Mhcp provider Manual – Authorization Requirement Tables for Dental Services



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MHCP Provider Manual – Authorization Requirement Tables for Dental Services



Crowns

Fixed Partial Denture — Pontics

Periodontal Services

Fixed Partial Denture Retainers — Crowns

Complete Dentures

Oral Surgery

Partial Dentures

Temporomandibular Joint (TMJ) Disorder

Dental Implants

Orthodontic Treatment



Crowns

Authorization is always required for the listed codes.



D2710

Crown — indirect resin based composite

D2720

Crown — resin with high noble metal

D2721

Crown — resin with predominantly base metal

D2722

Crown — resin with noble metal

D2740

Crown — porcelain/ceramic

D2750

Crown — porcelain fused to high noble metal

D2751

Crown — porcelain fused to predominantly base metal

D2752

Crown — porcelain fused to noble metal

D2780

Crown — 3/4 cast high noble metal

D2781

Crown — 3/4 cast predominately based metal

D2782

Crown — 3/4 cast noble metal

D2783

Crown — 3/4 porcelain/ceramic

D2790

Crown — full cast high noble metal

D2791

Crown — full cast predominantly base metal

D2792

Crown — full cast noble metal

D2793

Crown — provisional retainer crown

D2710

Crown — titanium

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Periodontal Services

Authorization is always required.



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

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).

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Complete Dentures

Authorization required only if replacement is preformed in less than 3 years



D5110

Complete upper

D5120

Complete lower

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Partial Dentures

Authorization always required

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

  • Periapical of the involved arch for all partial denture requests

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

  • “X” all missing teeth

  • “O” all teeth to be replaced by partial dentures

  • Periodontal charting and periodontal prognosis of remaining teeth when requesting metal framework partial dentures

  • If requesting replacement of existing prosthesis:

  • 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)

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Dental Implants

Authorization is always required.

The Authorization Request for Dental Implants 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

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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:



  • 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

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

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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:



  • 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

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

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Oral Surgery

Authorization is always required



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

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Temporomandibular Joint (TMJ) Disorder

Authorization is always required



D7880

Occlusal orthotic appliance

D7899

Unspecified TMD therapy, by report

D7953

Bone replacement graft for ridge preservation —- per site

Varied codes

All TMJ splints.

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Orthodontic Treatment

Authorization is always required

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 treatment code in the area labeled procedure number)

  • 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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