Dental Authorization Requirement Tables

Revised: March 12, 2026

· Overview

· Diagnostic

· Restorative

· Endodontics

· Periodontics

· Prosthodontics

· Maxillofacial Prosthetics

· Implant Services

· Oral and Maxillofacial Surgery

· Orthodontics

· Adjunctive General Services

· Legal References

Overview

Minnesota Health Care Programs (MHCP) offers comprehensive dental benefits. The following codes all require prior authorization through MHCP and the medical review agent. Review Dental under Authorization in the MHCP Provider Manual for how to submit authorization requests for dental services. All services requested must be medically necessary and cost-effective.

Radiographs and imaging submitted must be labeled with the patient’s name, date of birth, and date of exposure of the image. Imaging (all types) must meet the 2026 American Dental Association recommendations for dental imaging (American Dental Association and American Academy of Oral and Maxillofacial Radiology patient selection for dental radiography and cone-beam computed tomography)

Records and notes submitted must follow the Minnesota Board of Dentistry and Minnesota Rules, 3100.9600 with respect to dental record keeping. Up-to-date, appropriate information should be maintained and available to demonstrate the medical necessity and effectiveness of the procedure, including but not limited to:

· Treatment records, including periodontal charting and clinical examination records (including tooth charting records).

· Clinical notes that clearly describe the condition and diagnosis of each tooth/surface being treated.

· Comprehensive treatment plans that address acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Diagnostic quality radiographs and imaging.

· Additional pertinent information which support the authorization request. Examples include the following:

· intra-oral photos or scans to demonstrate a lesion

· tooth or surface being treated

· risk assessment(s)

· notes about the unique status or situation of the member

Clinical notes or additional narratives may be submitted with prior authorization requests when extenuating circumstances exist and are pertinent to the request.

Minnesota Rules, 9505.5010, subpart 1, prescribes the required prior authorization submission materials.

Note: The Minnesota Department of Human Services has discontinued the referenced forms
DHS-3065 and DHS-3066.

Diagnostic

Authorization or retro authorization requests for D0150 must include rationale for increased frequency. Rationale examples include the following:

· Second opinion

· Change in provider

· Change in health status of member warranting reevaluation

Restorative

Authorization requests for restorative treatment must meet the following criteria:

· Dentition and soft tissues must have a good prognosis pocket depth(s) of 6 mm or less.

Submit requests for authorization with the following documentation:

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes which support the request for coverage.

· Current six-point periodontal charting with clinical attachment loss, recession, bleeding on probing, mobility, and other periodontal metrics.

· Comprehensive treatment plan that addresses acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Copies of imaging (radiographs, scans, photographs) which demonstrate the dental condition of the tooth/surface, teeth, or soft tissue involved with the request. X-rays must be labeled with patient name and the date obtained. Do not submit original images; they could be lost and compromise the member’s care.

CDT Code	Description
D2710	Crown - resin based composite (indirect)
D2720	Crown - resin with high noble metal
D2721	Crown - resin with predominantly base metal
D2722	Crown - resin with noble metal
D2934	Prefabricated esthetic coated stainless steel crown - primary tooth
D2952	Post and core in addition to crown, indirectly fabricated
D2953	Each additional indirectly fabricated post - same tooth
D2960	Labial veneer (resin laminate) - chairside
D2961	Labial veneer (resin laminate) - laboratory
D2962	Labial veneer (porcelain laminate) - chairside
D2971	Additional procedures to construct new crown under existing partial denture framework
D2975	Coping
D2999	Unspecified restorative procedure

Endodontics

A complete treatment plan, including prosthesis and all related services, must be approved prior to the start of treatment. Specific syndromes or conditions do not pre-qualify a member for implant approval.

Requests for dental implants must meet the following criteria:

· Bone and tooth loss that compromises chewing or breathing

· The implants must be medically necessary and cost-effective

Submit requests for authorization with the following documentation:

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes which support the request for coverage.

· Current six-point periodontal charting with clinical attachment loss, recession, bleeding on probing, mobility, tissue condition, calculus deposit levels, and tissue condition. This includes a periodontal disease diagnosis and prognosis.

· Comprehensive treatment plan that addresses acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Copies of imaging (radiographs, scans, photographs) which demonstrate the dental condition of the tooth/surface, teeth, or soft tissue involved with the request. X-rays must be labeled with patient name and the date obtained. Do not submit original images; they could be lost and compromise the member’s care.

