PA Lookup

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Limited to beneficiaries age 13 and older
• * Allowed one time in a 12-calendar month period (for example, a beneficiary

receiving bitewings on any date in January would be eligible for additional bitewings on any date the following January)

• * Any combination of D0220, D0230, D0270, D0272, D0273, or D0274

taken on the same date of service that exceeds the maximum allowed fee for D0210 is reimbursed at the same fee as D0210

• * Not allowed on same date of service as D0270, D0272, or D0274
• * Not allowed within the same 12 calendar month period as D0210, D0270,

D0272, or D0274

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Limited to beneficiaries age 13 and older
• * Allowed one time in a 12-calendar month period (for example, a beneficiary

receiving bitewings on any date in January would be eligible for additional bitewings on any date the following January)

• * Any combination of D0220, D0230, D0270, D0272, D0273, or D0274

taken on the same date of service that exceeds the maximum allowed fee for D0210 is reimbursed at the same fee as D0210

• * Not allowed on same date of service as D0270, D0272, or D0273
• * Not allowed within the same 12 calendar month period as D0210, D0270,

D0272, or D0273

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Limits

• * Allowed as part of the orthodontic records if the previous panoramic radiographic image is more than one year old
• * Once in a lifetime service as part of the orthodontic records * Not allowed on the same date of service as D0210

Exclusions

Not covered:

• a. Interceptive or Phase I treatment cases of the primary and transitional

dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;

• b. Minor tooth movement cases requiring a relatively short treatment period

(less than 12 months);

• c. Cuspid impactions with a poor prognosis of being brought down into

occlusion in the presence of no other significant problems;

• d. Bilateral or unilateral posterior crossbites of moderate severity without a

significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;

• e. Class I malocclusions with moderate crowding, no crossbites, overbite and

overjet within normal limits;

• f. Simple space closure of mild to moderate anterior spacing;
• g. Simple one arch treatment;
• h. Localized tooth alignment problems requiring a relatively short period of

treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);

• i. Orthodontic treatment begun prior to the patient becoming eligible for

Medicaid;

• j. Habit appliance therapy;
• k. Occlusal guard (including splint therapy for the treatment of

temporomandibular dysfunction); and

• l. Orthodontic treatment started as a private pay arrangement before Medicaid

approval is requested.

Age Group Details

• * Limited to beneficiaries age six and older

Additional Service Specifics

Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4B
• Records Management and Documentation Manual

Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Limits

• * Allowed as part of the orthodontic records if the previous panoramic radiographic image is more than one year old * Once in a lifetime service as part of the orthodontic records * Not allowed on the same date of service as D0210

Exclusions

Not covered:

• a. Interceptive or Phase I treatment cases of the primary and transitional

dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;

• b. Minor tooth movement cases requiring a relatively short treatment period

(less than 12 months);

• c. Cuspid impactions with a poor prognosis of being brought down into

occlusion in the presence of no other significant problems;

• d. Bilateral or unilateral posterior crossbites of moderate severity without a

significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;

• e. Class I malocclusions with moderate crowding, no crossbites, overbite and

overjet within normal limits;

• f. Simple space closure of mild to moderate anterior spacing;
• g. Simple one arch treatment;
• h. Localized tooth alignment problems requiring a relatively short period of

treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);

• i. Orthodontic treatment begun prior to the patient becoming eligible for

Medicaid;

• j. Habit appliance therapy;
• k. Occlusal guard (including splint therapy for the treatment of

temporomandibular dysfunction); and

• l. Orthodontic treatment started as a private pay arrangement before Medicaid

approval is requested.

Age Group Details

• * Limited to beneficiaries age six and oder

Additional Service Specifics

Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4B
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Limited to beneficiaries age six and older
• * Allowed one time in five years
• * Not allowed on the same date of service as D0210

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Limits

• * Once in a lifetime service

Exclusions

Not covered:

• a. Interceptive or Phase I treatment cases of the primary and transitional

dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;

• b. Minor tooth movement cases requiring a relatively short treatment period

(less than 12 months);

• c. Cuspid impactions with a poor prognosis of being brought down into

occlusion in the presence of no other significant problems;

• d. Bilateral or unilateral posterior crossbites of moderate severity without a

significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;

• e. Class I malocclusions with moderate crowding, no crossbites, overbite and

overjet within normal limits;

• f. Simple space closure of mild to moderate anterior spacing;
• g. Simple one arch treatment;
• h. Localized tooth alignment problems requiring a relatively short period of

treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);

• i. Orthodontic treatment begun prior to the patient becoming eligible for

Medicaid;

• j. Habit appliance therapy;
• k. Occlusal guard (including splint therapy for the treatment of

temporomandibular dysfunction); and

• l. Orthodontic treatment started as a private pay arrangement before Medicaid

approval is requested.

