Prior authorization required for Attachment A codes

Prior authorization (pre-service) or retrospective review is required for the CDT procedure codes listed in Attachment A; requests may be submitted electronically, by telephone, fax, or written request to UM or the Delegate and will be reviewed against the Health Plan's definition of Medically Necessary and applicable dental clinical criteria.

• Attachment A lists the specific CDT codes that require authorization or retrospective review.
• Requests may be submitted electronically, by phone, fax, or written request to UM/Delegate.

Anesthesia (D9222, D9239) may be prior authorized

D9222 (deep sedation/general anesthesia — first 15 minutes) and D9239 (IV moderate sedation — first 15 minutes) may be prior authorized when the submitted documentation meets one of the policy's listed clinical criteria (for example: multiple/impacted extractions, failed local anesthesia, excision of lesions >1.25 cm, or significant medical comorbidity).

• D9222/D9239 may be prior authorized; D9223/D9243 are retro-authorized with an anesthesia log.
• Submit a narrative of medical necessity and supporting clinical records per the anesthesia criteria.

Listed procedure codes require authorization or are subject to review

The policy identifies a set of procedure codes that either require prior authorization or are subject to retrospective review; these codes must be authorized or will be reviewed according to the code-specific Auth Reqd flags and documentation requirements.

• Codes such as D7511, D7520, D7521, D7871, D7962, D7970, D7999, D8080, D8210, D8220, D8680, D8703, D8704, D9223, D9243, D9248, D9930, D9947 are among those identified for authorization or review.
• Check the Procedure Codes and Eligibility Criteria section for each code's Auth Reqd, Req Docs, age, and frequency limits.

Prior authorization required for crown codes; submit x‑rays and narrative

Crown procedure codes flagged Auth Reqd = Yes (for example D2710, D2721, D2740, D2751, D2752, D2791) require prior authorization and must be supported by pre-operative radiographs and a narrative of medical necessity.

• Req Docs for crown codes: pre-operative x‑rays of adjacent and opposing teeth and a narrative of medical necessity.
• Period limits (e.g., 1 per tooth every 5 years) are shown on the code entries — obtain authorization where Auth Reqd = Yes to avoid denial.

Prior authorization required for specified major procedures with required docs

Many major procedures listed (for example posts/cores, selected endodontic, surgical root, excisions, selected periodontal and prosthetic codes) require prior authorization and must include the specified supporting documentation (pre‑operative radiographs, narratives of medical necessity, periodontal charting, pathology reports where applicable).

• Examples of codes requiring documentation: D2952/D2954 (posts & cores), D3310/D3320 (endodontics), D3471–D3503 (surgical root procedures), D7450–D7461 (lesion/tumor removal).
• Follow the 'Req Docs' column in the Procedure Codes and Eligibility Criteria for code‑specific required images/reports.

Codes flagged 'Auth Reqd = Yes' require prior authorization

Codes marked 'Auth Reqd = Yes' in the Procedure Codes and Eligibility Criteria tables must be authorized prior to service delivery; providers should obtain pre‑service authorization to comply with the policy.

• The Procedure Codes and Eligibility Criteria include an Auth Reqd flag (Yes/No) for each code.
• If Auth Reqd = Yes, prior authorization is required before the service is rendered.

Submit sufficient clinical information and consultant findings when requested

Providers must submit sufficient clinical information and consultant findings when requested; lack of medically necessary information or consultant findings may prompt a request for additional information and delay or denial per UM procedures.

• If information submitted is insufficient, UM/Delegate staff will request additional information; lack of consultant findings or medically necessary details triggers this process.
• Written or faxed documentation received for requests is stored in the document imaging system and handled per PHI policies.

General documentation required (radiographs, narratives, perio charting, pathology)

Required documentation varies by service but commonly includes pre‑operative or periapical radiographs (showing root and crown), panoramic or full‑mouth radiographs for abutments, periodontal charting, narratives of medical necessity, pathology reports, and photos where specified.

• Endodontic codes (e.g., D3310/D3320) require pre‑operative x‑rays excluding bitewings and a narrative of medical necessity.
• Surgical and oral surgery codes require pre‑operative x‑rays (excluding bitewings in many cases) and narrative or pathology report as applicable.

