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.