Authorization is required for fixed dentures for individuals unable to use removable dentures because of their medical condition. Replacement of damaged fixed dentures for such individuals also requires authorization.
Documentation
To ask for authorization for fixed dentures you or your provider must submit:
Current periodontal charting
Explanation of the reason you are unable to use a removable denture
Radiographs of the current dental condition of the remaining dentition
The mental/physical condition, including ICD-CM diagnoses, that cause the your inability to use a removable denture
Specific treatment plan and the long-range prognosis for the remaining dentition.
Specific treatment plan and appliances (enter the appropriate procedure code)
A separate letter may be included with additional information. If the above information is not adequate, DHS may request study models. Do not send models unless requested.
Periodontal scaling and root planing criteria must be documented in the recipient's record to be eligible for reimbursement:
Classification of the periodontology case type must be in accordance with documentation established by the American Academy of Periodontology
Evidence of bone loss must be present on the current radiographs (panoramic, full mouth series or bitewing) to support the diagnosis of periodontitis
Periodontal charting must be current with six point and mobility noted and include the presence of pathology and periodontal prognosis
Pocket depths must be greater than four millimeters.
Periodontal maintenance
Criteria includes:
Current radiographs
Date of original periodontal scaling and root planing
Documentation showing response to treatment/benefit from treatment (e.g., initial and current periodontal charting)
Claims will be denied for any combination of D1110 adult prophylaxis, D4355 full mouth debridement, or D4341 periodontal scaling and root planing (4 or more teeth per quadrant) or D4342 (1 to 3 teeth per quadrant) processed on the same date. Claims for multiple quadrants for D4341 (4 or more teeth per quadrant) and D4342 (1 to 3 teeth per quadrant) on the same day are allowed.
Abutment teeth must not have large restorations or stainless steel crowns (metal framework partials only)
Crown to root ratio must at least 1:1
Surrounding abutment teeth and remaining teeth must not have extensive tooth decay.
Documentation
Submit requests for authorization for partial dentures, interim or permanent with the following dental history, case information and documentation:
History regarding all previous prostheses
Dental history pertinent to request
Indicate on the American Dental Association claim form all missing teeth and teeth to be replaced by the partial denture ("x" for all missing teeth and "o" for teeth to be replaced by partial)
Periapical of the involved arch for all partial denture requests
Periodontal charting and periodontal prognosis of remaining teeth when requesting metal framework partial dentures.
If requesting replacement of existing prosthesis, specify:
Reason for request
Why existing partial denture can not be relined, rebased or repaired
It is reasonably calculated to prevent, diagnose, or treat conditions in the client that endanger life, cause pain, or cause functionally significant deformity or malfunction
There is no other equally effective course of treatment available or suitable
The service meets professionally recognized standards of health care and *is substantiated by records including evidence of medical necessity and quality. These records will be made available to DHS upon request.
Program HH does not cover treatment deemed to be cosmetic or for aesthetic reasons.
