Dental authorization - Program HH criteria

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.

Documentation

To ask for authorization for fixed dentures you or your provider must submit:

• Current periodontal charting
• Explanation of the reason you are unable to use a removable denture
• Radiographs of the current dental condition of the remaining dentition
• The mental/physical condition, including ICD-CM diagnoses, that cause the your inability to use a removable denture
• Specific treatment plan and the long-range prognosis for the remaining dentition.

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

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
  
• Overbite to the extent that the lower anterior teeth impinge on the roof of the mouth when the person bites
• Positioning of jaws or teeth impairs chewing or biting function
• Spacing between adjacent teeth that 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 the above information is not adequate, DHS may request study models. Do not send models unless requested.

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 planing
• Documentation showing response to treatment/benefit from treatment (e.g., initial and current periodontal charting)

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.

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 involved 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

A service is medically necessary if:

• 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
• There is no other equally effective course of treatment available or suitable
• The service meets professionally recognized standards of health care and *is substantiated by records including evidence of medical necessity and quality. These records will be made available to DHS upon request.

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