CurrentExecutive Office of Health and Human ServicesPolicy N/A

Dental Services Coverage Manual — Dental services coverage for Rhode Island Medicaid

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Defines coverage, medical necessity criteria, provider billing rules, and scope of dental services for Rhode Island Medicaid Fee-For-Service recipients (with note that children born after May 1, 2000 may be covered under RIte Smiles managed care).

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDental Services Coverage Manual — Dental services coverage for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation (radiographs, probing depths, HLD scoring, or letters) when required for listed procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3.0manual version

May 2026version date

FFSprogram scope

<21

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

Dental Services Coverage Manual — Dental services coverage for Rhode Island Medicaid

Customize your policy alerts

Sign up for all Executive Office of Health and Human Services policy alerts

Know when Executive Office of Health and Human Services releases new policies or updates existing guidance.

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Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDental Services Coverage Manual — Dental services coverage for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation (radiographs, probing depths, HLD scoring, or letters) when required for listed procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3.0manual version

May 2026version date

FFSprogram scope

<21

Many codesPA requirement

Coverage and Medical Necessity

General coverage criteria

Covered when ALL of the following are met

Eligibility and inclusion: Recipient is eligible for Rhode Island Medicaid FFS or covered under EPSDT if under 21; services are included in the State Plan or definable under Section 1905(a); for children born after May 1, 2000 coverage may be through RIte Smiles managed care.

See RIte Smiles provider manuals for managed care recipients

Medical necessity: Service is medically necessary as defined by Medicaid (required for prevention, diagnosis, cure or treatment of a health‑related condition or to prevent a detrimental change in medical/mental health status); services must be provided in a cost‑effective manner.

Determinations are made by Medicaid staff, trained consultants, and designees; services denied by Medicare for lack of medical necessity are not reimbursable.

Billing and provider requirements: Providers must bill Medicaid at the same usual and customary rates charged to the public and must verify recipient eligibility prior to providing services; payments will not exceed Medicaid maximum reimbursement and retroactive eligibility billing is allowed under conditions.

Medicaid conducts pre‑payment and post‑payment reviews and is the final arbiter of medical necessity.

Medical Necessity Determination

Covered only when Medicaid determines services are medically necessary based on documentation and review by EOHHS staff/consultants.

Medicaid medical necessity determination: Service is required for prevention, diagnosis, cure or treatment of a health‑related condition or to prevent detrimental change in medical/mental health status and must be reasonable and necessary.

Determinations made case‑by‑case by EOHHS staff and consultants; provider recommendation is required but not determinative; Medicaid is final arbiter.

Documentation for review: Medical necessity determinations rely on submitted documentation (clinical findings, radiographs, treatment plans, and any requested records) to support the need and prognosis for the service.

Providers must submit requested documentation for utilization review and prior authorization when required.

Investigative/Experimental Exclusion

Procedures deemed investigational/experimental are not covered.

Investigational/experimental criteria: Service is not approved by the appropriate governmental regulatory body OR is the subject of Phase I/II clinical trials OR is furnished under an investigational/research protocol OR requires written informed consent acknowledging non‑standard nature of treatment.

Determination is based on demonstrated reliable evidence from authoritative peer‑reviewed literature and regulatory approvals.

Services included as part of total treatment (no separate fee)

The following services are considered part of total treatment and are included (no additional fee) when provided in conjunction with other services:

Included services (no separate fee): Alveolectomy (with extractions); Analgesia; Cardiac monitoring; Diagnostic cast construction (study models); Diagnostic photographs; Dietary counseling; Direct and indirect pulp capping; Dressing change; Electrosurgery; Equilibration of occlusion; File broken tooth; Local anesthesia; Medicated pulp chambers; Odontoplasty; Oral hygiene instruction; Periodontal charting/probing; Post extraction treatment for alveolitis; Pulp vitality tests; Special infection control procedures; Surgical procedure for isolation of tooth with rubber dam; Surgical splint construction; Surgical stent construction; Suture removal.

These items are included in the primary service fee and are not billable separately when performed as part of another covered service.

Therapeutic Services Covered

Therapeutic services covered when indicated:

Therapeutic services covered: Pulp therapy of permanent and primary teeth (restricted to recipients under 21 years of age); restorations of primary and permanent teeth using amalgam, composite, stainless steel or polycarboxylate; subgingival scaling and curettage; a removable prosthesis when masticatory function is impaired (e.g., fewer than six opposing teeth).

