Skip To: Main content|Subnavigation|
Minnesota Department of Human Services Provider Manual
Advanced Search

Authorization Requirement Tables for Children and Pregnant Women

Revised: 11-19-2013

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:

  • • Copies of 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 which must be in accordance with documentation established by the American Academy of Periodontology
  • 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 3 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

  • 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
  • • 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
  • 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
  • • Copies of current radiographs that show 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 Authorization Medical Review Agent.

  • 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
  • • Copies of current radiographs that show 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
  • • Copies of the current radiographs that show 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.

    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 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
  • • For each tooth to be extracted, there must be objective documentation of at least one of the following symptoms:
  • • Significant infection which includes at least one of the following
  • • Presence of severe pain/swelling
  • • Documented recurrent episodes of pericoronitis
  • • An episode of cellulitis
  • • An episode of abscess formation or untreatable pulpal/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
  • 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
    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 Authorization Medical Review Agent and copies of current 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)

  • 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 non comprehensive orthodontic treatment, MHCP does not authorize or reimburse for initial banding. Request limited and interceptive treatment based on the number of expected visits utilizing:

  • • the appropriate limited orthodontic treatment code; or
  • • 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

  • Or 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 non comprehensive orthodontic treatment, MHCP does not authorize or reimburse for initial banding. Request limited and interceptive treatment based on the number of expected visits utilizing:

  • • the appropriate limited orthodontic treatment code; or
  • • 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.

    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.

    Rate/Report this page Report/Rate this page

    © 2014 Minnesota Department of Human Services
    Minnesota.gov is led by MN.IT Services
    Updated: 11/19/13 10:03 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 11/19/13 10:03 AM