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The Minnesota Department of Human Services provides services for more than one million Minnesotans in 87 counties and 11 tribes.

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Dental authorization - Program HH criteria

  • Fixed partial denture — Pontics and crowns (for children through age 20)

    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 dentures for individuals who are unable to use removable dentures due to medical condition also require authorization.

    Documentation

    Submit requests for authorization for fixed denture with the following documentation:

    • Current periodontal charting
    • Explanation of the reason the recipient is unable to use a removable denture
    • Radiographs of the recipient’s current dental condition of the remaining dentition
    • Recipient's mental/physical condition including ICD-CM diagnoses that cause the recipient's inability to use a removable denture
    • Specific treatment plan and the long-range prognosis for the remaining dentition
  • Molar root canal

    Criteria

    All of the following criteria must be met. Tooth must:

    • Have adequate remaining tooth structure to be restored without a cast crown
    • Have good long-term prognosis
    • Have minimal mobility
    • Not have a single pocket depth of seven or greater
  • Orthodontic treatment (limited to children through age 20)

    If a client is covered under Medicaid (MA), prior authorization must go through MA.

    Criteria

    At least one of the following criteria must be met:

    • Disfigurement of the patient's facial appearance including protrusion of upper or lower jaws or teeth
    • Overall problem that interferes with the biting function based on a comparable assessment of the criteria
    • Overbite to the extent that the lower anterior teeth impinge on the roof of the moth when the person bites
    • Positioning of jaws or teeth impairs chewing or biting function
    • Spacing between adjacent teeth which interferes with the biting function

    Documentation

    The dentist must submit the following documentation when considering orthodontic care:

    • Appropriate radiographs (panorex or full mouth and cephalometric)
    • Contributing factors (e.g., missing teeth, impacted teeth, etc.)
    • Description of classification of occlusion (e.g., angle class, arch crowding or spacing, etc.)
    • Disfiguring characteristics (e.g., facial asymmetry, etc.)
    • Five intraoral photographs; upper and lower occlusal; Prints or mounted slides are acceptable; Include profile photos
    • Functional problems (e.g., overbite, overjet, cross bites, etc.)
    • Specific treatment plan and appliances (enter the appropriate procedure 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.

  • Periodontal scaling and root planing

    Documentation

    Periodontal scaling and root planing criteria must be documented in the recipient's record to be eligible for reimbursement:

    • Classification of the periodontology case type must be in accordance with documentation established by the American Academy of Periodontology
    • Evidence of bone loss must be present on the current radiographs - panoramic, full mouth series or bitewing - to support the diagnosis of periodontitis
    • Periodontal charting must be current with six point and mobility noted and include the presence of pathology and periodontal prognosis
    • Pocket depths must be greater than four millimeters

    Periodontal maintenance

    Criteria includes:

    • Current radiographs
    • Date of original periodontal scaling and root planning
    • Documentation showing response to treatment/benefit from treatment (e.g., initial and current periodontal charting) 

    Claims will deny for any combination of D1110 adult prophylaxis, D4355 full mouth debridement, or D4341 periodontal scaling and root planing (4 or more teeth per quadrant) or D4342 (1 to 3 teeth per quadrant) processed on the same date. Claims for multiple quadrants for D4341 (4 or more teeth per quadrant) and D4342 (1 to 3 teeth per quadrant) on the same day are allowed.

  • Removable partial dentures

    Criteria

    All of the following criteria must be met:

    • Abutment teeth must not have large restorations or stainless steel crowns (metal framework partials only)
    • Crown to root ratio must at least 1:1
    • Surrounding abutment teeth and remaining teeth must not have extensive tooth decay

    Documentation

    Submit requests for authorization for partial dentures, interim or permanent with the following dental history, case information and documentation:

    • History regarding all previous prostheses
    • Dental history pertinent to request
    • Indicate on the American Dental Association claim form all missing teeth and teeth to be replaced by the partial denture (“x” for all missing teeth and “o” for teeth to be replaced by partial)
    • Periapical of the involve arch for all partial denture requests
    • Periodontal charting and periodontal prognosis of remaining teeth when requesting metal framework partial dentures

    If requesting replacement of existing prosthesis, specify:

    • Reason for request
    • Why existing partial denture can not be relined, rebased or repaired
  • Miscellaneous

    A service is medically necessary if:

    1. It is reasonably calculated to prevent, diagnose, or treat conditions in the client that endanger life, cause pain, or cause functionally significant deformity or malfunction and
    2. There is no other equally effective course of treatment available or suitable for the client requesting the service which is more conservative or substantially less costly and
    3. Services shall be of a quality that meets professionally recognized standards of health care and *must be substantiated by records including evidence of such medical necessity and quality. These records will be made available to DHS upon request.

    If criteria are not specified by Program HH, the criteria for Medical Assistance (MA) is applied.

    Program HH does not cover treatment deemed to be cosmetic or for aesthetic reasons.


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