Section 140.421 Limitations on Dental Services

Section 140

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 140 MEDICAL PAYMENT

SECTION 140.421 LIMITATIONS ON DENTAL SERVICES

Section 140.421  Limitations

on Dental Services

Effective for dates of service

on or after July 1, 2018:

a)         The Department shall impose prior approval requirements to

determine the medical necessity of dental services listed in this Section.

Prior approval is required for:

1)         Crowns;

2)         Partial Pulpotomy;

3)         Periodontal services, except full mouth debridement for

diagnostic purposes;

4)         Apexification and recalcification;

5)         Apicoectomy;

6)         Dentures, partial dentures and denture relines;

7)         Maxillofacial prosthetics;

8)         Prosthodontics;

9)         Removal of impacted teeth;

10)         Surgical removal of residual roots;

11)         Surgical

exposure to aid eruption;

12)         Alveoloplasty;

13)         Incision

and drainage of abscess;

14)         Removal

of cysts or tumors;

15)         Frenulectomy;

16)         Orthodontics.

Effective January 1, 2017, medically necessary orthodontic treatment is

approved only for patients under the age of 21 and is defined as:

A)        Treatment

necessary to correct a condition that scores 28 points or more on the Handicapping

Labio-Lingual Deviation Index (HLD);

B)        Treatment

necessary to correct the following conditions, effective January 1, 2025:

i)          Cleft palate or other

craniofacial anomalies;

ii)         Deep

impinging bite with signs of tissue damage, not just touching palate;

iii)        Anterior

crossbite with gingival recession;

iv)        Severe

traumatic deviation (i.e., accidents, tumors, etc.; attach description);

v)

Overjet of 9mm or greater or

;

vi)        Impacted

teeth where eruption is impeded but extraction is not indicated

eft palate or other

craniofacial anomalies;

ii)         Deep

impinging bite with signs of tissue damage, not just touching palate;

iii)        Anterior

crossbite with gingival recession;

iv)        Severe

traumatic deviation (i.e., accidents, tumors, etc.; attach description);

v)

Overjet of 9mm or greater or

;

vi)        Impacted

teeth where eruption is impeded but extraction is not indicated.

C)        Effective

January 1, 2025, if a prior authorization request for orthodontic treatment is

denied, the provider who submitted the request shall be provided with the HLD

scoring tool and the HLD score that prompted denial of the request.

17)         General anesthesia, conscious sedation or deep sedation;

18)         Therapeutic drug injection;

19)         Other drugs and medicaments;

20)         Unspecified miscellaneous adjunctive general services or

procedures;

21)         Dental services not listed in Table D.

b)         The dentist may request post-approval when a dental procedure

requiring prior approval is provided on an emergency basis.  Approval of the

procedures shall be given if the dental procedure is medically necessary.