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Department of Human Services Department of Human Services  
 
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.

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