MHCP Provider Manual – Authorization Requirement Tables for Dental Services
Crowns
Periodontal Services
Complete Dentures
Partial Dentures
Dental Implants
Fixed Partial Denture — Pontics
Fixed Partial Denture Retainers — Crowns
Oral Surgery
Temporomandibular Joint (TMJ) Disorder
Orthodontic Treatment
Crowns
Authorization is always required for the listed codes.
D2710
Crown — indirect resin based composite
D2720
Crown — resin with high noble metal
D2721
Crown — resin with predominantly base metal
D2722
Crown — resin with noble metal
D2740
Crown — porcelain/ceramic
D2750
Crown — porcelain fused to high noble metal
D2751
Crown — porcelain fused to predominantly base metal
D2752
Crown — porcelain fused to noble metal
D2780
Crown — 3/4 cast high noble metal
D2781
Crown — 3/4 cast predominately based metal
D2782
Crown — 3/4 cast noble metal
D2783
Crown — 3/4 porcelain/ceramic
D2790
Crown — full cast high noble metal
D2791
Crown — full cast predominantly base metal
D2792
Crown — full cast noble metal
D2793
Crown — provisional retainer crown
D2710
Crown — titanium
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Periodontal Services
Authorization is always required.
D4210
Gingivectomy or gingivoplasty - per quadrant
D4211
Gingivectomy or gingivoplasty - per tooth
D4220
Gingival curettage, surgical, per quadrant, by report
D4240
Gingival flap procedures, including root planning - per quadrant
D4241
Gingival flap procedure, including root planing - one to three contiguous teeth
D4245
Apically positioned flap
D4249
D4260
D4261
D4263
D4264
D4266
Crown lengthening - hard and soft tissue, by report
Osseous surgery, including flap entry and closure per quadrant
Osseous surgery (including flap entry and closure) - one to three teeth, per quadrant
Bone replacement graft - first site in quadrant
Bone replacement graft - each additional site in quadrant
Guided tissue regeneration - resorbable barrier, per site, per tooth
D4267
D4268
D4270
D4271
D4273
Guided tissue regeneration - nonresorbable barrier, per site, per tooth (includes membrane removal)
Surgical revision procedure, per tooth
Pedicle soft tissue grafts
Free soft tissue grafts including donor site
Subepithelial connective tissue graft procedure (including donor site surgery)
D4274
D4275
Distal or proximal wedge procedure (when not performed in conjunction with surgical
Soft tissue allograft
D4276
D4320
D4321
Combined connective tissue and double pedicle graft, per tooth
Provisional splinting, intracoronal
Provisional splinting, extracoronal
Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue,
by tooth, by report
Periodontal maintenance (Program HH only, authorization is sometimes required).
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D4381
D4910
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Complete Dentures
Authorization required only if replacement is preformed in less than 3 years
D5110
Complete upper
D5120
Complete lower
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Partial Dentures
Authorization always required
Requests for authorization for partial dentures, interim or permanent, must be submitted with the following dental history, case
information, and documentation:
 History regarding all previous prostheses
 Dental history pertinent to request
 Periapical of the involved arch for all partial denture requests
 Indicate on the 2006 ADA claim form all missing teeth and teeth to be replaced by the partial denture
 “X” all missing teeth
 “O” all teeth to be replaced by partial dentures
 Periodontal charting and periodontal prognosis of remaining teeth when requesting metal framework partial dentures
 If requesting replacement of existing prosthesis:
 Specific reason for request
Specify why existing full or partial denture cannot be relined, rebased, or repaired
D5211
Upper partial — resin base (including any conventional clasps, rests and teeth)
D5212
Lower partial — resin base (including any conventional clasps, rests and teeth)
D5213
Upper partial — cast metal base with resin saddles (including any conventional clasps, rests and teeth)
D5214
Lower partial — cast metal base with resin saddles (including any conventional clasps, rests and teeth)
D5225
Maxillary partial denture — flexible base (including any clasps, rests and teeth)
D5226
Mandibular partial denture — flexible base (including any clasps, rests and teeth)
D5820
Interim Partial Denture — upper (Maxillary)
D5821
Interim Partial Denture — lower (Mandibular)
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Dental Implants
Authorization is always required.
The Authorization Request for Dental Implants form must be completed and included with the necessary documentation
requirements sent to CDMI.
The following criteria must be met to receive payment for dental implants and related services:
 There must be bone and tooth loss that compromises chewing or breathing
 The implants must be medically necessary and cost-effective
 A complete treatment plan, including prosthesis and all related services, must be approved prior to the start of treatment
D6053
D6054
Implant/abutment supported removable denture for completely edentulous arch
Implant/abutment supported removable denture for partially edentulous arch
D6055
D6056
Implant connecting bar
Prefabricated abutment
D6057
D6058
D6059
D6060
D6061
D6062
Custom abutment
Abutment supported porcelain/ceramic crown
Abutment supported porcelain fused to metal crown (high noble metal)
Abutment supported porcelain fused to metal crown (predominantly base metal)
Abutment supported porcelain fused to metal crown (noble metal)
Abutment supported cast metal crown (high noble)
D6063
D6064
D6065
D6066
D6067
D6068
Abutment supported cast metal crown (predominately base metal)
Abutment supported cast metal crown (noble metal)
Implant supported porcelain/ceramic crown
Implant supported porcelain fused to metal crown
Implant supported metal crown
Abutment supported retainer for porcelain/ceramic FPD
D6069
D6070
D6071
D6072
D6073
D6074
Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
Abutment supported retainer for porcelain fused to metal FPD (predominately base metal)
Abutment supported retainer for porcelain fused to metal FPD (noble metal)
Abutment supported retainer for cast metal FPD (high noble metal)
Abutment supported retainer for cast metal FPD (predominately base metal)
Abutment supported retainer for cast metal FPD (noble metal)
D6075
D6076
D6077
D6078
D6079
Implant supported retainer for ceramic FPD
Implant supported retainer for porcelain fused to metal FPD
Implant supported retainer-forecast metal FPD (titanium, titanium alloy, or high noble metal)
Implant/abutment supported fixed denture for completely edentulous arch
Implant/abutment supported fixed denture for partially edentulous arch
Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutment
reinsertion of prosthesis
Repair implant supported prosthesis, by report
Abutment Supported Crown - (Titanium)
D6080
D6090
D6094
D6095
D6190
D6194
D6199
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Repair implant abutment, by report
Radiographic/Surgical Implant Index
Abutment Supported Retainer Crown For FPD - (Titanium)
Unspecified implant procedure, by report
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Fixed Partial Denture — Pontics
Authorization is required for fixed dentures (that are cost-effective) for persons who are unable to use removable dentures
because of their medical condition.
