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13.3.4.16 Adjunctive General Services
Refer to individual procedure codes in the following table for prior authorization requirements:
|
Procedure Code
|
Limitations
|
|
D9110
|
A = NA
|
|
D9120
|
A = 13 years of age and older, prior authorization
|
|
D9210
|
A = NA, refer to previously listed limitations
|
|
D9211
|
A = NA, refer to previously listed limitations
|
|
D9212
|
A = NA, refer to previously listed limitations
|
|
D9215
|
A = NA, refer to previously listed limitations
|
|
D9220
|
A = NA, prior authorization, DOC, refer to previously listed limitations
|
|
D9221
|
A = NA, prior authorization, refer to previously listed limitations
|
|
D9230
|
A = NA, refer to previously listed limitations
|
|
D9241
|
A = NA, refer to previously listed limitations
|
|
D9242
|
A = NA
|
|
D9248
|
A = NA, more than 2 services/12 months requires prior authorization, refer to previously listed limitations
|
|
D9310
|
A = NA, prior authorization
|
|
D9420
|
A = NA, prior authorization, refer to previously listed limitations
|
|
D9430
|
A = NA
|
|
D9440
|
A = NA
|
|
D9610
|
A = NA, prior authorization, limited to once per client per day, is denied when billed with procedure codes D9220, D9221, D9248, or D9920, DOC
|
|
D9612
|
A = NA, prior authorization, limited to once per client per day, is denied when billed with procedure codes D9220, D9221, D9248, or D9920, DOC
|
|
D9630
|
A = NA, prior authorization, is denied when billed with procedure code D9220, D9221, D9230, D9240, D9241, D9248, D9610, D9612, or D9920
|
|
D9910
|
A = NA, limited to once per year, not used for base, liners, or adhesives
|
|
D9920
|
A = 1 year of age and older, prior authorization, denied when billed on the same day as procedure code D9220, D9221, D9230, D9241, or D9248; claim must include diagnosis of MR, refer to previously listed limitations
|
|
D9930
|
A = NA
|
|
D9940
|
A = NA, prior authorization
|
|
D9950
|
A = 13 years of age and older, prior authorization
|
|
D9951
|
A = 13 years of age and older, prior authorization, is reimbursed once per year per client, considered full-mouth procedures
|
|
D9952
|
A = 13 years of age and older, prior authorization, is reimbursed once per lifetime per provider, considered full-mouth procedures
|
|
D9974
|
A = 13 years of age and older, prior authorization, DOC
|
|
D9999
|
A = NA, prior authorization
|
|
|
Note: For those procedures requiring prior authorization, the prior authorization is valid up to 90 days from the date it is issued.
|
