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13.3.4.6 Prosthodontics (Removable) and Maxillofacial Prosthetics
Local anesthesia is denied as part of removable prosthodontics procedures.
The cost of repairs cannot exceed replacement costs.
Denture reline procedures are allowed if the reline makes the denture serviceable. Denture reline procedures are denied if billed within one year of a complete or partial denture.
The following are benefit limitations for maxillary reline and rebase procedures:
• Maxillary reline and rebase procedure codes D5710, D5720, D5730, D5740, D5750, and D5760 are denied as part of complete or partial maxillary denture procedures D5110, D5130, D5211, and D5213.
•Mandibular reline and rebase procedure codes D5711, D5721, D5731, D5741, D5751, and D5761 are denied as part of complete or partial mandibular denture procedures D5120, D5140, D5212, and D5214.
Procedure code D5670 is denied as part of maxillary procedure codes D5211, D5213, D5281, and D5640. Procedure code D5671 is denied as part of mandibular procedure codes D5212, D5214, D5281, and D5640.
Procedure codes D5867 and D5875 are denied as part of any repair or modification of any removable prosthetic.
Use the following procedure codes for prosthodontic (removable) services:
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Procedure Codes
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Limitations
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D5110
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A = 1 year of age and older, prior authorization
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D5120
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A = 1 year of age and older, prior authorization
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D5130
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A = 3 years of age and older, prior authorization
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D5140
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A = 6 years of age and older, prior authorization
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D5211
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A = 6 years of age and older, prior authorization
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D5212
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A = 6 years of age and older, prior authorization
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D5213
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A = 6 years of age and older, prior authorization
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D5214
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A = 6 years of age and older, prior authorization
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D5281
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A = 6 years of age and older, prior authorization
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D5410
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A = 1 year of age and older
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D5411
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A = 1 year of age and older
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D5421
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A = 6 years of age and older
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D5422
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A = 6 years of age and older
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D5510
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A = 1 year of age and older, prior authorization
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D5520
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A = 6 years of age and older, prior authorization
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D5610
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A = 3 years of age and older
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D5620
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A = 6 years of age and older
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D5630
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A = 6 years of age and older
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D5640
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A = 6 years of age and older
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D5650
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A = 6 years of age and older
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D5660
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A = 6 years of age and older
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D5670
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A = 6 years of age and older
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D5671
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A = 6 years of age and older
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D5710
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A = 1 year of age and older, refer to previously listed limitations, prior authorization
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D5711
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A = 1 year of age and older, refer to previously listed limitations, prior authorization
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D5720
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A = 6 years of age and older, refer to previously listed limitations, prior authorization
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D5721
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A = 6 years of age and older, refer to previously listed limitations, prior authorization
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D5730
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A = 1 year of age and older, refer to previously listed limitations
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D5731
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A = 1 year of age and older, refer to previously listed limitations
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D5740
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A = 6 years of age and older, refer to previously listed limitations
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D5741
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A = 6 years of age and older, refer to previously listed limitations
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D5750
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A = 1 year of age and older, refer to previously listed limitations
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D5751
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A = 1 year of age and older, refer to previously listed limitations
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D5760
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A = 6 years of age and older, refer to previously listed limitations
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D5761
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A = 6 years of age and older, refer to previously listed limitations
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D5810
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A = 1 year of age and older, prior authorization
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D5811
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A = 1 year of age and older, prior authorization
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D5820
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A = 6 years of age and older, prior authorization
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D5821
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A = 6 years of age and older, prior authorization
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D5850
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A = 1 year of age and older, prior authorization
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D5851
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A = 1 year of age and older, prior authorization
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D5860
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A = 6 years of age and older, prior authorization
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D5861
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A = 6 years of age and older, prior authorization
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D5862
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A = 13 years of age and older, prior authorization
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D5899
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A = 13 years of age and older, prior authorization
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