Skip to: Main content | Subnavigation |
Department of Human Services Department of Human Services  
 
Authorization Requirement Tables for Non Pregnant Adults

Revised: 11-04-2013

Complete Overdenture
Partial Dentures

Prophylaxis (Adult)

Oral Surgery

Temporomandibular Joint Disorder (TMD)

Complete Overdenture
Authorization always required.

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

Requests for complete overdenture 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
• Current six point periodontal charting and periodontal progress of remaining teeth.
D5860 Overdenture - complete

Partial Dentures
Authorization always required.

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

Prophylaxis (Adult)
Authorization required if more than one prophylaxis is performed in a 365 day period.

On or after 7/1/13, adult prophylaxis is allowed:

• In accordance with an appropriate individualized treatment plan that meets criteria for covering the additional prophylaxis service(s)
• Not more than four times per calendar year (365 days)

Authorization for additional prophylaxis services for MHCP fee-for-service (FFS) recipients must be authorized by MHCP’s Medical Review Agent. DHS is in the process of amending MCO’s contracts to allow the MCO’s to pay for D1110 retroactively for dates of service on or after 7/1/13. Providers should contact the enrollee’s MCO’s dental contractor to verify the MCO’s readiness date before sending claims for adjudication.
Prophylaxis (Adult) – D1110

Oral Surgery
Authorization is always required for the removal of impacted teeth.

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 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
• 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 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
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

© 2014 Minnesota Department of Human Services Online
North Star is led by the Office of Enterprise Technology
Updated: 11/4/13 1:54 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page |