Age Group Details

• * Limited to beneficiaries under 21 years of age

Additional Service Specifics

Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4B
• Records Management and Documentation Manual

Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Limits

• * Once in a lifetime service

Exclusions

Not covered:

• a. Interceptive or Phase I treatment cases of the primary and transitional

dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;

• b. Minor tooth movement cases requiring a relatively short treatment period

(less than 12 months);

• c. Cuspid impactions with a poor prognosis of being brought down into

occlusion in the presence of no other significant problems;

• d. Bilateral or unilateral posterior crossbites of moderate severity without a

significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;

• e. Class I malocclusions with moderate crowding, no crossbites, overbite and

overjet within normal limits;

• f. Simple space closure of mild to moderate anterior spacing;
• g. Simple one arch treatment;
• h. Localized tooth alignment problems requiring a relatively short period of

treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);

• i. Orthodontic treatment begun prior to the patient becoming eligible for

Medicaid;

• j. Habit appliance therapy;
• k. Occlusal guard (including splint therapy for the treatment of

temporomandibular dysfunction); and

• l. Orthodontic treatment started as a private pay arrangement before Medicaid

approval is requested.

Additional Service Specifics

Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4B
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Limits

• * Once in a lifetime service

Exclusions

Not covered:

• a. Interceptive or Phase I treatment cases of the primary and transitional

dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;

• b. Minor tooth movement cases requiring a relatively short treatment period

(less than 12 months);

• c. Cuspid impactions with a poor prognosis of being brought down into

occlusion in the presence of no other significant problems;

• d. Bilateral or unilateral posterior crossbites of moderate severity without a

significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;

• e. Class I malocclusions with moderate crowding, no crossbites, overbite and

overjet within normal limits;

• f. Simple space closure of mild to moderate anterior spacing;
• g. Simple one arch treatment;
• h. Localized tooth alignment problems requiring a relatively short period of

treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);

• i. Orthodontic treatment begun prior to the patient becoming eligible for

Medicaid;

• j. Habit appliance therapy;
• k. Occlusal guard (including splint therapy for the treatment of

temporomandibular dysfunction); and

• l. Orthodontic treatment started as a private pay arrangement before Medicaid

approval is requested.

Age Group Details

• * Limited to beneficiaries under 21 years of age

Additional Service Specifics

Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4B
• Records Management and Documentation Manual

Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Limits

• * Once in a lifetime service
• * Study models must be properly occluded and trimmed with markings that identify the beneficiary’s accurate occlusion
• * Print the NC DHHS Prior Approval Health Services Attachment Review Cover Sheet to include in the mailing package with the study models

Exclusions

Not covered:

• a. Interceptive or Phase I treatment cases of the primary and transitional

dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;

• b. Minor tooth movement cases requiring a relatively short treatment period

(less than 12 months);

• c. Cuspid impactions with a poor prognosis of being brought down into

occlusion in the presence of no other significant problems;

• d. Bilateral or unilateral posterior crossbites of moderate severity without a

significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;

• e. Class I malocclusions with moderate crowding, no crossbites, overbite and

overjet within normal limits;

• f. Simple space closure of mild to moderate anterior spacing;
• g. Simple one arch treatment;
• h. Localized tooth alignment problems requiring a relatively short period of

treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);

• i. Orthodontic treatment begun prior to the patient becoming eligible for

Medicaid;

• j. Habit appliance therapy;
• k. Occlusal guard (including splint therapy for the treatment of

temporomandibular dysfunction); and

• l. Orthodontic treatment started as a private pay arrangement before Medicaid

approval is requested.

