TMPPM 2008 > Texas Medicaid Services > Dental > Benefits and Limitations

    
 

19.15.9 Implant Services

All of the following implant services codes require prior authorization.

Periapical radiographs are required for each tooth involved in the authorization request. The criteria used by the TMHP Dental Director are:

•At least one abutment tooth requires a crown (based on traditional requirements of medical necessity and dental disease).

•Space cannot be filled with removable partial denture.

•The purpose is to prevent the drifting of teeth in all dimensions (anterior, posterior, lateral, and the opposing arch).

Procedure Code
Limitations
Maximum Fee

D6010

A 16-20, N, PPXR, CCP

$1,125.00

D6040

A 16-20, N, PPXR, CCP

$2,000.00

D6050

A 16-20, N, PPXR, CCP

Manually priced
Implant Supported Prosthetics

D6053

Deny as global to other services.

NC

D6054

Deny as global to other services.

NC

D6055

A 16-20, N, PXR, CCP

$300.00

D6056

Requires prior authorization. A 16-20, N, PPXR, CCP

$350.00

D6057

Requires prior authorization. A 16-20, N, PPXR, CCP

$350.00

D6058

Not considered medically necessary.

NC

D6059

Not considered medically necessary.

NC

D6060

Not considered medically necessary.

NC

D6061

Not considered medically necessary.

NC

D6062

Not considered medically necessary.

NC

D6063

Not considered medically necessary.

NC

D6064

Not considered medically necessary.

NC

D6065

Not considered medically necessary.

NC

D6066

Not considered medically necessary.

NC

D6067

Not considered medically necessary.

NC

D6068

Not considered medically necessary.

NC

D6069

Not considered medically necessary.

NC

D6070

Not considered medically necessary.

NC

D6071

Not considered medically necessary.

NC

D6072

Not considered medically necessary.

NC

D6073

Not considered medically necessary.

NC

D6074

Not considered medically necessary.

NC

D6075

Not considered medically necessary.

NC

D6076

Not considered medically necessary.

NC

D6077

Not considered medically necessary.

NC

D6078

Not considered medically necessary.

NC

D6079

Not considered medically necessary.

NC

D6080

A 16-20, N, PXR, CCP

$43.75

D6090

A 16-20, N, PXR, CCP

$137.50

D6095

A 16-20, N, PPXR, CCP

$175.00

D6100

A 16-20, N, PXR, CCP

$225.00

D6199

A 16-20, N, PXR, CCP

Manually priced
A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

Texas Medicaid & Healthcare Partnership
CPT only copyright 2007 American Medical Association. All rights reserved.
PreviousNextIndex