Covered and Noncovered Services : Preventive Services

Sealants

The application of sealants is a method of preventing tooth decay.

ForwardHealth covers the application of sealants for the following:

• Members 20 years of age and younger without PA. Sealants are covered for tooth numbers/letters 2, 3, 4, 5, 12, 13, 14, 15, 18, 19, 20, 21, 28, 29, 30, 31, A, B, I, J, K, L, S, and T and are allowable for members 20 years of age and younger once every three years per tooth, per provider.
• Members 21 years of age and older with PA. Sealants are covered for tooth numbers 2, 3, 14, 15, 18, 19, 30, and 31 and are allowable for members 21 years of age and older once every three years per tooth, per provider.

Sealants on teeth numbers 4, 5, 12, 13, 20, 21, 28, and 29 or tooth letters A, B, I, J, K, L, S, and T are not allowed for routine preventative reasons. Providers must document the high risk condition, oral health factors, or disability affecting the member's ability to perform daily oral health care in the dental record.

In all cases the provider must document the medical necessity for sealants in the member's dental record.

Note: ForwardHealth does not cover sealant repair (D1353 [sealant repair-per tooth]).

Allowable Procedure Code

Providers are required to indicate the application of sealants using CDT procedure code D1351 (sealant - per tooth) on all PA requests and claims.

Claims

Tooth numbers are required on claims and PA.