repair broken denture base, maxillary 01 Not payable if billed within 6 months of placement Not payable if billed within 6 months of placement No None D5520 replace missing or broken teeth - complete denture (each tooth) 1-32 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5611 repair resin partial denture, mandibular 02 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5612 repair resin partial denture, maxillary 01 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5621 repair cast partial framework, mandibular 02 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5622 repair cast partial framework, maxillary 01 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5630 repair or replace broken clasp 1-32 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5640 replace broken teeth - per tooth 1-32 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5650 add tooth to existing partial denture 1-32 Not payable if billed within 6 months of placement
Not payable if billed within 6 months of placement
No None D5730 reline complete maxillary denture (chair side) N/A One (1) per 24 months, either D5730, D5740, D5750 or D5760 One (1) per 24 months, either D5730, D5740, D5750 or D5760 Yes Eff. 1/1/2021 Date of denture placement D5731 reline complete mandibular denture (chair side) N/A One (1) per 24 months, either D5731, D5741, D5751 or D5761 One (1) per 24 months, either D5731, D5741, D5751 or D5761 Yes Eff. 1/1/2021 Date of denture placement D5740 reline maxillary partial denture (chair side) N/A One (1) per 24 months, either D5730, D5740, D5750 or D5760 One (1) per 24 months, either D5730, D5740, D5750 or D5760 Yes Eff. 1/1/2021 Date of denture placement D5741 reline mandibular partial denture (chair side) N/A One (1) per 24 months, either D5731, D5741, D5751 or D5761 One (1) per 24 months, either D5731, D5741, D5751 or D5761 Yes Eff. 1/1/2021 Date of denture placement D5750 reline complete maxillary denture (laboratory) N/A One (1) per 24 months, either D5730, D5740, D5750 or D5760 One (1) per 24 months, either D5730, D5740, D5750 or D5760 Yes Eff. 1/1/2021 Date of denture placement D5751 reline complete mandibular denture (laboratory) N/A One (1) per 24 months, either D5731, D5741, D5751 or D5761 One (1) per 24 months, either D5731, D5741, D5751 or D5761 Yes Eff. 1/1/2021 Date of denture placement D5760 reline maxillary partial denture (laboratory) N/A One (1) per 24 months, either D5730, D5740, D5750 or D5760 One (1) per 24 months, either D5730, D5740, D5750 or D5760 Yes Eff. 1/1/2021 Date of denture placement D5761 reline mandibular partial denture (laboratory) N/A One (1) per 24 months, either D5731, D5741, D5751 or D5761 One (1) per 24 months, either D5731, D5741, D5751 or D5761 Yes Eff. 1/1/2021 Date of denture placement 1) Not payable within six (6) months of denture delivery to the dentist or dental group that delivered the denture. 2) Incudes all adjustments within six (6) months of reline for the dentist or dental group who delivered the denture. 3) One (1) per 24 months, either D5730, D5740, D5750 or D5760. 4) One (1) per 24 months, either D5731, D5741, D5751 or D5761. Denture Reline Procedures Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 10

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D5899 unspecified removable prosthodontic procedure, by report N/A 1) Payable only to a Federally Qualified Healthcare Center 2) Payable up to four (4) encounters per denture 3) Payable only in conjunction with approval of pre-auth for the denture 4) One (1) denture per 60 months per arch 5) All encounters must be a different date of service 1) Payable only to a Federally Qualified Healthcare Center 2) Payable up to four (4) encounters per denture 3) Payable only in conjunction with approval of pre-auth for the denture 4) One (1) denture per 60 months per arch 5) All encounters must be a different date of service Yes Eff. 1/1/2021 Date of denture placement D5911 facial moulage(sectional) N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5912 facial moulage (complete) N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5913 nasal prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5914 auricular prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5915 orbital prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5916 ocular prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5919 facial prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5922 nasal septal prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5923 ocular prosthesis, interim N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5924 cranial prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5925 facial augmentation implant prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5926 nasal prosthesis, replacement N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5927 auricular prosthesis, replacement N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5928 orbital prosthesis, replacement N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5929 facial prosthesis, replacement N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5931 obturator prosthesis, surgical N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5932 obturator prosthesis, definitive N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5933 obturator prosthesis, modification N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5934 mandibular resection prosthesis with guide flange N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5935 mandibular resection prosthesis without guide flange N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5936 obturator prosthesis, interim N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5937 trismus appliance (not for TMD treatment) N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5951 feeding aid N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5952 speech aid prosthesis, pediatric N/A Limited to ages 0-12 Not a plan benefit Yes Eff. 1/1/2021 Narrative detailing medical necessity D5953 speech aid prosthesis, adult N/A Limited to ages 13-20 Not a plan benefit Yes Eff. 1/1/2021 Narrative detailing medical necessity D5954 palatal augmentation prosthesis N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 11