CDT Code	Description
D3460	Endodontic endosseous implant

Periodontics

MHCP covers medically necessary non-surgical periodontal therapy. The classification of the periodontology case type, established by the American Academy of Periodontology, must be included in the request.

Submit requests for authorization with the following documentation:

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes which support the request for coverage.

· Current six-point periodontal charting with clinical attachment loss, recession, bleeding on probing, mobility, tissue condition, calculus deposit levels, and tissue condition.. This includes a periodontal disease diagnosis and prognosis.

· Comprehensive treatment plan that addresses acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Copies of imaging (radiographs, scans, photographs) which demonstrate the dental condition of the tooth/surface, teeth, or soft tissue involved with the request. Vertical bite-wings are preferred. X-rays must be labeled with patient name and the date obtained. Do not submit original images; they could be lost and compromise the member’s care.

CDT Code	Description
CDT Code	Description
D4240	Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant
D4241	Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant
D4245	Apically positioned flap
D4249	Clinical crown lengthening – hard tissue
D4260	Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant
D4261	Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant
D4263	Bone replacement graft – retained natural tooth – first site in quadrant
D4264	Bone replacement graft – retained natural tooth – each additional site in quadrant
D4266	Guided tissue regeneration – resorbable barrier, per site
D4267	Guided tissue regeneration – nonresorbable barrier, per site (includes membrane removal)
D4268	Surgical revision procedure, per tooth
D4270	Pedicle soft tissue graft procedure
D4273	Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in graft
D4274	Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)
D4275	Non-autogenous connective tissue graft procedure (including member surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site
D4276	Combined connective tissue and double edicle graft, per tooth
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 antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

Prosthodontics

Removable Prosthodontics Including Complete and Partial Dentures
Initial placement of complete dentures (D5110, D5120, D5130 and D 5140) under Minnesota Health Care Programs do not require authorization.

All partial dentures require authorization.

All removeable prosthodontics have a service limit of three years. If requesting replacement of existing prosthesis in less than three years from receiving current prosthesis:

· Include the specific reason for the request;

· Specify why the existing full or partial denture cannot be relined, rebased, or repaired to meet the current needs of the member.

Requests for cast metal or flexible base prosthesis must meet 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.

· Dentition must have a good long-term prognosis including minimal mobility of remaining teeth.

Authorization
Submit requests for authorization with the following documentation:

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes, including prognosis of remaining dentition which support the request for coverage.

· Current six-point periodontal charting with clinical attachment loss, recession, bleeding on probing, mobility, tissue condition, calculus deposit levels, and tissue condition. This includes a periodontal disease diagnosis and prognosis

· Comprehensive treatment plan that addresses acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Copies of imaging (radiographs, scans, photographs) which demonstrate the dental condition of the tooth/surface, teeth, or soft tissue involved with the request. X-rays must be labeled with patient name and the date obtained. Do not submit original images; they could be lost and compromise the member’s care.

CDT Code	Description
D5211	Maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth)
D5212	Mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth)
D5213	Maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)
D5214	Mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)
D5221	Immediate maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth)
D5222	Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth)
D5223	Immediate maxillary partial denture – cast metal framework with resin denture bases (including retentive/ clasping materials, rests and teeth)
D5224	Immediate mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, 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 (maxillary)
D5821	Interim partial denture (mandibular)
D5862	Precision attachment
D5863	Overdenture – complete maxillary
D5864	Overdenture – partial maxillary
D5865	Overdenture – complete mandibular
D5866	Overdenture – partial mandibular
D5867	Replacement of replaceable part of semi-precision or precision attachment (male or female component)
D5875	Modification of removable prosthesis following implant surgery
D5899	Unspecified removable prosthodontic procedure – to be used as denture adjustment, encounter in preparation for denture/partial, additional visit requiring professional or for the identification of dentures

Fixed Prosthodontics Including Crown and Dental Bridge
The listed fixed prosthodontic services require authorization.

Authorization requests for fixed prosthodontic treatment must meet the following criteria:

· Dentition must have a good prognosis and minimal mobility.

· Pocket depth of 6 mm or less for the tooth or teeth involved in the crown or bridge.

Submit requests for authorization with the following documentation:

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes which support the request for coverage.

· Current six-point periodontal charting with clinical attachment loss, recession, bleeding on probing, mobility, tissue condition, calculus deposit levels, and tissue condition. This includes a periodontal disease diagnosis and prognosis.

