Blue Cross Blue Shield FEP Dental
Section 5 Dental Services and Supplies Class A Basic

D1110 Prophylaxis – adult - Limit 3 during the calendar year. Age 13 and under will be processed as D1120 Prophylaxis - child - Additional information on the following page.

D1120 Prophylaxis – child - Limit 3 during the calendar year. Age 14 and over will be processed as D1110 Prophylaxis – adult - Additional information on the following page.

D1206 Topical application of fluoride varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1208 Topical application of fluoride - excluding varnish

D1208 Topical application of fluoride - excluding varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1206 Topical application of fluoride varnish

D1351 Sealant - per tooth - Unrestored 1st and 2nd permanent molars for patient up to age 22 - Any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months

D1352 Preventive resin restoration in a moderate to high caries risk patient - Permanent tooth - Unrestored 1st and 2nd permanent tooth for patient up to age 22 - Any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months

D1353 Sealant repair - per tooth - Unrestored 1st and 2nd permanent molar for patient up to age 22 - Any combination of a sealant or preventive resin restoration - Limit 1 every 36 months

D1354 Application of caries arresting medicament - per tooth - Limited to molars and premolars

D1510 Space maintainer - fixed, unilateral - per quadrant - Limited to patients up to age 22

D1516 Space maintainer – fixed – bilateral, maxillary - Limited to patients up to age 22

D1517 Space maintainer – fixed – bilateral, mandibular - Limited to patients up to age 22

D1520 Space maintainer - removable, unilateral - per quadrant - Limited to patients up to age 22

D1526 Space maintainer – removable – bilateral, maxillary - Limited to patients up to age 22

D1527 Space maintainer – removable – bilateral, mandibular - Limited to patients up to age 22

D1551 Re-cement or re-bond bilateral space maintainer - maxillary

D1552 Re-cement or re-bond bilateral space maintainer – mandibular

D1553 Re-cement or re-bond unilateral space maintainer – per quadrant

D1556 Removal of fixed unilateral space maintainer – per quadrant - Allowed if removed by dentist or dental practice that did not originally place the appliance

D1557 Removal of fixed bilateral space maintainer – maxillary - Allowed if removed by dentist or dental practice that did not originally place the appliance

D1558 Removal of fixed bilateral space maintainer – mandibular - Allowed if removed by dentist or dental practice that did not originally place the appliance

D1575 Distal shoe space maintainer - fixed – Unilateral - per quadrant - Limited to patients up to age 22

Class A Basic Preventive Services Notes:

• Prophylaxis and scaling in presence of generalized moderate or severe gingival inflammation: Limit 3 per calendar year for any combination of D1110 Prophylaxis - adult, D1120 Prophylaxis - child, and D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation. Age 13 and under will be processed as D1120 Prophylaxis - child, and age 14 and over will be processed as D1110 Prophylaxis - adult.
• Treatments such as fluorides are combined under one limitation by the plan. For example, D1206 Topical application of fluoride – varnish and D1208 Topical application of fluoride - excluding varnish are combined and limited to 2 per calendar year for patients up to age 22.