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14.2.4.4 Dental Sealants
Dental sealants may be considered for reimbursement for clients younger than 21 years of age. Sealants may be applied to the occlusal, buccal, and lingual pits and fissures of any tooth. The tooth must be at risk for dental decay and be free of proximal caries and restorations on the surface to be sealed. Each tooth must be billed separately using procedure code D1351. Reimbursement is on a per tooth basis, regardless of the number of surfaces sealed. Tooth numbers and surfaces must be indicated on the claim form. Replacement sealants are not reimbursed. Claims and documentation submitted that include language, terms, or acronyms that indicate a preventive resin was applied, may be reimbursed as a sealant (procedure code D1351), and not as a restorative procedure.
If, upon claims processing or retrospective review, the finding of the claim, narrative, documentation, or charting, by a provider, of terms or acronyms indicating preventive resin or combination of similar words, the procedure may be reimbursed as a dental sealant only and not for any of the restorative procedures. Procedure code D1351 is not payable on the same date of service as any of D4000 series (periodontal) procedure codes.
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