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19.15.10 Prosthodontic (Fixed) Services
All of the following prosthodontic 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).
•The space cannot be filled with a removable partial denture.
•The purpose is to prevent the drifting of teeth in all dimensions (anterior, posterior, lateral, and the opposing arch).
•Each abutment or each pontic constitutes a unit in a bridge.
•Porcelain is allowed on all teeth.
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