· Comprehensive treatment plan that addresses acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Copies of imaging (radiographs, scans, photographs) which demonstrate the dental condition of the tooth/surface, teeth, or soft tissue involved with the request. X-rays must be labeled with patient name and the date obtained. Do not submit original images; they could be lost and compromise the member’s care.

CDT Code	Description
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 and titanium alloys
D6240	Pontic – porcelain fused to high noble metal
D6241	Pontic – porcelain fused to predominantly base metal
D6242	Pontic – porcelain fused to noble metal
D6243	Pontic – porcelain fused to titanium and titanium alloys
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	Provisional pontic – further treatment or completion of diagnosis necessary prior to final impression
D6545	Retainer – cast metal for resin bonded fixed prosthesis
D6548	Retainer – porcelain/ceramic for resin bonded fixed prosthesis
D6624	Retainer inlay – titanium
D6634	Retainer onlay – titanium
D6710	Retainer crown – indirect resin-based composite
D6720	Retainer crown – resin with high noble metal
D6721	Retainer crown – resin with predominantly base metal
D6722	Retainer crown – resin with noble metal
D6740	Retainer crown – porcelain/ceramic
D6750	Retainer crown – porcelain fused to high noble metal
D6751	Retainer crown – porcelain fused to predominantly base metal
D6752	Retainer crown – porcelain fused to noble metal
D6753	Retainer crown – porcelain fused to titanium and titanium alloys
D6780	Retainer crown – ¾ cast high noble metal
D6781	Retainer crown – ¾ cast predominantly base metal
D6782	Retainer crown – ¾ cast noble metal
D6783	Retainer crown – ¾ porcelain/ceramic
D6784	Retainer crown – ¾ titanium and titanium alloys
D6790	Retainer crown – full cast high noble metal
D6791	Retainer crown – full cast predominantly base metal
D6792	Retainer crown – full cast noble metal
D6793	Provisional retainer crown – further treatment or completion of diagnosis necessary prior to final impression
D6794	Retainer crown – titanium and titanium alloys
D6920	Connector bar
D6940	Stress breaker
D6950	Precision attachment
D6985	Pediatric partial denture, fixed

Maxillofacial Prosthetics

Submit requests for authorization with the following documentation:

· Medical history that supports medical necessity for the member.

· Additional relevant information not otherwise listed which supports the request for coverage.

· Copies of imaging, radiographs, and/or photographs that demonstrate the current condition

· Complete treatment plan.

CDT Code	Description
D5911	Facial moulage (sectional)
D5912	Facial moulage (complete)
D5937	Trismus appliance (not for TMD treatment)
D5951	Feeding aid
D5952	Speech aid prosthesis, pediatric
D5953	Speech aid prosthesis, adult
D5954	Palatal augmentation prosthesis
D5958	Palatal lift prosthesis, interim
D5959	Palatal lift prosthesis, modification
D5960	Speech aid prosthesis, modification
D5982	Surgical stent
D5983	Radiation carrier
D5984	Radiation shield
D5985	Radiation cone locator
D5986	Fluoride gel carrier
D5987	Commissure splint

Implant Services

A complete treatment plan, including prosthesis and all related services, must be approved prior to the start of treatment. Specific syndromes or conditions do not pre-qualify a member for implant approval.

Requests for dental implants must meet he following criteria:

· Bone and tooth loss that compromises chewing or breathing

· The implants must be medically necessary

Submit requests for authorization with the following documentation:

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes which support the request for coverage.

· Current six-point periodontal charting with clinical attachment loss, recession, bleeding on probing, mobility, tissue condition, calculus deposit levels, and tissue condition. This includes a periodontal disease diagnosis and prognosis.

· Comprehensive treatment plan that addresses acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Copies of imaging (radiographs, scans, photographs) which demonstrate the dental condition of the tooth/surface, teeth, or soft tissue involved with the request. X-rays must be labeled with patient name and the date obtained. Do not submit original images; they could be lost and compromise the member’s care.

