Authorization Requirement Tables for Children and Pregnant Women



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Authorization Requirement Tables for Children and Pregnant Women

Revised: 02-10-2016



Oral Hygiene Instructions

Fixed Partial Denture — Pontics

Periodontal Services

Fixed Partial Denture Retainers — Crowns

Complete Dentures

Oral Surgery

Partial Dentures

Temporomandibular Joint Disorder (TMD)

Dental Implants

Orthodontic Treatment



Oral Hygiene Instructions

Authorization is required after the service has been provided once for the recipient.


For authorization, submit a copy of the organized education program to be carried out by or under the supervision of the dentist to instruct the patient about the care of their teeth.
Requests for authorization must include:

  • Assessment findings or risk factors for oral disease specific to the patient

  • Detailed counseling components presented, based on the assessments or risk factors

  • Objectives of the customized care plan

  • Educational methodology used and how each educational component is to be presented

  • The amount of time scheduled to complete the organized education program

  • For children under age six, the name of the parent or legal guardian to whom the educational program is to be presented

CPT code

Code description

D1330

Oral hygiene instructions



Periodontal Services

Authorization is always required.


Requests for authorization for periodontal services must be submitted with the following dental history, case information, and documentation:

  • Copies of current radiographs; panoramic, full mouth series or bitewing

  • Current periodontal chart notations that includes the following:

  • Six point measurements

  • Pocket depths of greater than four millimeters for periodontal scaling and root planing Mobility

  • Presence of pathology

  • Periodontal prognosis

  • Classification of the periodontology case type, which must be in accordance with documentation established by the American Academy of Periodontology

CPT Code

Code description

D4240

Gingival flap procedures, including root planning–per quadrant

D4241

Gingival flap procedure, including root planing–one to three contiguous teeth

D4245

Apically positioned flap

D4249

Crown lengthening–hard and soft tissue, by report

D4260

Osseous surgery, including flap entry and closure per quadrant

D4261

Osseous surgery (including flap entry and closure)–one to three teeth, per quadrant

D4263

Bone replacement graft–first site in quadrant

D4264

Bone replacement graft–each additional site in quadrant

D4266

Guided tissue regeneration–resorbable barrier, per site, per tooth

D4267

Guided tissue regeneration–nonresorbable barrier, per site, per tooth (includes membrane removal)

D4268

Surgical revision procedure, per tooth

D4270

Pedicle soft tissue grafts

D4273

Subepithelial connective tissue graft procedure (including donor site surgery)

D4274

Distal or proximal wedge procedure (when not performed in conjunction with surgical)

D4275

Soft tissue allograft

D4276

Combined connective tissue and double pedicle graft, per tooth

D4320

Provisional splinting, intracoronal

D4321

Provisional splinting, extracoronal

D4341

Periodontal scaling and root planing–four or more teeth per quadrant

D4342

Periodontal scaling and root planing–one to three teeth per quadrant

D4381

Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, by tooth, by report

D4910

Periodontal maintenance (Program HH only, authorization is sometimes required)



Complete Dentures

Authorization required only if replacement is performed in less than three years.


If requesting replacement of existing prosthesis:

  • Include the specific reason for request

  • Specify why existing full or partial denture cannot be relined, rebased, or repaired


Overdenture

Authorization always required.


For each dental arch, removable prostheses are limited to one every six years.

Submit requests for overdenture with the following dental history, case information, and documentation:



  • History regarding all previous prostheses

  • Dental history pertinent to the request

  • Radiographs of the current dental condition for all remaining teeth of the involved arch

  • Current six-point periodontal charting and periodontal progress of remaining teeth

CPT Code

Code description

D5863

Complete maxillary overdenture

D5865

Complete mandibular overdenture



Partial Dentures

Authorization always required.

Initial placement or replacement of a removable prosthesis is limited to once every three years.

