Preventive Section - Dental Prophylaxis,
Adult and Child
|Topic: Dental Prophylaxis,
Adult and Child
||Date of Origin: March 1997
||Policy No: 08
|Last Reviewed: January 2013
|Approved: January 2013
This Dental Policy has been developed through consideration of
generally accepted standards of dental practice, review of dental literature,
dental necessity, and as appropriate, government approval.
Benefit determinations should be based
in all cases on the applicable contract language.
To the extent there are any conflicts between these guidelines and the
contract language, the contract language will control.
The purpose of dental policy is to provide a guide to coverage. Dental
policy is not intended to dictate to providers how to practice dentistry.
Providers are expected to exercise their clinical judgment in providing
the most appropriate care.
Prophylaxis – adult (D1110):
A dental prophylaxis performed on transitional or permanent dentition which includes scaling and polishing procedures to remove coronal plaque, calculus and stains. Some patients may require more than one appointment or one extended appointment to complete a prophylaxis.
Prophylaxis – child (D1120):
Refers to a dental prophylaxis performed
on primary or transitional dentition only.
Procedures are in accordance with generally
accepted standards of dental practice.
Billing for an adult verses a child prophylaxis is determined by the dentist based on the dentition of the patient.
Process to contract benefits.
If the dentist reports two routine dental prophylaxis on the same claim and indicates the treatment required more than one visit to complete, process each routine prophylaxis separately. Additional charges for difficult or prolonged periods of time on the same date of service are considered inclusive of the fee for a prophylaxis.
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