CDT Code	Description
D6055	Connecting bar – implant supported or abutment supported
D6056	Prefabricated abutment – includes modification and placement
D6057	Custom fabricated abutment – includes placement
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 metal)
D6063	Abutment supported cast metal crown (predominantly base metal)
D6064	Abutment supported cast metal crown (noble metal)
D6065	Implant supported porcelain/ceramic crown
D6066	Implant supported crown – porcelain fused to high noble alloys
D6067	Implant supported crown – high noble alloys
D6068	Abutment supported retainer for porcelain/ceramic fixed partial dental (FPD)
D6069	Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070	Abutment supported retainer for porcelain fused to metal FPD (predominantly 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 (predominantly base metal)
D6074	Abutment supported retainer for cast metal FPD (noble metal)
D6075	Implant supported retainer for ceramic FPD
D6076	Implant supported retainer for FPD – porcelain fused to high noble alloys
D6077	Implant supported retainer for metal FPD – high noble alloys
D6080	Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments
D6082	Implant supported crown – porcelain fused to predominantly base alloys
D6083	Implant supported crown – porcelain fused to noble alloys
D6084	Implant supported crown – porcelain fused to titanium or titanium alloys
D6086	Implant supported crown – predominantly base alloys
D6087	Implant supported crown – noble alloys
D6088	Implant supported crown – titanium and titanium alloys
D6094	Abutment supported crown titanium and titanium alloys
D6097	Abutment supported crown – porcelain fused to titanium or titanium alloys
D6098	Implant supported retainer – porcelain fused to predominantly base alloys
D6099	Implant supported retainer for FPD – porcelain fused to noble alloys
D6120	Implant supported retainer – porcelain fused to titanium and titanium alloys
D6121	Implant supported retainer for metal FPD – predominantly base alloys
D6122	Implant supported retainer for metal FPD – noble alloys
D6123	Implant supported retainer for metal FPD – titanium and titanium alloys
D6190	Radiographic/surgical implant index
D6194	Abutment supported retainer crown for FPD – titanium and titanium alloys
D6195	Abutment supported retainer – porcelain fused to titanium and titanium alloys

Oral and Maxillofacial 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 demonstrate pathology to substantiate the medical necessity for its removal, per tooth number.

A referring provider must release the member’s health record to another provider regardless of the status of the member’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.

Impacted Teeth
Requests for authorization must include per tooth documentation of evidence of pathology along with documentation which supports the medical necessity for each tooth’s removal, such as:

· Presence of severe pain or swelling with tooth number or quadrant noted

· Documented (dates) episodes of pericoronitis with tooth number or quadrant noted

· An episode of cellulitis, with tooth number or quadrant noted

· An episode of abscess formation or untreatable pulpal or periapical pathology with tooth number noted

· Active current periodontal disease due to the position of the third molar and its association with the second molar. Designate per tooth number in the request.

· External resorption of the third molar or of the second molar where this would reasonably appear to be caused by the third molar. Indicate tooth number(s).

· 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, including tooth number(s)

· A pathological condition such as a dentigerous cyst or other related pathology. Indicate with tooth number or quadrant

· Other conditions as deemed medically necessary (must include narrative)

A coronectomy instead of complete extraction can be provided if the following criteria is met:

· The tooth must demonstrate pathology or medical necessity with high risk of inferior alveolar nerve (IAN) injury to justify coronectomy. The anatomy must be amenable to complete removal of enamel and reduction of the remaining tooth structure to 3mm below the level of the bone

· The tooth must not be mobile

· The tooth must not be actively infected (chronic periodontitis on the adjacent second molar is acceptable)

· The tooth must not have a cyst or tumor associated with it

· The tooth must not have decay into the pulp

PA requests for coronectomy MUST include a screen shot of the pertinent sections only of the CBCT. These must be of diagnostic quality with respect to the tooth or teeth being requested for PA, and clearly labeled according to Board of Dentistry protocol.

Submit authorization requests with the following documentation:

· Documentation of pain and/or pathology for each tooth requested for approval, by tooth number in the dental record, and submitted with prior authorization request.

· Designate pain and/or pathology per tooth number. Periodontal charting for the tooth or teeth being requested for extraction, if erupted.

· Copies of imaging (radiographs, scans, photographs) which demonstrate the dental condition of the tooth/surface, teeth, or soft tissue involved with the request. X-rays must be labeled with patient name and the date obtained. Do not submit original images; they could be lost and compromise the member’s care.