Requests for authorization for partial dentures, interim or permanent, must be submitted with the following dental history, case information, and documentation:



  • History regarding all previous prostheses

  • Dental history pertinent to request

  • Copies of current radiographs that show the current dental condition for all remaining teeth of the involved arch

  • On the 2012 ADA claim form or on supporting clinical documentation identify all:

  • Missing teeth with a “X”

  • Tooth numbers of the teeth to be replaced by partial dentures

  • Current six-point periodontal charting and periodontal prognosis of remaining teeth

Requests for cast metal removable prosthesis must meet all of the following criteria:



  • The crown to root ratio must be better than 1:1

  • The surrounding abutment teeth and the remaining teeth must not have extensive decay; and

  • The abutment teeth must not have large restorations or stainless steel crowns

If requesting replacement of existing prosthesis:



  • Include the specific reason for request

  • Specify why existing full or partial denture cannot be relined, rebased, or repaired

CPT Code

Code Description

D5211

Upper partial — resin base (including any conventional clasps, rests and teeth)

D5212

Lower partial — resin base (including any conventional clasps, rests and teeth)

D5213

Upper partial — cast metal base with resin saddles (including any conventional clasps, rests and teeth)

D5214

Lower partial — cast metal base with resin saddles (including any conventional clasps, rests and teeth)

D5225

Maxillary partial denture — flexible base (including any clasps, rests and teeth)

D5226

Mandibular partial denture — flexible base (including any clasps, rests and teeth)

D5820

Interim Partial Denture — upper (Maxillary)

D5821

Interim Partial Denture — lower (Mandibular)

D5864

Overdenture—partial maxillary

D5866

Overdenture—partial mandibular



Dental Implants

Authorization is always required.


Requests for authorization for dental implants must be submitted with the following dental history, case information, and documentation:

  • Medical and dental history that supports the medical necessity

  • Copies of current radiographs that show the current dental condition

  • Complete treatment plan, including prosthesis and all related services

  • The Dental Implants Authorization Form (DHS-3538) (PDF) must be completed and included with the necessary documentation requirements sent to Authorization Medical Review Agent.

The following criteria must be met to receive payment for dental implants and related services:



  • Bone and tooth loss that compromises chewing or breathing

  • The implants must be medically necessary and cost-effective

  • A complete treatment plan, including prosthesis and all related services, must be approved prior to the start of treatment

CPT Code

Code description

D6053

Implant/abutment supported removable denture for completely edentulous arch

D6054

Implant/abutment supported removable denture for partially edentulous arch

D6055

Implant connecting bar

D6056

Prefabricated abutment

D6057

Custom abutment

D6058

Abutment supported porcelain/ceramic crown

D6059

Abutment supported porcelain fused to metal crown (high noble metal)

D6060

Abutment supported porcelain fused to metal crown (predominantly base metal)

D6061

Abutment supported porcelain fused to metal crown (noble metal)

D6062

Abutment supported cast metal crown (high noble)

D6063

Abutment supported cast metal crown (predominately base metal)

D6064

Abutment supported cast metal crown (noble metal)

D6065

Implant supported porcelain/ceramic crown

D6066

Implant supported porcelain fused to metal crown

D6067

Implant supported metal crown

D6068

Abutment supported retainer for porcelain/ceramic FPD

D6069

Abutment supported retainer for porcelain fused to metal FPD (high noble metal)

D6070

Abutment supported retainer for porcelain fused to metal FPD (predominately base metal)

D6071

Abutment supported retainer for porcelain fused to metal FPD (noble metal)

D6072

Abutment supported retainer for cast metal FPD (high noble metal)

D6073

Abutment supported retainer for cast metal FPD (predominately base metal)

D6074

Abutment supported retainer for cast metal FPD (noble metal)

D6075

Implant supported retainer for ceramic FPD

D6076

Implant supported retainer for porcelain fused to metal FPD

D6077

Implant supported retainer-forecast metal FPD (titanium, titanium alloy, or high noble metal)

D6078

Implant/abutment supported fixed denture for completely edentulous arch

D6079

Implant/abutment supported fixed denture for partially edentulous arch

D6080

Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutment reinsertion of prosthesis

D6090

Repair implant supported prosthesis, by report

D6094

Abutment Supported Crown - (Titanium)

D6095

Repair implant abutment, by report

D6190

Radiographic/Surgical Implant Index

D6194

Abutment Supported Retainer Crown For FPD - (Titanium)

D6199

Unspecified implant procedure, by report



Fixed Partial Denture — Pontics

Authorization is required for fixed dentures (that are cost-effective) for people who are unable to use removable dentures because of their medical condition.

Replacement of damaged fixed denture for people who are unable to use a removable denture due to a medical condition requires authorization.

