Dental Authorization Requirement Tables

Revised: April 19, 2024

· Overview

· 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.

Radiographs and imaging submitted must be labeled with the patient name, date of birth, and date of exposure of the image.

Records and notes submitted must follow the Minnesota Board of Dentistry and Minnesota Rules, 3100.9600 with respect to dental record keeping.

Restorative

Authorization requests for restorative treatment must meet all of the following criteria:

· Dentition must have a good long-term prognosis and minimal mobility

· Pocket depth of 6 mm or less

Submit requests for authorization with the following documentation:

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Copies of current diagnostic imaging which demonstrate the current dental condition of the tooth or teeth involved with the request. X-rays must be mounted (when applicable), and be labelled with patient name and the date of X-ray exposure. Do not submit original X-rays; they could be lost and compromise the member’s care.

· Complete treatment plan and long-range prognosis for the remaining dentition

· Clinical documentation supporting the cost effectiveness and medical necessity for a crown versus a filling

· Current six-point periodontal charting

CDT Code	Description
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

Authorization requests for endodontic endosseous implant treatment must meet all the following criteria:

· Dentition must have a good long-term prognosis and minimal mobility

· Pocket depth of 6 mm or less

· Submit requests for authorization with the following documentation: Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Copies of current diagnostic imaging which demonstrate the current dental condition of the tooth or teeth involved with the request. X-rays must be mounted (when applicable), and be labelled with patient name and the date of X-ray exposure. Do not submit original X-rays; they could be lost and compromise the member’s care.

· Complete treatment plan and long-range prognosis for the remaining dentition

CDT Code	Description
D3460	Endodontic endosseous implant

Periodontics

Submit requests for authorization with the following documentation:

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Copies of current diagnostic imaging which demonstrate the current dental condition. X-rays must be mounted (when applicable); and be labelled with patient name and the date of X-ray exposure. Do not submit original X-rays; they could be lost and compromise the member’s care.

· Industry standard are bite wing x-rays (vertical preferred)

· Current periodontal chart notations that include the following:

· Six-point periodontal charting, including attachment loss and mobility per tooth

· Pocket depth of greater than 4 mm to meet criteria for periodontal scaling and root planing

· Presence of pathology, including bleeding, deposit levels and tissue conditions

· Periodontal prognosis

· Classification of the periodontology case type, which must be in accordance with documentation established by the American Academy of Periodontology

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) 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 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.

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

Authorization
Submit requests for authorization with the following documentation:

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· History regarding all previous prostheses

· Copies of current diagnostic imaging which demonstrate the current dental condition of the tooth or teeth involved with the request. X-rays must be mounted (when applicable), and be labelled with patient name and the date of X-ray exposure. Do not submit original X-rays; they could be lost and compromise the member’s care.

· American Dental Association (ADA) Dental Claim Form with supporting clinical documentation, identifying all of the following:

· Missing teeth with an “X”

· Tooth numbers of the teeth to be replaced by partial dentures

· Prognosis of remaining teeth

· Current six-point periodontal charting including clinical attachment loss and mobility per tooth.

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 all of the following criteria:

· Dentition must have a good long-term prognosis and minimal mobility

· Pocket depth of 6 mm or less

Submit requests for authorization with the following documentation:

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Member's mental or physical condition, including ICD-CM and DSM-5 diagnoses when pertinent, that causes their inability to use a removable denture

· An explanation of the reason the member is unable to use a removable denture

· Copies of current diagnostic imaging that demonstrate the current dental condition of the tooth or teeth involved with the request. X-rays must be mounted (when applicable), and be labelled with patient name and the date of X-ray exposure. Do not submit original X-rays; they could be lost and compromise the member’s care.

· The specific treatment plan and the long-range prognosis for the remaining dentition

· Current six-point periodontal charting including clinical attachment loss and mobility per tooth.

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, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Copies of current radiographs that demonstrate the current dental condition

· Complete treatment plan and long-range prognosis for the remaining dentition

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.

Requests for dental implants must meet all of 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:

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Member's mental or physical condition, including ICD-CM and DSM-5 diagnoses when pertinent, that causes their inability to use a removable denture

· An explanation of the reason the member is unable to use a removable denture

· Copies of current diagnostic imaging that demonstrate the current dental condition

· The specific treatment plan and the long-range prognosis for the remaining dentition

· Current six-point periodontal charting including clinical attachment loss and mobility per tooth

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 recurrent 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

Submit authorization requests with the following documentation:

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Oral and Maxillofacial Surgery Medical Necessity Questionnaire on the medical review agent website

· Documentation of pathology for each tooth to be extracted, by tooth number

· Periodontal charting (when applicable) of the teeth recommended for extraction

· Copies of current radiographs with diagnostic value and chart documentation for each tooth to be extracted. X-rays must be mounted (when applicable), and be labelled with patient name and the date of X-ray exposure. Do not submit original X-rays; 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
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:

· Orthodontia Medical Necessity Questionnaire on the medical review agent website

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

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Specific treatment plan and appliances (enter the appropriate procedure code)

· Additional pertinent information

· Five intraoral photographs labelled with the patient name and date taken; upper and lower occlusal; prints or mounted slides are acceptable; include profile photos

· Appropriate radiographs (panoramic or full mouth and cephalometric) labelled with patient name and date of exposure

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
D8210	Removable appliance therapy
D8220	Fixed appliance therapy
D8670	Periodic orthodontic treatment visit
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:

· Medical, dental, and behavioral histories that support medical necessity for the member

· Additional pertinent information

· Copies of current radiographs that demonstrate the current dental condition

· Complete dental treatment plan and long-range prognosis for the remaining dentition

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)