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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.23 Adjunctive General Services : 4.2.23.1 Benefit Limitations for Adjunctive General Services

4.2.23.1
Procedure code D9110 is a benefit for the following:
Placement of a temporary crown by other than the patient’s regular dentist and one who is not in the process, has not previously, or does not in the future intend to perform an acrylic, polycarbonate, stainless steel or cast crown on this same tooth
Procedure code D9110 is not a benefit for the following:

Texas Medicaid & Healthcare Partnership
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