Age Group Details

• * Limited to beneficiaries under 21 years of age

Additional Service Specifics

Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4B
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Limited to beneficiaries age 13 and older

Exclusions

Allowed once per beneficiary per six calendar month period for the same provider. Dental prophylaxis is not allowed on the same date of service as a periodontal procedure for the same beneficiary.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Limited to beneficiaries under 13 years of age

Exclusions

Allowed once per beneficiary per six calendar month period for the same provider. Dental prophylaxis is not allowed on the same date of service as a periodontal procedure for the same beneficiary.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Limited to beneficiaries under 21 years of age
• * Procedure code D1206 must be billed on the detail line before D0145

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Physician fluoride varnish services are defined as preventive procedures provided by or under the supervision of a physician. This includes caries screening, recording of notable findings in the oral cavity, preventive oral health and dietary counseling, and administration of topical fluoride varnish. Such services shall maintain a high standard of quality and shall be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations hereinafter specified. Only the procedure codes listed in this policy are covered under the N.C. Medicaid Physician Fluoride Varnish Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Must be billed in conjunction with D0145.

Limited to beneficiaries under 3½ years of age.

Allowed once every 60 calendar days.

Limited to six times before the beneficiary reaches 3½ years of age.

D1206 must be billed on the detail line before D0145.

Reimbursement is allowed only when teeth are present and fluoride varnish is applied to the teeth.

Topical fluoride must be applied to all teeth erupted on the date of service.

The oral screening package may be provided at well-child checkups, during a sick visit, or at a separately scheduled visit.

Exclusions

Medicaid will not reimburse this procedure when teeth are not present or when fluoride varnish is not applied to the teeth.

Place of Service

The oral screening package is allowed in the physician’s office, health department clinics, Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), and the beneficiary’s residence.

Additional Service Specifics

D1206 - Topical application of fluoride varnish * replaced procedure code D1203 effective January 1, 2007 * must be billed in conjunction with D0145 * limited to beneficiaries under 3½ years of age * allowed once every 60 calendar days * limited to six times prior to the beneficiary reaching 3½ years of age * procedure code D1206 must be billed on the detail line before D0145

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-23
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Limited to beneficiaries under 21 years of age

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

• * Covered for permanent first and second molars for beneficiaries under 16

years of age

• * Covered for primary molars for beneficiaries under eight years of age (for

children age 8 through 20 years of age with special needs, refer to Subsection 5.3.13 for special approval requirements)

• * Teeth to be sealed must have pits and fissures that are susceptible to caries
• * Teeth to be sealed must be free of proximal caries and free of restorations on

the surface to be sealed

• * Teeth should be sealed after being identified at high risk for decay
• * Allowed once in a lifetime per tooth

Age Group Details

Covered for permanent first and second molars for beneficiaries under 16 years of age.

Covered for primary molars for beneficiaries under eight years of age.

For children age 8 through 20 years with special needs, primary molar sealants require reference to special approval requirements. Allowed once in a lifetime per tooth.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual

Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

∗ Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure ∗ Allowed for beneficiaries of all ages ∗ Allowed once every six calendar months per tooth (for example, a beneficiary seen for interim caries arresting medicament application – per tooth on any date in January would be eligible for the next interim caries arresting medicament application – per tooth on any date in July) ∗ Limited to a total of four applications per tooth ∗ Valid tooth numbers (A-T, 1-32) ∗ Recommended for beneficiary who is deemed to be at risk for progression of disease to pulpal infection ∗ Since the potential for staining of carious enamel and dentin exists, providers must obtain informed consent from the beneficiary’s parent or caregiver prior to rendering the service ∗ Reapplication of the caries arresting medicament at recall visits is only indicated if the carious lesions do not appear arrested ∗ Treated carious lesions can be restored after treatment with carious arresting medicament

• * Reimbursement is at 100 percent for the first tooth and cutback to 50 percent

for three additional teeth for a total of four teeth reimbursed per date of service (D1354 or D1355). If more than four teeth need treatment, all teeth should be treated (reimbursement of a total of four teeth constitutes payment of all affected teeth)

Age Group Details

Covered for permanent first and second molars for beneficiaries under 16 years of age.

Covered for primary molars for beneficiaries under eight years of age.

For children age 8 through 20 years with special needs, primary molar sealants require reference to special approval requirements. Allowed once in a lifetime per tooth.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 4A
• Records Management and Documentation Manual