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Children's Medical Services - Special services for children with special needs
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Father and daughter; Text - Bringing health care professionals together to serve children and families Family in front of house; Text - Offering high-quality care in a nurturing environment Parents and daughter laughing; Text - Creating a medical home where families are respected and supported
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CMS Network Dental Benefits

Preventive Services

  • Office Visits
  • Cleanings/Prophylaxis
  • Topical fluoride application, limit one every six months
  • Sealants, limit one application per tooth every 3 years
  • Space maintainers
Oral Exam
  • Initial Oral Exam
  • Periodic Oral Exam, limit one every 6 months


  • Intraoral periapical
  • Bitewings, limit one set (2 or 4) every 6 months
  • Complete set of x-rays, limit one every 3 years
  • Panoramic x-rays, limit one every 3 years

Restorative Services (Fillings and Crowns)

  • Amalgam restoration (silver fillings)
  • Composite/Resin restorations (white fillings)
  • Prefabricated stainless steel and resin crowns
  • Crowns (porcelain fused to metal)

Oral Surgery (Extractions)

  • Extractions
  • Biopsies
  • Surgical treatment of diseases
  • Injuries, deformities and defects

Endodontic Services (Root Canals)

  • Root canal therapy on primary and permanent teeth
  • Apicoectomy, surgery involving the root of the tooth

Periodontal Services

  • Gingival curettage, including local anesthesia
  • Gingival flap procedure
  • Scaling and root planing

Prosthodontics (Dentures)

  • Upper, lower or full set of dentures
  • Partial dentures (fixed and removable)

Orthodontic Services (Braces)

  • Prior authorization is required for all orthodontic services, except the initial evaluation and for partial dentures for beneficiaries of any age
  • Services are limited to those circumstances where the child's condition creates a disability and is an impairment to the child’s physical development. Not covered for cosmetic purposes

Analgesia and Sedation

  • Limited to children who have severe physical or mental disability or are difficult to manage. Service is limited to 3 times every 12 months
  • Intravenous administration of drugs
  • Non-intravenous administration of drugs, limit 3 times per year
  • Nitrous Oxide

Injectable Medications

  • The injection of medication to treat illness or disease

Palliative Treatment

  • Covered services necessary to relieve pain and discomfort on an emergency basis


  • Hospitalization for dental treatment is covered only if a child's health is so jeopardized that procedures cannot be safely performed in the dental office; and/or, the child is so uncontrollable due to emotional instability or developmental and sedation has been ineffective


The following services are not covered:

  • Fixed bridge work
  • Sealants applied to deciduous (baby) teeth
  • Orthodontic services are not covered for cosmetic purposes


The provider may request prior authorization for reimbursement for services in excess of the service limitations.