Program HH (HIV/AIDS) Dental Authorization Requirement Chart
For Minnesota Health Care Programs (MHCP) covered dental services that require authorization and are not listed in this section, Program HH follows MHCP Authorization guidelines. For members eligible for both Medical Assistance (MA) and Program HH, or only Program HH, refer to the following and submit appropriate documentation to the medical review agent.
Members enrolled in Program HH are eligible for the benefits in the MHCP Dental Benefit and the additional services listed in this section. Some dental procedures are covered more frequently in Program HH than in the MHCP Dental Benefit.
Dental Authorization Requirement Tables
Maxillofacial ProstheticsAuthorization is always required for Maxillofacial Prosthetics. Submit authorization requests to the medical review agent with the following documentation: Include in narrative: diagnosis, treatment plan and medical justification for the prosthesis. | |
CDT code | Description |
D5999 | Unspecified Maxillofacial prosthesis |
Fixed Partial Denture – PonticsAuthorization is always required for fixed dentures or replacement of damaged fixed dentures. Submit authorization requests to the medical review agent with the following documentation: | |
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 |
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 – CrownsAuthorization is always required for fixed partial dentures and replacement of damaged fixed partial dentures. Submit authorization requests for fixed partial dentures to the medical review agent with the following documentation: | |
CDT code | Description |
D2740 | Crown - Porcelain or ceramic substrate |
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 - ¾ cast high noble metal |
D2781 | Crown - ¾ cast predominantly base metal |
D2782 | Crown - ¾ cast noble metal |
D2783 | Crown - ¾ porcelain or ceramic |
D2790 | Crown - Full cast high noble metal |
D2791 | Crown - Full cast predominantly base metal |
D2792 | Crown - Full cast noble metal |
D2794 | Crown - Titanium |
D2799 | Crown - provisional |
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 |
Report this page