Attachment C lists procedure-level authorization, age, frequency, and reporting requirements

Attachment C (Procedure Codes and Eligibility Criteria) lists code‑level authorization flags, age ranges, maximum counts, period lengths, and reporting requirements (Reporting Require- N/T/Q) that providers must follow when submitting requests.

• Reporting Require- = T indicates tooth‑level supporting information is expected; Q indicates quadrant reporting.
• Check Attachment C for each code's Age Min/Max, Max Count and Period Type before submitting an authorization request.

Required documentation for crowns: pre‑op radiographs and narrative

For crown codes flagged Auth Reqd = Yes, providers must include pre‑operative radiographs of adjacent and opposing teeth and a narrative of medical necessity with the authorization request.

• Each crown code's 'Req Docs' column specifies 'Pre‑operative x‑rays of adjacent teeth and opposing' and 'Narrative of medical necessity.'
• Failure to include these documents where required may result in denial or delay.

Reporting required for selected restorations (Reporting Require- = T)

Selected restorative and crown‑related recementation codes list Reporting Require- = T, indicating that tooth‑level supporting information must be provided when requested.

• Examples include D2910, D2915, D2920/D2930 entries showing Reporting Require- = T for selected recement/recementation procedures.
• Provide the tooth‑level details (tooth number, narrative) when reporting is required.

Required supporting documentation (specific imaging, narratives, perio charts, pathology)

Required supporting documentation for many major procedures includes pre‑operative radiographs (excluding bitewings for certain endodontic and surgical codes), a narrative of medical necessity, periodontal charting, and pathology reports where applicable.

• Endodontic codes D3310/D3320: pre‑operative x‑rays excluding bitewings and narrative of medical necessity are required.
• Excision/tumor codes D7450–D7461: copy of pathology report is required.

Code‑specific clinical documentation must be supplied per Attachment C

Clinical documentation requirements vary by code and can include pre‑operative x‑rays (often excluding bitewings), narrative of medical necessity, and copies of pathology reports; follow each code's 'Req Docs' entry in Attachment C.

• Check the 'Req Docs' field for each code in the Procedure Codes and Eligibility Criteria before submitting the authorization request.
• Missing required clinical documentation may cause denial or request for additional information.

Orthodontic authorizations require Salzmann form and panoramic/cephalometric x‑ray

Orthodontic authorizations require a completed Salzmann Criteria Index Form and panoramic and/or cephalometric x‑ray; D8210 and D8220 also require a narrative of medical necessity and other supporting items listed in the code entry.

• Salzmann Criteria Index score of 25 points or greater is required to support comprehensive orthodontic services.
• Provide diagnostic photos and the completed Salzmann form with the authorization request.

D9947 requires lab Rx and physician LOMN consistent with sleep study criteria

Custom sleep apnea appliance (D9947) authorization requires a laboratory prescription containing the participant name and a physician letter of medical necessity; the physician LOMN must document diagnosis G47.33 and meet the sleep study and face‑to‑face evaluation requirements in the clinical criteria.

• Physician LOMN within past 12 months must document diagnosis G47.33 and a face‑to‑face evaluation.
• Sleep study (polysomnogram or approved home test) must show AHI/RDI ≥ 5 and document PAP intolerance/contraindication if applicable.

Verify participant eligibility and provider participation before request

UM/Delegate staff must verify participant eligibility and provider participation with the Health Plan before processing requests; if eligibility or provider participation cannot be verified the request is denied per Policy #UM017P.

• Verification occurs at intake; inability to verify results in denial notification per denial notice policy.
• Providers should confirm participant eligibility and their participation status prior to submitting requests.

Denial risk for crowns if radiographs or clinical criteria are missing

Crown requests missing required radiographs or failing to meet the clinical criteria (for example: opposing tooth/abutment status, minimum 50% bone support, absence of active advanced periodontal disease, or structural destruction thresholds) risk denial.

• Clinical crown criteria include minimum 50% bone support and specific structural destruction thresholds by tooth type.
• Include pre‑operative x‑rays of adjacent and opposing teeth and a clear narrative of medical necessity to support authorization.

Denial risk for root canal therapy if required x‑rays or criteria are missing

Root canal therapy requests (D3310, D3320, D3330) that lack pre‑operative radiographs or do not meet criteria (minimum 50% bone support, absence of active advanced periodontal disease, closed apex, tooth crucial to arch/occlusion, and evidence of apical pathology or symptoms) are at risk for denial.