CDT Code	Description
D7220	Removal of impacted tooth – soft tissue
D7230	Removal of impacted tooth – partially bony
D7240	Removal of impacted tooth – completely bony
D7241	Removal of impacted tooth – completely bony, with unusual surgical complications
D7251	Coronectomy – intentional partial tooth removal
D7252	Partial extraction for immediate implant placement
D7272	Tooth transplantation (includes re-implantation from one site to another and splinting and stabilization)
D7283	Placement of device to facilitate eruption of impacted tooth
D7290	Surgical repositioning of teeth
D7291	Transseptal fiberotomy/supra crestal fiberotomy
D7490	Radical resection of maxilla or mandible
D7880	Occlusal orthotic device
D7899	Unspecified TMD therapy
D7953	Bone replacement graft for ridge preservation – per site

Orthodontics

Effective Jan. 1, 2022, MHCP is following the American Association of Orthodontists (AAO) 2019 "Medically Necessary Orthodontics Parameters” for coverage of orthodontic treatment.

The AAO defines “medically necessary orthodontics” as “orthodontic services to prevent, diagnose, minimize, alleviate, correct, or resolve a malocclusion (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity.

Requests for comprehensive or interceptive orthodontic treatment must meet one or more of the following criteria:

· Overjet greater than 9 mm

· Reverse overjet greater than 3.5 mm

· Anterior or posterior cross bite, or both, of three or more teeth per arch

· Lateral or anterior open bite 2 mm or more; of four or more teeth per arch

· Impinging overbite with evidence of occlusal contact into the opposing soft tissue

· Impactions where eruption is impeded but extraction is not indicated (excluding third molars)

· Jaws or dentition, or both, which are profoundly affected by a congenital or developmental disorder (craniofacial anomalies), trauma or pathology

· Congenitally missing teeth (excluding third molars) of at least one tooth per quadrant

· Crowding or spacing of 10 mm or more, in either the maxillary or mandibular arch (excluding third molars).

· Other conditions as deemed medically necessary (must include narrative)

Submit requests for orthodontic authorization with the following documentation:

· ADA Dental Claim Form or supporting clinical documentation identifying the noted qualifying criteria and associated tooth numbers, or measurements, as required.

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes which support the request for coverage.

· Comprehensive treatment plan that addresses acute findings (infections, dental caries, periodontal conditions and so on) and oral function.

· Appropriate radiographs (panoramic or full mouth series and cephalometric).

· Five intra-oral photographs labelled with the patient name and date taken: upper and lower occlusal and profile photographs should be included.

· Specific treatment plan and appliance listed by CDT code on the ADA claim form.

CDT Code	Description
D8010	Limited orthodontic treatment of the primary dentition
D8020	Limited orthodontic treatment of the transitional dentition
D8030	Limited orthodontic treatment of the adolescent dentition
D8040	Limited orthodontic treatment of the adult dentition
D8070	Comprehensive orthodontic treatment of the transitional dentition
D8080	Comprehensive orthodontic treatment of the adolescent dentition
D8090	Comprehensive orthodontic treatment of the adult dentition
D8091	Comprehensive orthodontic treatment with orthognathic surgery
D8210	Removable appliance therapy
D8220	Fixed appliance therapy
D8670	Periodic orthodontic treatment visit
D8671	Periodic orthodontic treatment visit associated with orthognathic surgery
D8680	Orthodontic retention (removal of appliances, construction and placement of retainers)
D8681	Removable orthodontic retainer adjustment
D8999	Unspecified orthodontic procedure – to be used as initial placement, initial banding or initial treatment

Adjunctive General Services

Submit requests for authorization with the following documentation:

· Current dental hard tissue (tooth) charting including existing restorations, caries, hard-tissue pathology, and other examination notes which support the request for coverage. This includes a dental treatment plan.

· Comprehensive treatment plan that addresses findings and oral function.

· Copies of radiographs that demonstrate the current dental condition.

· Other conditions as deemed medically necessary (include narrative).

CDT Code	Description
D9941	Fabrication of athletic mouth guard
D9952	Occlusal adjustment – complete
D9971	Odontoplasty 1-2 teeth; includes removal of enamel projections
D9972	External bleaching – per arch – performed in office
D9973	External bleaching – per tooth
D9974	Internal bleaching – per tooth
D9999	Unspecified adjunctive procedure

Legal References

Minnesota Rules, 9505.5010 (Prior Authorization Requirement)
Minnesota Rules, 9505.5030 (Criteria for Approval of Prior Authorization Request)
American Association of Orthodontists House of Delegates 2019 (Criteria for requests for comprehensive or interceptive orthodontic treatment)