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D5955 palatal lift prosthesis, definitive N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5958 palatal lift prosthesis, interim N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5959 palatal lift prosthesis, modification N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5960 speech aid prosthesis, modification N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5982 surgical stent N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5983 radiation carrier N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5984 radiation shield N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5985 radiation cone locator N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5986 fluoride gel carrier N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5987 commissure splint N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5988 surgical splint N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D5999 unspecified maxillofacial prosthesis, by report N/A None None Yes Eff. 1/1/2021 Narrative detailing medical necessity D6210 pontic - cast high noble metal 6-11, 22-27 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6211 pontic - cast predominantly base metal 6-11, 22-27 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6212 pontic - cast noble metal 6-11, 22-27 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6240 pontic - porcelain fused to high noble metal 6-11, 22-27 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6241 pontic - porcelain fused to predominantly base metal 6-11, 22-27 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6242 pontic - porcelain fused to noble metal 6-11, 22-27 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6251 pontic - resin with predominantly base metal 6-11, 22-27 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6721 crown - resin with predominantly base metal 6-11, 22-28 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6750 crown - porcelain fused to high noble metal 6-11, 22-29 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6751 crown - porcelain fused to predominantly base metal 6-11, 22-30 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6752 crown - porcelain fused to noble metal 6-11, 22-31 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date PROSTHODONTICS, fixed 1) Local anesthesia is usually considered to be part of Fixed Prosthodontic procedures. 2) Fixed bridgework will only be considered for the replacement of permanent anterior teeth. 3) All necessary restorative, endodontic, periodontics, and oral surgery must be completed before the fixed bridgework can be authorized. Completion must be documented. 4) Fixed bridgework will not be allowed in conjunction with the placement of a partial denture in the same arch. 5) Fixed bridgework will not be covered when replacing a removable appliance less than five years old. 6) The date of delivery for the prosthetic is the date of service (billing date). 7) One (1) per 60 months either D6210, D6211, D6212, D6240, D6241, D6242, D6251, D6721, D6750, D6751, D6752, D6753, D6790, D6791, or D6792. Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 12

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D6753 crown - porcelain fused to titanium and titanium alloys 6-11, 22-32 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6791 crown - full cast predominantly base metal 6-11, 22-33 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date D6792 crown - full cast noble metal 6-11, 22-34 1) One (1) per 60 months per tooth 2) See Prosthodontics, fixed Notes Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) If applicable, prior placement date
D6930 re-cement or re-bond fixed partial denture 6-11, 22-35 Not payable within six (6) months to dentist or dental group that delivered appliance Not payable within six (6) months to dentist or dental group that delivered appliance Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity. D6999 unspecified fixed prosthodontic procedure, by report 1-32 Description of service and narrative of medical necessity Not a plan benefit Yes Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity 3) If applicable, prior placement date D7140 extraction, erupted tooth or exposed tooth (elevation and/or forceps removal) A-T, 1-32 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 No None D7210 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated A-T, 1-32 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 No None D7220 removal of impacted tooth - soft tissue A-T, 1-32 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 