• Required documentation: pre‑operative x‑rays (excluding bitewings) and a narrative of medical necessity where applicable.
• Ensure the request demonstrates the tooth meets all listed clinical criteria (closed apex, essential to occlusion, etc.).

Denial risk for custom sleep apnea appliance without LOMN, eval, or sleep study

Custom sleep apnea appliance requests lacking a physician letter of medical necessity within 12 months documenting diagnosis G47.33, face‑to‑face physician evaluation, and qualifying sleep study (AHI/RDI ≥ 5) — plus documentation of PAP intolerance/contraindication when required — may be denied.

• Provide physician LOMN, sleep study results, and documentation of PAP intolerance/contraindication or non‑tolerance when applicable.
• D9947 also requires a lab prescription containing the participant name.

Claims for certain crowns may be denied without prior authorization

Claims for crown codes (e.g., D2710, D2721, D2740, D2751, D2752, D2791) may be denied if prior authorization is not obtained where Auth Reqd = Yes; providers should obtain pre‑service authorization per the code entries.

• Auth Reqd = Yes is indicated on the code rows in Attachment C; absence of pre‑auth can result in claim denial.
• Follow the procedure for submitting pre‑service authorization outlined in the Dental Authorization Review Process.

Failure to obtain prior authorization or required documentation may lead to denial

Services for many major procedures (for example D2952, D2954, D3310, D3320, D3471‑D3473, D3501‑D3503, D3921, D4210, D4341) are identified as requiring prior authorization; failure to obtain required authorization or to submit required documentation (pre‑op x‑rays, narratives, periodontal charting) may trigger denial.

• Review each code's 'Auth Reqd' and 'Req Docs' entries in Attachment C prior to providing the service.
• Submit complete supporting documentation with the authorization request to reduce risk of denial.

Impacted tooth removals (D7220‑D7240) require prior auth and pre‑op x‑rays

Procedures coded D7220, D7230, D7240 (impacted tooth removals) require prior authorization and pre‑operative x‑rays (excluding bitewings); failure to submit the required pre‑operative x‑rays and narrative may trigger denial.

• Req Docs for impacted tooth removals explicitly state pre‑operative x‑rays (excluding bitewings) and a narrative of medical necessity.
• Ensure radiographs document the impaction type and correlate with clinical symptoms when applicable.

Oral surgery and pathology codes require prior auth and specific documentation

Several oral surgery codes (for example D7250, D7260, D7280, D7320) require prior authorization and/or specific documentation (pre‑operative x‑rays, narratives, or pathology reports); missing these documents risks denial.

• D7250/D7260/D7280 require pre‑operative x‑rays or narratives as specified in their 'Req Docs' entries.
• Excision/tumor removal codes (D7450–D7461) require a copy of the pathology report.

Orthodontic and sedation codes require authorization and specific forms/narratives

Orthodontic (D8080, D8210, D8220, D8680, D8703/D8704) and sedation/behavior management codes often require authorization and specific forms, photos, or narratives; absence of the required Salzmann Criteria form, panoramic/cephalometric x‑rays, or narratives may lead to denial.

• D8080/D8210/D8220 entries specify required documentation such as Panorex/cephalometric x‑rays, 5–7 diagnostic photos, and the completed Salzmann Criteria Index Form.
• Behavior management and sedation codes have Auth Reqd flags; check each code's requirements before submitting.

Submit sufficient clinical records and consultant findings when requested; written/faxed docs are stored

If requested by UM/Delegate staff or Dental Reviewer, providers must submit sufficient clinical information, supporting x‑rays, consultant findings, or other records; written or faxed documentation will be stored in the document imaging system and handled per PHI policies.

• Lack of sufficient information (e.g., medically necessary details or consultant findings) will prompt a request for additional information.
• Providers may be contacted to supply missing documentation during review and denial processes.

Attachment C procedure‑level reporting and flags must be followed

Procedure‑level reporting requirements in Attachment C must be followed: the table indicates Auth Reqd, required documentation, Reporting Require- flags (N/T/Q), age limits, maximum counts, and period lengths that govern authorization and claims.

• Reporting Require- = T requires tooth‑level supporting information; Q requires quadrant reporting.
• Confirm the Age Min/Max, Max Count and Period Type before submitting authorizations or claims to ensure compliance.