Connecticut Dental Pediatric EHB
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Mandatory Prior Authorization Chart Connecticut Dental Pediatric EHB Code Dental Services DIAGNOSTIC D0100 - D0999 Clinical Oral Evaluations D0150 Comprehensive oral evaluation - new or established patient D0160 Detailed and extensive oral evaluation - problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation - new or established patient RESTORATIVE D2000 - D2999 D2140-D2161 Amalgam restorations D2330-D2390 Direct anterior resin based composite restorations D2391-D2394 Direct posterior resin based composite restorations Crowns single restorations D2710-D2794 D2930-D2934; D2950-D2954; D2957; D2970; D2980 ENDODONTICS D3000 – D3999 D3220 D3222 Documentation Requirements If > 1 per dentist and 3 years has not elapsed since previous Narrative Narrative Narrative if within 21 days of operative procedure Narrative by primary dentist Only if tooth #s A, B, I, J, K, L, S, or T and > 9 yrs old Only if tooth #s D, E, F, G, N, O, P, or Q and > 6 yrs old or tooth #s C, H, M, or R and > 9 yrs old Only if tooth #s A, B, I, J, K, L, S, or T and > 9yrs old D3310-D3331 D3346-D3348 Endodontic retreatment D3351 D3410-D3430 Apexification Apicoectomy, periradicular services Unspecified endodontic procedure PA PA and/or PBW PA (unless emergency) PA Complete missing tooth chart PA both pre and post operative x-rays PA PA Narrative PERIODONTICS D4000 – D4999 1 DDNJ/CT-Jan 2014 PS 11/13 PA and/or PBW PA and/or FMX and/or Pano Complete missing tooth chartnarrative and photo (if radiograph does not show need) PA and/or FMX and/or Pano Complete missing tooth chart Other restorative services Pulpotomy Partial pulpotomy for apexogenesis Endodontic therapy D3999 Prior-Authorization Required Notes if appropriate Code Dental Services D4210-D4211 Gingivectomy D4212 Gingivectomy to allow access for Restorative procedure, per tooth Anatomical Crown exposure Gingival flap procedure D4230-D4231 D4240-D4241 D4245 D4249 D4260-D4261 Bone replacement grafts D4265-D4268 Biologic materials to aid in soft and osseous tissue generation Guided Tissue Regeneration Surgical Revision procedure Soft Tissue Grafts Distal or proximal wedge Soft Tissue Grafting Periodontal Splinting Periodontal scaling and root planning D4341-D4342 D4381 PA and/or FMX and/or Pano Periodontal Charting Narrative (if more than two quadrants are to be performed on the same day) PA Periodontal Charting PA Periodontal Charting Periodontal Charting PA Periodontal Charting Periodontal Charting, Narrative (if more than two quadrants are to be performed on the same day) PA Periodontal Charting post scaling and root planning and prior to D4381 placement Narrative Localized delivery of a chemotherapeutic agents via a controlled release vehicle D4999 Unspecified periodontal procedure by report PROSTHODONTICS (REMOVABLE) D5000 – D5890 D5110-D5120 Complete denture D5130-D5140 FMX and/or Pano and/or appropriate radiograph Narrative FMX and/or Pano Narrative Immediate denture 2 DDNJ/CT-Jan 2014 PS 11/13 Documentation Requirements Periodontal Charting, Narrative (if more than two quadrants are to be performed on the same day) PA Periodontal Charting PA Narrative Periodontal Charting, Narrative (if more than two quadrants are to be performed on the same day) Periodontal Charting PA Apically positioned flap Clinical crown lengthening – hard tissue Osseous Surgery D4263-D4264 D4270D4273 D4274 D4275D4278 D4320-D4321 Prior-Authorization Required Notes if appropriate Code Dental Services D5211-D5214 Removable partial dentures D5410-D5422 D5510-D5671 Adjustments to dentures Repairs to complete and partial dentures D5710-D5761 Denture rebase/relines D5862 Precision attachment D5867 Replacement of a component of precision attachment PROSTHODONTICS, FIXED D6200 - D6999 D6205-D6254 Fixed partial denture pontics D6545-D6795 Fixed partial denture retainers D6975 D6970 D6972 D6976 D6977 D6980 D6999 ORAL SURGERY D7000 - D7999 D7111 D7140 D7210-D7240 D7241 D7250 D7310-D7340 D7471-D7485 D7510 Coping Other fixed partial denture services Prior-Authorization Required Notes if appropriate If > 3 per denture/year If > 1 per denture/year These codes were deleted in CDT 2013 Fixed partial denture repair necessitated by Restorative material failure Unspecified fixed prosthodontic procedure by report Extraction coronal remnants deciduous tooth Extraction erupted tooth Narrative Narrative PA and/or FMX and/or Pano identify all missing teeth in both arches. Use tooth chart if available on claim form PA PA Narrative Narrative Prior-authorization only if primary teeth near exfoliation Tooth #s A, B, C, H, I, J, K, L, M, R, S, or T and ≥ 9 years old OR Tooth #s D, E, F, G, N, O, P, or Q and ≥ 6 years old Surgical removal of erupted tooth and removal of impacted teeth Removal of impacted tooth completely bony with unusual surgical complications Surgical removal of residual root (cutting procedure) Alveoloplasty Vestibuloplasty PA PA and/or Pano Narrative (reasons for removal) PA and/or Pano Narrative (reasons for removal and describe unusual complications PA and/or Pano Narrative PA and/or FMX and/or Pano (if in conjunction with extractions) and Narrative Narrative Tori removal Reduction of osseous tuberosity Incision and drainage of abscess intraoral Narrative 3 DDNJ/CT-Jan 2014 PS 11/13 Documentation Requirements FMX and/or Pano Complete missing tooth chart Treatment plan Narrative Narrative Code Dental Services D7960 D7970 Frenulectomy Excision of hyperplastic tissue Excision of pericoronal gingiva Surgical reduction of fibrous tuberosity D7971 D7972 Prior-Authorization Required Notes if appropriate Documentation Requirements Narrative ORTHODONTICS D8000- D8999 ADJUNCTIVE GENERAL SERVICES D9000 - D9999 D9220-D9242 Deep sedation, general anesthesia, analgesia, anxiolysis, intravenous conscious sedation Narrative describing need for anesthesia/sedation including medical conditions 4 DDNJ/CT-Jan 2014 PS 11/13 Standard ADA claim form Procedure code and nomenclature Narrative including: treatment plan, treatment time, total case fee, initial fee, retention fee, Diagnostic photographs are required, including three facial photographs (profile, frontal, and smiling), and five intraoral photographs (frontal, right lateral, left lateral, and maxillary and mandibular occlusal). In lieu of photographs, properly trimmed stone models, bite registration (will not be returned) Properly completed and scored Salzmann Malocclusion Severity Assessment form Radiographs (cephalometric and/or panoramic) Additional documentation from referring general dentists, pediatric behavioral health or mental health providers, or a statement that no other documentation was presented. A narrative description of any severe deviation(s) affecting the mouth and/or underlying structures that would not be evident from the diagnostic materials provided. Code Dental Services D9310 Consultation D9999 Unspecified adjunctive procedure Prior-Authorization Required Notes if appropriate Documentation Requirements Narrative by primary dentist making referral Narrative *See Chapter 4 of the Participating Dentist Handbook for (1) definitions of terms and abbreviations and (2) additional documentation requirements. 5 DDNJ/CT-Jan 2014 PS 11/13