Yes Eff. 1/1/2021 Pre-treatment radiographic image D7230 removal of impacted tooth - partially bony A-T, 1-32 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 Yes Eff. 1/1/2021 Pre-treatment radiographic image D7240 removal of impacted tooth - completely bony A-T, 1-32 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 One (1) per lifetime per tooth either D7140, D7210, D7220, D7230, D7240 or D7250 Yes Eff. 1/1/2021 Pre-treatment radiographic image D7250 surgical removal of residual tooth roots (cutting procedure) A-T, 1-32 1) One per lifetime per tooth, either D7140, D7210, D7220, D7230, D7240 or D7250 2) Not payable to dentist or dental group that originally extracted tooth 1) One per lifetime per tooth, either D7140, D7210, D7220, D7230, D7240 or D7250 2) Not payable to dentist or dental group that originally extracted tooth Yes Eff. 1/1/2021 Pre-treatment radiographic image D7270 tooth reimplantation and/or stabilization of accidently evulsed or displaced tooth 1 to 32 None Not a plan benefit Post review Eff. 1/1/2021 Post -op radiographic image D7280 surgical access of an unerupted tooth 1 to 32 1) Payable only if used to expose crown of impacted tooth not to be extracted for orthodontic treatment 2) Only allowed on approved orthodontic treatment Not a plan benefit Yes Eff. 1/1/2021 Pre-treatment radiographic image D7283 placement of device to facilitate eruption of impacted tooth 1 to 32 1) One (1) per lifetime per tooth 2) Only allowed on approved orthodontic treatment Not a plan benefit Yes Eff. 1/1/2021 Pre-treatment radiographic image D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 10, 20, 30, 40 One (1) per lifetime per quadrant, either D7310 or D7311
One (1) per lifetime per quadrant, either D7310 or D7311
Yes Eff. 1/1/2021 Pre-treatment radiographic image D7311 alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant 10, 20, 30, 40 One (1) per lifetime per quadrant, either D7310 or D7311 One (1) per lifetime per quadrant, either D7310 or D7311
Yes Eff. 1/1/2021 Pre-treatment radiographic image D7320 alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 10, 20, 30, 40 One (1) per lifetime per quadrant, either D7320 or D7321 One (1) per lifetime per quadrant, either D7320 or D7321
Yes Eff. 1/1/2021 Pre-treatment radiographic image D7321 alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant 10, 20, 30, 40 One (1) per lifetime per quadrant, either D7320 or D7321 One (1) per lifetime per quadrant, either D7320 or D7321
Yes Eff. 1/1/2021 Pre-treatment radiographic image D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm N/A None None Post review Eff. 1/1/2021 Pathology report D7451 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm N/A None None Post review Eff. 1/1/2021 Pathology report D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm N/A None None Post review Eff. 1/1/2021 Pathology report ORAL AND MAXILLOFACIAL SURGERY Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care) 1) Local anesthesia is usually considered to be part of Oral and Maxillofacial Surgical procedure 2) Tuberosity reduction is not payable in conjunction with extractions or alveoloplasty in the same quadrant. 3) Prophylactic removal of asymptomatic teeth or teeth free from pathology is not a covered benefit. 4) For oral surgery performed as part of emergency care, the prior authorization requirement is waived. The service is subject to retrospective review. Emergency care is defined as treatment of pain, infection, swelling, uncontrolled bleeding or traumatic injury. Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 13

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm N/A None None Post review Eff. 1/1/2021 Pathology report D7510 incision and drainage of abscess - intraoral soft tissue A-T , 1-32 1) One (1) per day per tooth either D7510 or D7511 2) Not payable if billed with D7140-D7250 on same date of service 1) One (1) per day per tooth either D7510 or D7511 2) Not payable if billed with D7140-D7250 on same date of service Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7511 incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) A-T , 1-32 1) One (1) per day per tooth either D7510 or D7511 2) Not payable if billed with D7140-D7250 on same date of service 1) One (1) per day per tooth either D7510 or D7511 2) Not payable if billed with D7140-D7250 on same date of service Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7610 maxilla - open reduction (teeth immobilized, if present) - simple N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7620 maxilla - closed reduction (teeth immobilized, if present) - simple N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7630 mandible - open reduction (teeth immobilized, if present) - simple N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7640 mandible - closed reduction (teeth immobilized, if present) - simple N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7710 maxilla - open reduction - compound N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7720 maxilla - closed reduction -compound N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7730 mandible - open reduction - compound N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7740 mandible - closed reduction - compound N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7810 open reduction of dislocation N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7820 closed reduction of dislocation