|
13.3.4.9 Fixed Prosthodontics
Prior authorization is required for fixed prosthodontics for CSHCN Services Program clients 16 years of age and older. The client must be old enough to have mature teeth and minimal jaw growth remaining.
To obtain prior authorization, the following must be submitted:
• The CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form.
•Documentation of medical necessity for the requested procedure includes, but is not limited to:
•Documentation supporting that the mouth is free of disease; no untreated periodontal or endodontic disease, or rampant caries.
•Documentation supporting only one virgin abutment tooth; at least one tooth must require a crown, except when a Maryland bridge is placed.
•Tooth Identification (TID) System noting only permanent teeth.
•Documentation supporting that a removable partial is not a viable option to fill the space between the teeth.
•Appropriate pretreatment, precementation, and postcementation radiographs of each involved tooth, such as periapical views must be maintained in the client's medical record and submitted to the CSHCN Services Program on request. Panoramic films are inadequate to detect caries or tooth structure necessary to evaluate the request.
Prior authorization will not be given when documentation indicates:
•Films show two good abutment teeth (virgin teeth do not require a crown), except when a Maryland bridge is placed.
•There is untreated periodontal or endodontic disease or rampant caries, which would contraindicate the treatment.
The following fixed prosthetics (pontics, retainers, and abutments), may be reimbursed with a maximum fee and include any preparatory work before placement of the fixed prosthetic. Use the following procedure codes for fixed prosthetic services:
•Each abutment and each pontic constitutes a unit in a fixed partial-denture bridge (bridgework).
The following procedure codes are considered part of any other service and are not reimbursed separately:
Use the following procedure codes for fixed prosthodontics services:
|
Procedure Codes
|
Limitations
|
|
Fixed Partial Denture Pontics
|
|
D6210
|
A = 16 years of age and older, prior authorization
|
|
D6211
|
A = 16 years of age and older, prior authorization
|
|
D6212
|
A = 16 years of age and older, prior authorization
|
|
D6240
|
A = 16 years of age and older, prior authorization
|
|
D6241
|
A = 16 years of age and older, prior authorization
|
|
D6242
|
A = 16 years of age and older, prior authorization
|
|
D6245
|
A = 16 years of age and older, prior authorization
|
|
D6250
|
A = 16 years of age and older, prior authorization
|
|
D6251
|
A = 16 years of age and older, prior authorization
|
|
D6252
|
A = 16 years of age and older, prior authorization
|
|
Fixed Partial Denture Retainers-Inlays or Onlays
|
|
D6545
|
A = 16 years of age and older, prior authorization
|
|
D6548
|
A = 16 years of age and older, prior authorization
|
|
Fixed Partial Denture Retainers-Crowns
|
|
D6720
|
A = 16 years of age and older, prior authorization
|
|
D6721
|
A = 16 years of age and older, prior authorization
|
|
D6722
|
A = 16 years of age and older, prior authorization
|
|
D6740
|
A = 16 years of age and older, prior authorization
|
|
D6750
|
A = 16 years of age and older, prior authorization
|
|
D6751
|
A = 16 years of age and older, prior authorization
|
|
D6752
|
A = 16 years of age and older, prior authorization
|
|
D6780
|
A = 16 years of age and older, prior authorization
|
|
D6781
|
A = 16 years of age and older, prior authorization
|
|
D6782
|
A = 16 years of age and older, prior authorization
|
|
D6783
|
A = 16 years of age and older, prior authorization
|
|
D6790
|
A = 16 years of age and older, prior authorization
|
|
D6791
|
A = 16 years of age and older, prior authorization
|
|
D6792
|
A = 16 years of age and older, prior authorization
|
|
Other Fixed Partial Denture Services
|
|
D6920
|
A = 16 years of age and older, prior authorization
|
|
D6930
|
A = 16 years of age and older, prior authorization
|
|
D6940
|
A = 16 years of age and older, prior authorization
|
|
D6950
|
A = 16 years of age and older, prior authorization
|
|
D6970
|
A = 16 years of age and older, prior authorization
|
|
D6972
|
A = 16 years of age and older, prior authorization
|
|
D6973
|
A = 16 years of age and older, prior authorization
|
|
D6975
|
A = 16 years of age and older, prior authorization
|
|
D6976
|
A = 16 years of age and older, prior authorization
|
|
D6977
|
A = 16 years of age and older, prior authorization
|
|
D6980
|
A = 16 years of age and older, prior authorization
|
|
D6999
|
A = 16 years of age and older, prior authorization
|
|
|
|