Replacement of damaged fixed denture for individuals who are unable to use a removable denture due to a medical condition
requires authorization.
Requests for authorization for fixed denture must be submitted with the following documentation:
 The recipient’s mental/physical condition including ICD-9-CM and DSM III-R diagnoses that cause the recipient’s inability to
use a removable denture
 An explanation of the reason the recipient is unable to use a removable denture
The specific treatment plan and the long-range prognosis for the remaining dentition
D6205
Pontic — Indirect Resin Based Composite
D6210
Pontic — cast high noble metal
D6211
Pontic — cast predominantly base metal
D6212
Pontic — cast noble metal
D6214
Pontic — Titanium
D6240
D6241
Pontic — porcelain fused to high noble metal
Pontic — porcelain fused to predominantly base metal
D6242
D6245
D6250
D6251
D6252
D6253
Pontic — porcelain fused to noble metal
Pontic — porcelain/ceramic
Pontic — resin with high noble metal
Pontic — resin with predominantly base metal
Pontic — resin with noble metal
Pontic — provisional
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Fixed Partial Denture Retainers — Crowns
Authorization is required for fixed dentures (that are cost-effective) for persons who are unable to use removable dentures
because of their medical condition.
Replacement of damaged fixed denture for individuals who are unable to use a removable denture due to a medical condition
requires authorization.
Requests for authorization for fixed denture must be submitted with the following documentation:
 The recipient’s mental/physical condition including ICD-9-CM and DSM III-R diagnoses that cause the recipient’s inability to
use a removable denture
 An explanation of the reason the recipient is unable to use a removable denture
The specific treatment plan and the long-range prognosis for the remaining dentition
D6710
Crown — indirect resin based composite
D6720
Crown — resin with high noble metal
D6721
Crown — resin with predominantly base metal
D6722
Crown — resin with noble metal
D6740
Crown — porcelain/ceramic
D6750
Crown — porcelain fused to high noble metal
D6751
Crown — porcelain fused to predominantly base metal
D6752
Crown — porcelain fused to noble metal
D6780
Crown — 3/4 cast high noble metal
D6781
D6782
D6783
D6790
D6791
D6792
D6793
D6794
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Crown — 3/4 cast predominately based metal
Crown — 3/4 cast noble metal
Crown — 3/4 porcelain/ceramic
Crown — full cast high noble metal
Crown — full cast predominantly base metal
Crown — full cast noble metal
Crown — provisional retainer crown
Crown — titanium
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Oral Surgery
Authorization is always required
D7272
Tooth transplantation
D7283
D7290
D7291
D7490
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Placement of device to facilitate eruption of impacted tooth
Surgical repositioning of teeth
Transseptal fiberotomy
Radical resection of maxilla or mandible
Temporomandibular Joint (TMJ) Disorder
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Authorization is always required
D7880
D7899
D7953
Varied codes
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Occlusal orthotic appliance
Unspecified TMD therapy, by report
Bone replacement graft for ridge preservation —- per site
All TMJ splints.
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Orthodontic Treatment
Authorization is always required
The dentist must submit the following documentation when considering orthodontic care:
 Description of classification of occlusion (e.g., angle class, arch crowding or spacing, etc.)
 Functional problems (e.g., overbite, overjet, cross bites, etc.)
 Disfiguring characteristics (e.g., facial asymmetry, etc.)
 Contributing factors (e.g., missing teeth, impacted teeth, etc.)
 Specific treatment plan and appliances (enter the appropriate treatment code in the area labeled procedure number)
 Five intraoral photographs; upper and lower occlusal. Prints or mounted slides are acceptable. Include profile photos
 Appropriate radiographs (panorex or full mouth and cephalometric)
A separate letter may be included with additional information if desired. If the above information is not adequate, DHS may
request study models. Do not send models unless requested.
D8010
Limited orthodontic treatment of primary dentition
D8020
Limited orthodontic treatment of transitional dentition
D8030
Limited orthodontic treatment of adolescent dentition
D8040
Limited orthodontic treatment of adult dentition
D8050
Interceptive orthodontic treatment of primary dentition
D8060
Interceptive orthodontic treatment of transitional dentition
D8070
Comprehensive orthodontic treatment of transitional dentition
D8080
Comprehensive orthodontic treatment of adolescent dentition
D8090
Comprehensive orthodontic treatment of adult dentition
Rebonding or recementing; and/or repair, as required, of fixed retainers (authorize only if a limit of 2 per year will
D8691
be exceeded)
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