N/A None None Post review Eff. 1/1/2021 1) Pre-treatment radiographic image 2) Narrative detailing medical necessity D7961 buccal/labial frenectomy (frenulectomy) 01, 02 Six (6) per lifetime Not a plan benefit Yes Eff. 1/1/2021 1) Narrative detailing medical necessity 2) Photographs D7962 lingual frenectomy (frenulectomy) NA One (1) per lifetime Not a plan benefit Yes Eff. 1/1/2021 1) Narrative detailing medical necessity 2) Photographs D7963 frenuloplasty 01, 02 One per lifetime per arch, either D7960 or D7963 Not a plan benefit Yes Eff. 1/1/2021 1) Narrative detailing medical necessity 2) Photographs D7999 unspecified oral surgery procedure, by report N/A One (1) per day per dentist or dental group One (1) per day per dentist or dental group Yes Eff. 1/1/2021 Narrative detailing medical necessity D8080 comprehensive orthodontic treatment of the adolescent dentition N/A One (1) of (D8080) per lifetime per patient Not a plan benefit Yes Eff. 1/1/2021 1) Cephalometric, panoramic or full-mouth survey radiographic images 2) External facial photographs 3) Intraoral photographs 4) HLD Index ORTHODONTICS 1) In order for a member to receive orthodontic treatment, all treatment must have received prior authorization. Prior authorization is attained by: a) Using standard ADA approved claim form b) Completed Handicapping Labio-Lingual Deviation Index (HLD) c) Narrative describing medical necessity d) Diagnostic records 2) Provider is responsible for verifying member eligibility prior to beginning orthodontic treatment and on each date a service is provided. 3) Comprehensive orthodontic treatment includes, but not limited to: a) initial exam; b) complete diagnostic records and written narrative; c) placement of all necessary appliances to properly treat the participant (both removable and fixed appliances); d) broken brackets; e) removal of appliances at the completion of the active phase of treatment; g) placement of retainers or necessary retention techniques 4) If the orthodontic case does not qualify for treatment benefits, the provider may bill for orthodontic records and consultation using CDT code D8999. Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 14

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D8660 pre-orthodontic treatment visit N/A One (1) of (D8660) per lifetime per patient Not a plan benefit Yes Eff. 1/1/2021 1) Cephalometric, panoramic or full-mouth survey radiographic images 2) External facial photographs 3) Intraoral photographs 4) HLD Index D8670 periodic orthodontic treatment visit (as part of contract) N/A 1) One (1) per forty-five (45) days regardless of number visits with in the forty five (45) day period 2) Maximum of 11 payments Not a plan benefit Yes Eff. 1/1/2021 Approved orthodontic treatment D8680 orthodontic retention (removal of appliances, construction of and placement of retainer(s) N/A One (1) per lifetime Not a plan benefit Yes Eff. 1/1/2021 Debanding date with claim form D8999 unspecified orthodontic procedure, by report N/A 1) One (1) per lifetime 2) Only payable if case fails to reach HLD score Not a plan benefit Yes Eff. 1/1/2021 Denied orthodontic treatment D8080 D9110 palliative (emergency) treatment of dental pain - minor procedure N/A 1) One (1), per day per dentist or dental group 2) Only payable with radiographs 3) Not payable if billed with D0140 on same date of service 1) One (1), per day per dentist or dental group 2) Only payable with radiographs 3) Not payable if billed with D0140 on same date of service No None D9222 deep sedation/general anesthesia - first 15 minutes N/A 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Maximum of 1 unit per date of service per dentist or dental group 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Maximum of 1 unit per date of service per dentist or dental group Yes Narrative detailing medical necessity D9223 deep sedation/general anesthesia - each subsequent 15 minutes increment N/A 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Payable only if D9222 is billed on the same date of service 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Payable only if D9222 is billed on the same date of service Yes Eff. 1/1/2021 Narrative detailing medical necessity D9230 inhalation of nitrous oxide/analgesia, anxiolysis N/A Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group No Narrative detailing medical necessity D9239 intravenous moderate (conscious) sedation/analgesia - first 15 minutes N/A 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Maximum of 1 unit per date of service per dentist or dental group 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Maximum of 1 unit per date of service per dentist or dental group Yes Eff. 1/1/2021 Narrative detailing medical necessity 1) All licensed dentists who provide conscious sedation or deep sedation/general anesthesia must have an anesthesia permit. Permit A is required for moderate sedation (conscious sedation) regardless of the route of administration. Permit B is required for deep sedation/general anesthesia. Neither permit is required if the dentist is providing an oral medication or nitrous oxide analgesia to reduce anxiety. 2) General anesthesia, intravenous sedation, conscious sedation and nitrous oxide are only payable in conjunction with a covered dental procedure. 