Requests for authorization for fixed denture must be submitted with the following documentation:



  • Medical and dental history that supports the medical necessity

  • The recipient’s mental or physical condition including ICD-CM and DSM-5 diagnoses that cause the recipient’s inability to use a removable denture

  • An explanation of the reason the recipient is unable to use a removable denture

  • Copies of current radiographs that show the current dental condition

  • The specific treatment plan and the long-range prognosis for the remaining dentition

CPT Code

Code description

D6205

Pontic — Indirect Resin Based Composite

D6210

Pontic — cast high noble metal

D6211

Pontic — cast predominantly base metal

D6212

Pontic — cast noble metal

D6214

Pontic — Titanium

D6240

Pontic — porcelain fused to high noble metal

D6241

Pontic — porcelain fused to predominantly base metal

D6242

Pontic — porcelain fused to noble metal

D6245

Pontic — porcelain/ceramic

D6250

Pontic — resin with high noble metal

D6251

Pontic — resin with predominantly base metal

D6252

Pontic — resin with noble metal

D6253

Pontic — provisional



Fixed Partial Denture Retainers — Crowns

Authorization is required for fixed dentures (that are cost-effective) for people who are unable to use removable dentures because of their medical condition.

Replacement of damaged fixed denture for people who are unable to use a removable denture due to a medical condition requires authorization.

Requests for authorization for fixed denture must be submitted with the following documentation:



  • Medical and dental history that supports the medical necessity

  • The recipient’s mental or physical condition including ICD-CM and DSM-5 diagnoses that cause the recipient’s inability to use a removable denture

  • An explanation of the reason the recipient is unable to use a removable denture

  • Copies of the current radiographs that show the current dental condition

  • The specific treatment plan and the long-range prognosis for the remaining dentition

CPT Code

Code description

D6710

Crown — indirect resin based composite

D6720

Crown — resin with high noble metal

D6721

Crown — resin with predominantly base metal

D6722

Crown — resin with noble metal

D6740

Crown — porcelain/ceramic

D6750

Crown — porcelain fused to high noble metal

D6751

Crown — porcelain fused to predominantly base metal

D6752

Crown — porcelain fused to noble metal

D6780

Crown — 3/4 cast high noble metal

D6781

Crown — 3/4 cast predominately based metal

D6782

Crown — 3/4 cast noble metal

D6783

Crown — 3/4 porcelain/ceramic

D6790

Crown — full cast high noble metal

D6791

Crown — full cast predominantly base metal

D6792

Crown — full cast noble metal

D6793

Crown — provisional retainer crown

D6794

Crown — titanium



Oral Surgery

Authorization is always required for the codes listed below.



The routine prophylactic removal of third molars is not a covered service. Third molar extractions must have symptoms or show evidence of pathology to substantiate the medical necessity for its removal.
A referring provider must release the patient’s health record to another provider regardless of the status of the patient’s account. Rendering providers are responsible for working with the referring provider to obtain all needed documentation to request an authorization for an MHCP covered service.
Requests for authorization for the removal of impacted teeth must be submitted with the following dental history, case information, and documentation for each tooth to be extracted:

  • Copies of current radiographs with diagnostic value and chart documentation for each tooth to be extracted. Copies of periapical and bitewing x-rays must be mounted. Indicate the date of exposure on all x-rays. Do not submit original x-rays; they could be lost and compromise the recipient’s care

  • Objective documentation of significant infections and symptoms for each tooth to be extracted that includes at least one of the following:

  • Presence of severe pain or swelling

  • Documented recurrent episodes of pericoronitis

  • An episode of cellulitis

  • An episode of abscess formation or untreatable pulpal or periapical pathology

  • Active current periodontal disease due to the position of the third molar and its association with the second molar, periodontal charting required

  • External resorption of the third molar or of the second molar where this would reasonably appear to be caused by the third molar

  • A non-restorable carious lesion on a partially erupted third molar or a carious lesion on the distal of the second molar due to the position of the third molar

  • A pathological condition such as a dentigerous cyst or other related pathology



CPT Code

Code description

D7272

Tooth transplantation

D7283

Placement of device to facilitate eruption of impacted tooth

D7290

Surgical repositioning of teeth

D7291

Transseptal fiberotomy

D7220

Removal of impacted tooth – soft tissue

D7230

Removal of impacted tooth – partial boney

D7240

Removal of impacted tooth – completely bony

D7241

Removal of impacted tooth – completely bony, with unusual surgical complications

D7490

Radical resection of maxilla or mandible



Temporomandibular Joint Disorder (TMD)

Authorization is always required.


