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13.3.4.4 Reimbursement
Restorations
Restorations do not require prior authorization except for inlay or onlay restorations and crowns (single restorations only) in excess of four in a lifetime, any provider.
Consideration of restoration reimbursement is contingent on compliance with the following limitations:
• Restorations on primary teeth and permanent posterior teeth may be reimbursed on the basis of the surface or surfaces restored and are paid as a total maximum fee per tooth.
•More than one restoration on a single surface is considered a single restoration. A multiple surface restoration cannot be billed as two or more separate one-surface restorations.
•The restorations must show definite crossing of the plane of each surface listed for primary and permanent tooth restoration completed to be reimbursed as a multiple surface restoration.
•All reimbursement for tooth restorations include local anesthesia and pulp protection media, where indicated, without additional charges. These services will deny as part of another service if billed separately.
•The CSHCN Services Program reimburses restorations and therapeutic care based on medical necessity. Therapeutic procedures are not reimbursed for preventive purposes.
Amalgam and resin-based composite restorations are limited to clients 1 year of age and older.
Inlay or onlay restorations and crowns-single restorations only may be reimbursed at a maximum fee. This fee includes the actual inlay or onlay or crown, any provisional crown, and any preparatory work before the seating of the permanent crown.
Procedure code D2920 is payable to the same CSHCN Services Program dental provider that did the original cementation of the crown.
Crowns-single restoration only procedure codes are limited to CSHCN Services Program clients 13 years of age and older.
Procedure code D2799 is denied as part of the global fee for a crown.
Use the following procedure codes for restoration services:
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Procedure Codes
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Limitations
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Amalgam Restorations
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D2140
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2150
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2160
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2161
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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Resin-Based Composite Restorations
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D2330
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2331
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2332
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2335
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2390
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2391
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2392
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D3293
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2394
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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Gold Foil Restorations
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D2410
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure on same tooth, same day, same provider
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D2420
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2430
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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Inlay or Onlay Restorations
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D2510
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2520
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2530
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2542
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2543
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2544
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2610
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2620
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2630
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2642
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2643
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2644
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2650
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2651
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2652
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2662
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2663
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2664
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2710
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2720
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2721
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2722
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2740
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2750
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2751
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2752
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2780
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2781
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2782
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2783
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2790
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2791
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2792
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2794
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2910
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A = 13 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2915
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A = 6 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2920
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure, payable to the same provider that performed the original crown cementation
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D2930
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2931
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A = 6 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2932
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2933
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2934
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A = 1 year of age and older, procedure code D3110 may be reimbursed with procedure
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D2940
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A = 6 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2950
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A = 6 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2951
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A = 6 years of age and older, procedure code D3110 may be reimbursed with procedure
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D2952
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A = 13 years of age and older
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D2953
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A = 4 years of age and older
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D2954
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A = 13 years of age and older
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D2955
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A = 4 years of age and older
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D2957
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A = 13 years of age and older
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D2960
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A = 13 years of age and older
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D2961
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A = 13 years of age and older
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D2962
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A = 13 years of age and older
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D2971
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A = 13 years of age and older
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D2980
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A = 13 years of age and older
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D2999
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A = 1 year of age and older
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Endodontics
Endodontics do not require authorization or prior authorization except for an initial root canal therapy (procedure codes D3310, D3320, and D3330) or retreatment of previous root canal therapy (procedure codes D3346, D3347, and D3348) is limited to four permanent teeth without prior authorization. Endodontic work in excess of four permanent teeth requires prior authorization.
To obtain the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form must be submitted with documentation of medical necessity.
Documentation supporting medical necessity must be maintained in the client's medical record and include the following:
•The medical necessity before treatment, during treatment, and post treatment.
•Periapical radiographs.
•The final size of the file to which the canal was enlarged and the type of filling material used.
•Any reason that the root canal may appear radiographically unacceptable must be documented in the client's chart.
Prior authorization is required for procedure code D3460. Documentation of medical necessity must include the following:
•The client is 16 years of age or older.
•Regular treatment failed.
•The client's anatomy is such that no other fixed or removable prosthodontic alternatives are available, including, but not limited to anodontia, a result of trauma, or birth defect.
Prior authorization is required for an unspecified endodontic procedure, procedure code D3999.
Procedure code D3221 is considered part of all endodontic procedures and will not be reimbursed separately.
Pulp Caps
Procedure code D3110 may be reimbursed separately in addition to any final tooth restorations identified above for the same tooth on the same date of service by the same provider. Procedure code D3220 may be reimbursed within the six months preceding a root canal or re-treatment of a root canal procedure codes D3310, D3320, D3330, D3346, D3347 or D3348.
Procedure codes D3110 and D3120 are denied when billed with the following procedure codes for the same tooth, on the same day, by the same provider:
Root Canals
Root canals may only be reimbursed when performed on permanent teeth.
Reimbursement for a root canal (procedure codes D3310, D3320, and D3330), or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348) includes all appointments, radiographs, and procedures necessary to complete the treatment, including but not limited to:
•Pulpotomy.
•Radiographs performed pre-, intra-, and post-operatively.
The following services are not considered part of a root canal (procedure codes D3310, D3320, and D3330), or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348), and may be reimbursed separately:
•Diagnostic evaluation.
•Radiographs performed at the initial, periodic, or emergency service visits.
Root canal therapy not carried to completion with a final filling should not be billed using a root canal therapy procedure code. It must be billed using procedure code D3999. Providers must file with a narrative description of what procedures were completed.
The date of service for a root canal is the date when the service was initiated.
Procedure codes D3351, D3352, and D3353 performed on a tooth within the six months preceding a root canal is considered part of the root canal. The total amount reimbursed will not exceed the total dollar amount allowed for procedure codes D3310, D3320, and D3330, or D3346, D3347, and D3348.
Apicoectomy/periradiular surgery (procedure codes D3410, D3421, D3425, and D3426) billed after root canal therapy or retreatment of a previous root canal may be reimbursed separately.
Refer to the following table for age limitations for endodontic services:
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