TN 12 (10-89)

HI 00620.160 Dental Services Exclusion

Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered. “Structures directly supporting the teeth” means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.

For services before July 1, 1981, payment may be made to a doctor of dental medicine or dental surgery only for surgery related to the jaw or any structure contiguous to the jaw or the reduction of any fracture of the jaw or any facial bone, including dental splints or other appliances used for this purpose. For services furnished after June 30, 1981 see HI 00610.290.