Complete the TMD Information Request Form (DHS-6119) (PDF)

CPT Code

Code description

41899

Unlisted procedure, dentoalveolar structures



Orthodontic Treatment (through age 20)

Authorization is always required. Mail all documentation together to Authorization Medical Review Agent and include copies of current x-rays.


The dentist must submit the following documentation when considering orthodontic care:

  • Description of classification of occlusion (e.g., angle class, arch crowding or spacing, etc.)

  • Functional problems (e.g., overbite, overjet, cross bites, etc.)

  • Disfiguring characteristics (e.g., facial asymmetry, etc.)

  • Contributing factors (e.g., missing teeth, impacted teeth, etc.)

  • Specific treatment plan and appliances (enter the appropriate procedure code)

  • Five intraoral photographs; upper and lower occlusal. Prints or mounted slides are acceptable. Include profile photos

  • Appropriate radiographs (panorex or full mouth and cephalometric)

For comprehensive orthodontic treatment:



  • Request D8999 for initial banding and write “initial banding” in the narrative

  • Request adjustment visits utilizing the appropriate comprehensive code

For noncomprehensive orthodontic treatment, MHCP does not authorize or reimburse for initial banding. Request limited and interceptive treatment based on the number of expected visits utilizing either of the following:



  • The appropriate limited orthodontic treatment code

  • The appropriate interceptive orthodontic treatment code

A separate letter may be included with additional information if desired. If the above information is not adequate, DHS may request study models. Do not send models unless requested.


Criteria effective May 1, 2013 – Comprehensive orthodontic treatment is considered medically necessary when adequate corrective treatment is not achievable with less extensive means, and one of the following criteria is met:

  • Dentition affected by significant cleft palate, craniofacial or other congenital or developmental disorder

  • Significant skeletal disharmony requiring combination of orthodontic treatment and orthognathic surgery for correction

  • Overjet greater than 9mm or reverse overjet greater than 3.5mm

  • Anterior openbite greater than 4mm

If one of the criteria immediately above is not met, then one of the following criteria is met and demonstrated functional impairment is present:



  • Impeded eruption of teeth (with the exception of third molars) due to crowding, displacement, the presence of supernumerary teeth, retained deciduous teeth or other pathological cause, where conservative removal of the ectopic tooth would create a significant functional deficit in biting or chewing

  • Severe crowding of greater than 7mm in either the maxillary or mandibular arch

  • Extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure to obviate the need for prosthetic treatment

  • Significant posterior openbite (not involving partially erupted teeth or teeth slightly out of occlusion;

  • Anterior crossbite involving permanent incisors or canines creating a functional interference and a resulting functional shift, or gingival stripping

  • Posterior transverse discrepancies causing buccal or lingual crossbite involving permanent molar teeth and creating a functional interference and a resulting functional shift

  • Deep anterior overbite of multiple incisors resulting in soft tissue impingement or trauma

  • Overjet greater than 6mm or reverse overjet greater than 1mm

  • Other conditions as deemed medically necessary

For comprehensive orthodontic treatment:



  • Request D8999 for initial banding and write “initial banding” in the narrative

  • Request adjustment visits utilizing the appropriate comprehensive code

For noncomprehensive orthodontic treatment, MHCP does not authorize or reimburse for initial banding. Request limited and interceptive treatment based on the number of expected visits utilizing either of the following:



  • The appropriate limited orthodontic treatment code

  • The appropriate interceptive orthodontic treatment code

A separate letter may be included with additional information if desired. If the above information is not adequate, DHS may request study models. Do not send models unless requested.



CPT Code

Code description

D8010

Limited orthodontic treatment of primary dentition

D8020

Limited orthodontic treatment of transitional dentition

D8030

Limited orthodontic treatment of adolescent dentition

D8040

Limited orthodontic treatment of adult dentition

D8050

Interceptive orthodontic treatment of primary dentition

D8060

Interceptive orthodontic treatment of transitional dentition

D8070

Comprehensive orthodontic treatment of transitional dentition

D8080

Comprehensive orthodontic treatment of adolescent dentition

D8090

Comprehensive orthodontic treatment of adult dentition

D8691

Repair of orthodontic appliance - Does not include bracket and standard fixed orthodontic appliances. It does include functional appliances and palatal expanders.

D8999

Unspecified orthodontic procedure, by report. Utilize this code for the initial banding request for comprehensive orthodontic treatment.






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