Authorization is required for fixed dentures for individuals unable to use removable dentures because of their medical condition. Replacement of damaged fixed dentures for such individuals also requires authorization.
To ask for authorization for fixed dentures you or your provider must submit:
All of the following criteria must be met. Tooth must:
If a client is covered under Medicaid (MA), prior authorization must go through MA.
At least one of the following criteria must be met:
The dentist must submit the following documentation when considering orthodontic care:
A separate letter may be included with additional information. If the above information is not adequate, DHS may request study models. Do not send models unless requested.
Periodontal scaling and root planing criteria must be documented in the recipient's record to be eligible for reimbursement:
Claims will be denied 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.
All of the following criteria must be met:
Submit requests for authorization for partial dentures, interim or permanent with the following dental history, case information and documentation:
If requesting replacement of existing prosthesis, specify:
A service is medically necessary if:
Program HH does not cover treatment deemed to be cosmetic or for aesthetic reasons.