Coverage for pulp therapy is age‑restricted; other therapeutic services are subject to clinical indications and documentation.

Non-covered Services

Services not covered except if medically necessary for patients under 21:

Non‑covered categories: Crowns (ceramco, gold, other full cast, porcelain fused to metal); crowns for premolars and molars; desensitization; extensive periodontal surgery; fixed bridges; implants; occlusal equilibration; root canal therapy for premolars and molars.

Procedure codes not listed in the Medicaid Dental Fee Schedule are not covered; exceptions may be made if medically necessary for recipients under age 21 and require documentation/PA per Fee Schedule rules.

Emergency Services Coverage

Emergency services coverage rule:

Emergency coverage: Emergency services to control hemorrhage, relieve pain, and/or eliminate acute infection (including immediate treatment of injuries to dentition and supporting structures) are covered; emergency rule applies only to covered services and does not extend coverage to services that are not otherwise covered.

Routine treatment of incipient decay is not considered emergency care.

Medical necessity and frequency criteria

Covered when documentation supports medical necessity and frequency limits are met

General medical necessity standard: Service must be reasonable and necessary to protect life, prevent significant illness or disability, or alleviate severe pain.

Applies to adult medical necessity determinations.

Radiograph frequency limits: Intraoral complete series (D0210) and panoramic radiograph (D0330) are allowed once every 1460 days (four years); bitewing radiographs (D0270–D0274) are allowed once per calendar year with per‑day and per‑provider/location combination limits; total payment for periapical/intraoral radiographs cannot exceed D0210 rate.D0210/D0330: once/1460 days; D027x: once/calendar year

Findings and tooth numbers must be recorded for specified radiographs; payment may be denied if excessive.

Exams frequency limits: Comprehensive oral evaluation (D0150) limited to one lifetime per provider/location; periodic exams (D0120) allowed twice per calendar year.D0150: one lifetime; D0120: twice/year

Topical fluoride (D1206, D1208)

Topical fluoride coverage rules

Fluoride for recipients <21: Topical fluoride (D1206, D1208) is allowed twice every calendar year for recipients less than 21 years of age; fluoride must be applied separately from prophylaxis paste.Twice per year

Caries risk assessment must be completed one time per year.

Fluoride for adults with qualifying conditions: For recipients 21 years and older, topical fluoride is covered only when the recipient has medical or dental conditions that significantly interrupt saliva flow and create high caries risk (examples include radiation therapy, tumors, certain drug treatments); when used solely as a preventive measure for adults, topical fluoride is not covered.Clinical indication (high caries risk)

A caries risk assessment code denoting high risk must be listed on claims for adult fluoride and billed at $0.

Sealants (D1351)

Sealant coverage rules

Sealant eligibility and limits: Sealants (D1351) are covered only for permanent molars for patients less than 21 years of age; one treatment per tooth every five years; occlusal surface must be reported on the claim; payment not allowed when an occlusal restoration exists and not allowed on teeth #1, 16, 17, 32.Age <21; once per tooth every 5 years

Authorization is not required for D1351.

Space maintenance

Space maintenance coverage rules

Space maintenance criteria: Space maintenance services (fixed and removable) are limited to recipients under 21 years of age; radiographs and documentation of need are required; recementation/rebonding codes are available and subject to limitations.Age <21

Space maintainers will not be replaced if lost or damaged; providers should assess abutment health by radiographs.

Radiographs

Radiograph coverage and frequency

Payment cap for intraoral radiographs: Total payment for periapical and/or other intraoral radiographs cannot exceed the payment for a complete intraoral series (D0210); combinations exceeding FMX maximum will be reimbursed at the D0210 rate.Payment cap applies

Documentation of variation from ADA guidelines must be kept in the patient record.

Periapical and bitewing limits: Periapical (D0220/D0230) and bitewing (D0270–D0274) have specified per‑day and per‑calendar‑year limits (e.g., two bitewings per calendar year per provider/location; one per day per patient limits apply); tooth number and findings must be recorded where required.Varies by code

D0274 cannot be performed with D0272 on the same day.