3) Requests for sedation and general anesthesia will be reviewed on a case-by-case basis. A case will be covered for patients with physical or mental health problems of such severity that treatment cannot be attempted without. Sedation and general anesthesia may be allowed when a surgical procedure is being rendered. 4) Acceptable conditions for general anesthesia include: toxicity to local anesthesia supported by documentation, severe intellectual disability, severe physical disability uncontrolled management problem, extensive or complicated surgical procedures, failure of local anesthesia, documented medical complications and/or acute infection that would preclude the efficacy of local anesthesia. Apprehension alone is not typically considered medically necessary. 5) For cases requiring sedation, the following must be documented in the patient's chart for appropriate psychosomatic disorders: diagnosis, description of past evidence of situational anxiety or uncontrolled behaviors. In the case of a referral due to uncontrolled behavior, the name of the referring dentist must be included. 6) Chart audits may be performed to verify all criteria has been met. Services not documented as required may be denied for payment. 7) Local anesthesia is included in the fee for the procedure. 8) D9310 will only be reimbursed to a dentist other than the one providing definitive treatment. When billing, a copy of the written report must be attached. When the consulting dentist performs the service, reimbursement will be limited to the actual services rendered. 9) Anesthesia time begins when a doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. 10) Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties. 11) The level of anesthesia is determined by the anesthesia provider's documentation of the anesthetics effects upon the central nervous system and not dependent upon the route of administration. ADJUNCTIVE GENERAL SERVICES Anesthesia Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 15

CountyCare IL Medicaid Benefit Grid CDT CODE NOMENCLATURE RANGE (arch, quadrant or tooth) BENEFIT AND FREQUENCY LIMITATIONS (AGES 0-20) BENEFIT AND FREQUENCY LIMITATIONS (AGE 21 AND OLDER) AUTH REQUIRED DOCUMENTATION REQUIRED D9243 intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment N/A 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Payable only if D9239 is billed on the same date of service 1) Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group 2) Payable only if D9239 is billed on the same date of service Yes Eff. 1/1/2021 Narrative detailing medical necessity D9248 non-intravenous conscious sedation N/A Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group Either D9222, D9223, D9230, D9239, D9243 or D9248 is payable on the same date of service per dentist or dental group Yes Eff. 1/1/2021 Narrative detailing medical necessity D9310 consultation - diagnostic service provided by dentist of physician other than requesting dentist or physician N/A 1) See Anesthesia note # 8 2) Payable only to a dentist other than the one providing definitive treatment 3) Includes an examination and evaluation of the patient, and a written report from the consultant to the treating dentist 4) Copy of written report must be attached to claim 1) See Anesthesia note # 8 2) Payable only to a dentist other than the one providing definitive treatment 3) Includes an examination and evaluation of the patient, and a written report from the consultant to the treating dentist 4) Copy of written report must be attached to claim No Narrative detailing medical necessity D9610 therapeutic parenteral drug, single administration N/A Name of drug and amount administered Name of drug and amount administered Yes Eff. 1/1/2021 1) Narrative detailing medical necessity 2) Name of drug and amount administered D9630 other drugs and/or medicaments, by report N/A Name of drug and amount administered Name of drug and amount administered Yes Eff. 1/1/2021 1) Narrative detailing medical necessity 2) Name of drug and amount administered D9995 teledentistry - synchronous; real-time encounter N/A 1) One (1) per day per dentist or dental group 2) Payable only when submitted with code D0140 and Place of Service 02. 3) See Non-clinical Procedures note #1 1) One (1) per day per dentist or dental group 2) Payable only when submitted with code D0140 and Place of Service 02. 3) See Non-clinical Procedures note #1 No None D9996 teledentistry - asynchronous; iformation stored and forwarded to dentist for subsequent review N/A 1) One (1) per day per dentist or dental group 2) Payable only when submitted with code D0140 and Place of Service 02. 3) See Non-clinical Procedures note #1 1) One (1) per day per dentist or dental group 2) Payable only when submitted with code D0140 and Place of Service 02. 3) See Non-clinical Procedures note #1 No None D9999 unspecified adjunctive procedure, by report N/A Description of service and narrative of medical necessity Description of service and narrative of medical necessity Yes Eff. 1/1/2021 1) Narrative detailing medical necessity 2) Name of drug and amount administered Non-clinical Procedures 1) Member chart notes should include information on the member's complaint, method(s) used to review clinical presentation and symptoms (telephone, video, pictures, etc.), differential dignosis, treatment plan, method of triage, and prescribed prescriptions if indicated. Revised: 12.28.21 Effective: 01.01.22 Code on Dental Procedures and Nomenclature (CDT 2022) © 2021 American Dental Association 16