Authorization Requirement Tables for Children and Pregnant Women



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Authorization Requirement Tables for Children and Pregnant Women

Revised: 12-28-2010



Oral Hygiene Instructions

Fixed Partial Denture — Pontics

Periodontal Services

Fixed Partial Denture Retainers — Crowns

Complete Dentures

Oral Surgery

Complete Overdenture

Temporomandibular Joint Disorder (TMD)

Partial Dentures

Orthodontic Treatment

Dental Implants






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/risk factors for oral disease specific to the patient

  • Detailed counseling components presented, based on the assessments/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 6 years, the name of the parent/legal guardian to whom the educational program is to be presented




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:

  • Current radiographs; panoramic, full mouth series or bitewing

  • Chart documentation including:

  • Current periodontal charting with notations of :

  • Six point measurements

  • For periodontal scaling and root planing -pocket depths must be greater than four millimeters

  • Mobility

  • Presence of pathology

  • Periodontal prognosis

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




D4210

Gingivectomy or gingivoplasty   per quadrant

D4211

Gingivectomy or gingivoplasty   per tooth

D4220

Gingival curettage, surgical, per quadrant, by report

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

D4271

Free soft tissue grafts including donor site

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 3 years.


If requesting replacement of existing prosthesis:




Complete Overdenture

  • Authorization always required





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

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

  • Indicate on the 2006 ADA claim form all missing teeth and teeth to be replaced by the partial denture

  • “X” all missing teeth

  • Identify all 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




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)

D5861

Overdenture – partial



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 which supports the medical necessity

  • Radiographs of the current dental condition

  • Complete treatment plan, including prosthesis and all related services

  • The Authorization Request for Dental Implants (DHS-3538) form must be completed and included with the necessary documentation requirements sent to CDMI.


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



  • There must be 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




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 persons who are unable to use removable dentures because of their medical condition.


Replacement of damaged fixed denture for individuals 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 which supports the medical necessity

  • The recipient’s mental/physical condition including ICD-9-CM and DSM III-R 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

  • Radiographs of the current dental condition

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

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 persons who are unable to use removable dentures because of their medical condition.


Replacement of damaged fixed denture for individuals 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 which supports the medical necessity

  • The recipient’s mental/physical condition including ICD-9-CM and DSM III-R 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

  • Radiographs of the current dental condition

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

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.
Requests for authorization to remove third molars and/or impacted teeth must be submitted with the following dental history, case information, and documentation for each tooth to be extracted:

  • Current radiographs and chart documentation for each tooth to be extracted

  • For each tooth to be extracted, there must be objective documentation of at least one of the following symptoms:

  • Significant infection

  • Acute pain/swelling

  • Periodontal disease due to the position of the third molar and its association with the second molar

  • Recurrent episodes of pericoronitis

  • An episode of cellulitis

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

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

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

  • A carious lesion on a partially erupted third molar

D7272

Tooth transplantation

D7283

Placement of device to facilitate eruption of impacted tooth

D7290

Surgical repositioning of teeth

D7291

Transseptal fiberotomy

D7490

Radical resection of maxilla or mandible

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



Temporomandibular Joint Disorder (TMD)

Authorization is always required


TMD Information Request Form (DHS-6119) must be completed

41899

Unlisted procedure, dentoalveolar structures



Orthodontic Treatment (through age 20)

Authorization is always required. All documentation must be mailed together to CDMI and x-rays included.

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)

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.



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

Rebonding or recementing; and/or repair, as required, of fixed retainers (authorize only if a limit of 2 per year will be exceeded)






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