Sec. 10.09.05.06. Preauthorization Requirements

A. Preauthorization is issued when:

(1) Program procedures are met;

(2) Program limitations are met; and

(3) The provider submits to the Department, adequate documentation demonstrating that the service to be preauthorized is medically necessary.

B. Preauthorization is required for the following:

(1) Resin fused to metal crown;

(2) Porcelain fused to metal crown;

(3) Nonprecious metal crown (full cast);

(4) Apicoectomies and periradicular services;

(5) Periodontal services;

(6) Complete upper/lower denture;

(7) Partial upper/lower denture (including clasps and teeth);

(8) Any elective clinical or surgical procedure not listed on the current dental fee schedule;

(9) Surgery normally considered cosmetic but qualified by traumatic or pathological causation;

(10) Laboratory rebasing of dentures;

(11) Addition of teeth or clasps to an existing, functional complete or partial denture;

(12) General restorative treatment to be rendered in a hospital;

(13) Special periodontal appliances;

(14) Apexification and recalcification procedures;

(15) Occlusal adjustment, limited and complete;

(16) Hemisection, including any root removal, including endodontic therapy;

(17) Overdenture complete;

(18) Overdenture partial;

(19) Condylectomy;

(20) Meniscectomy; and

(21) Arthrotomy.

C. At a minimum, the documentation required when requesting preauthorization for the following services is:

(1) A complete radiographic survey of the mouth for:

(a) Complete or partial dentures; or

(b) Except in the case of special needs children, where sedation would be required for a complete radiograph of the mouth, special periodontal appliances and periodontal therapies;

(2) Individual periapical radiographs for:

(a) Except in the case of special needs children, where sedation would be required for an individual periapical radiograph or bitewing, endodontic therapy (periapicals and bitewings shall be submitted when the request is for posterior teeth);

(b) Apicoectomy;

(c) Except in the case of special needs children, where sedation would be required for an individual periapical radiograph, periradicular and apexification or recalcification services; and

(d) Full coverage permanent crown restorations (excludes stainless steel and provisional resin crowns); and

(3) Full mouth radiographs and a periodontal chart, identifying the depths and locations of the pockets, when periodontal services are requested.

D. Preauthorization is valid for dental services when the services are approved and completed within 6 months after the date of the receipt of the preauthorization number from the Program and is contingent on the participant’s continued eligibility.

E. Preauthorization normally required by the Program is waived when the services are covered and approved by Medicare. However, if the entire or any part of a claim is rejected by Medicare, and the claim is referred to the Program for payment, payment will be made for services covered by the Program only if authorization for those services has been obtained before billing. Non-Medicare claims require preauthorization according to §§A-D of this regulation.

F. Preauthorization is required for traditional orthodontic services and for self-ligating braces for the correction of medically necessary conditions, which cause dysfunction due to a handicapping malocclusion. At a minimum the following comprehensive pretreatment documentation shall be submitted:

(1) Cephalometric head film with analysis;

(2) Panoramic or full series of periapical radiographs;

(3) 6-8 diagnostic quality extra-oral and intra-oral photographs;

(4) Clinical summary with diagnosis;

(5) HLD score sheets from attending orthodontist; and

(6) Treatment plan.