Panoramic/cephalometric and additional imaging: Panoramic radiograph (D0330) is limited to once every 1460 days (four years); cephalometric (D0340) has age and specialty limits; selected additional imaging codes (D0310–D0322) may require prior authorization and may be billed via the medical carrier.

Restorative services

Restorative services policy notes

Replacement restoration timing and limits: The program will not pay for composite or amalgam restorations replaced within one year of completion of the original restoration when replaced by the same provider or dental group; initial payment includes replacements due to defects or failure within one year.1 year

Benefit limitations specify one restoration per tooth/surface per calendar year for many codes.

Resin-based restoration medical necessity

Resin-based restorations are covered when used to restore damage from decay, trauma, or pathology and when not purely esthetic

Resin-based restoration medical necessity: Resin restorations must address damage from caries, trauma, or other pathology and not be used to replace tooth structure lost due to wear or for purely esthetic purposes (e.g., closing diastemas, improving color); tooth preparation, acid etching, and adhesives are included in the restoration; pins reported separately.

Removal/replacement of non‑carious amalgam for esthetic or perceived health benefit is not covered.

Pulpotomy (D3220)

Pulpotomy coverage rules

Pulpotomy coverage criteria: Therapeutic pulpotomy (D3220) is allowed for calcium hydroxide pulpotomy on permanent teeth with vital exposed pulps and incompletely formed root apices, and formocresol pulpotomy on deciduous teeth; includes removal of pulp coronal to the dentinocemental junction and application of medicament.

Recipients limited to one pulpotomy per deciduous tooth per lifetime; D3220 age limitation <21 and cannot be billed in conjunction with root canal therapy codes.

Therapeutic pulpotomy

Pulpotomy (D3220) is allowed when ALL of the following are met

Therapeutic pulpotomy (D3220) - required conditions: 1) Procedure is calcium hydroxide pulpotomy on a permanent tooth with vital exposed pulp and incompletely formed root apex, or formocresol pulpotomy on a deciduous tooth; 2) Procedure consists of removal of coronal pulp and application of medicament; 3) Recipient age <21; 4) Teeth 1–32 and A–T are eligible; 5) Cannot be billed with root canal therapy (D3310, D3320, D3330); 6) One pulpotomy per deciduous tooth per lifetime.

D3220 excludes final restoration billing; authorization is not required for listed D3220 indications.

Root canal therapy

Root canal therapy codes are covered when ALL of the following are met

Root canal therapy coverage criteria: 1) Limited to one procedure per tooth per recipient per lifetime; 2) Generally limited to permanent teeth (exceptions when no permanent successor or for certain primary second molars); 3) Treatment must lead to a favorable prognosis; 4) Age and tooth‑type specific limitations apply (e.g., D3310 anterior teeth, D3320 premolars with age limits); 5) Codes exclude final restoration billing.

Authorization is not required for listed root canal codes but clinical justification and prognosis must be documented.

Apexification/Recalcification

Apexification/Recalcification is covered when ALL of the following are met

Apexification/Recalcification coverage: 1) Limited to permanent teeth only; 2) Recipient must be under age 21; 3) Limited to a maximum of five treatments (D3351, D3352, D3353); 4) No authorization required for listed codes.Maximum=5 treatments

Documentation of clinical indication required.

Periodontal scaling and root planing

Periodontal scaling/root planing (D4341/D4342) is covered when ALL of the following are met

Clinical documentation: Full‑mouth periodontal charting indicating abnormal pocket depths in multiple sites and probing depths of 5 mm or greater are required.Pockets >= 5 mm

Prior authorization for adults requires submission of full‑mouth probing depths and intraoral radiographs (recent bitewings and FMX or panorex within five years).

Radiographic evidence and prognosis: At least one of radiographic evidence of root‑surface calculus or radiographic evidence of noticeable loss of bone support must be present and a favorable long‑term prognosis documented.

Frequency limits apply and the procedure is therapeutic, not prophylactic.

Frequency and limits: D4341/D4342 allowed once every 3 years per quadrant; limits on number per day/provider/location apply (e.g., two codes per visit expected when indicated).Once per 3 years per quadrant

D4346 - scaling in presence of inflammation

Coverage notes for scaling in presence of inflammation (D4346)

D4346 coverage: D4346 is a full‑mouth additional cleaning for generalized moderate or severe gingival inflammation; limited to once every two years; may be performed without prior authorization when D4341/D4342 are denied due to lack of radiographic root surface calculus or infrabony pocketing, provided medical necessity is met.Once every 2 years

Local anesthetic may be used; not payable in conjunction with certain prophylaxis or gingivectomy codes on same date.

