DHS 107.07(1)(b) (b) Preventive services.

DHS 107.07(1)(c) (c) Restorative services.

DHS 107.07(1)(d) (d) Endodontic services.

DHS 107.07(1)(e) (e) Periodontic services.

DHS 107.07(1)(f) (f) Removable prosthodontic services.

DHS 107.07(1)(g) (g) Fixed prosthodontic services.

DHS 107.07(1)(h) (h) Oral and maxillofacial surgery services.

DHS 107.07(1)(j) (j) All of the following other services:

DHS 107.07(1)(j)1. 1. Unclassified treatment.

DHS 107.07(1)(j)2. 2. Palliative emergency treatment.

DHS 107.07(1)(j)3. 3. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.

DHS 107.07(1)(j)4. 4. Hospital calls.

DHS 107.07 Note Note: Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s. DHS 107.22 (4).

DHS 107.07(1m) (1m) Covered services; dental hygienists. Except as provided under subs. (2), (3), (4), and (4m), all of the following dental services are covered services when provided by a dental hygienist who is individually certified under ch. DHS 105 within the scope of dental hygiene as defined in s. 447.01 (3), Stats.:

DHS 107.07(1m)(a) (a) Oral screening and preliminary examination.

DHS 107.07(1m)(b) (b) Prophylaxis.

DHS 107.07(1m)(c) (c) Topical application of fluoride.

DHS 107.07(1m)(d) (d) Pit and fissure sealants.

DHS 107.07(1m)(e) (e) Scaling and root planing.

DHS 107.07(1m)(f) (f) Full mouth debridement.

DHS 107.07(1m)(g) (g) Periodontal maintenance.

DHS 107.07(2) (2) Services requiring prior authorization.

DHS 107.07(2)(a) (a) All of the following dental services require prior authorization in order to be reimbursed under MA:

DHS 107.07(2)(a)1. 1. Molar root canal therapy for recipients ages 21 and over.

DHS 107.07(2)(a)2. 2. All of the following periodontal services:

DHS 107.07(2)(a)2.a. a. Grafts, mucogingival and osseous surgical periodontal services.

DHS 107.07(2)(a)2.b. b. Provisional splinting.

DHS 107.07(2)(a)2.c. c. Gingivectomy and gingivoplasty.

DHS 107.07(2)(a)2.d. d. Scaling and root planing.