Periodontal maintenance

Maintenance and miscellaneous periodontal services

Periodontal maintenance (D4910): D4910 is allowed only for recipients under age 21 and is allowed once every six months after D4341; it will not be paid during the 6‑month period immediately following D4341.6 months

Unspecified periodontal procedures (D4999) require authorization and documentation.

Removable prosthodontics

Removable prosthodontics is covered when ALL of the following are met

Removable prosthodontics coverage: Limited to replacement of permanent teeth; radiographs are required to assess abutment health; partial denture construction paid only if there are two or more missing posterior teeth on a side (excluding second/third molars) or one or more missing anterior teeth with sound remaining dentition and good prognosis.

Recipients allowed one set of partial and/or complete dentures during an 1825‑day (5‑year) period from any provider.

Partial/Complete Denture Coverage

Covered when ALL of the following are met

Partial/Complete denture coverage criteria: Removable prosthodontics limited to replacement of permanent teeth; partial dentures require documentation that two or more posterior teeth are missing on a side (excluding second/third molars) or one or more missing anterior teeth with remaining dentition sound; radiographs required and providers must assess abutment prognosis.One set per 1825 days

One set of partial and/or complete dentures allowed per 1825 days (5 years).

Timing and Frequency Limits for Adjustments/Repairs/Rebases/Relines

Service-specific limitations and timing

Adjustments/repairs/rebases/relines timing: Adjustments, repairs, relines and rebases are included in the denture fee within the first 183 days (6 months) after delivery; after the initial 6 months, two adjustments per calendar year are covered; relines allowed once per 12 months as deemed medically necessary; rebases allowed once every 24 months; dentures will not be replaced if lost or damaged for 5 years except in extenuating circumstances with prior authorization.6 months; reline once/12 months; rebase once/24 months

Some repair codes have per‑year limits (e.g., D5520 up to three per 12 months).

Immediate Dentures

Immediate denture policy

Immediate denture provisions: Immediate dentures are allowed but selection should be judicious because a comparable traditional denture will not be covered within 60 months after immediate denture delivery; adjustments and relines are included in the first 6 months; immediate denture codes (D5130/D5140/D5221/D5222) are one per lifetime per member for those codes.One per lifetime for specified immediate codes

Delivery of an immediate denture triggers the 5‑year replacement limitation for conventional dentures.

Service-specific coverage criteria

Coverage and limitations summarized by service type

Denture fabrication and FQHC billing: Providers may bill specified numbers of fabrication encounters for dentures (e.g., complete denture up to 5 encounters; single partial up to 3; upper and lower partial up to 4); appliance D‑codes must be billed once on delivery date and fabrication encounters for FQHCs use D0999 with notation.

Claims for dentures must use date of delivery as date of service; failure may result in recoupment.

Implant services exclusion: Implant services are not a covered service.

Explicit exclusion in fee schedule.

Fixed prosthodontics limitations: Permanent bridges are allowed for anterior permanent teeth only and recipients must be less than 21 years of age; consult RIteSmiles manual for under‑21 policies.Age <21 for fixed bridges

Greater than four units or combined anterior/posterior tooth loss generally requires a partial denture approach.

Medically Necessary Orthodontic Treatment

Orthodontic services are covered when ALL of the following are met:

Orthodontic coverage criteria: 1) Recipient is under age 21 (continuation rules may apply for work initiated prior to the 21st birthday); 2) There is medically necessary handicapping malocclusion as determined by the HLD (RI Mod) Index applied by board‑qualified orthodontic consultants; 3) Prior authorization is submitted with required records and documentation demonstrating favorable prognosis and likely patient compliance.

Comprehensive orthodontic treatment codes require PA and age/unit restrictions apply (units may continue to <23 under conditions).

Frenectomy — coverage criteria

Frenectomy and related soft-tissue procedures are covered when performed for dental indications:

Frenectomy — coverage criteria: Frenectomy (buccal/labial D7961 or lingual D7962) may be performed when the frenum limits tongue mobility, causes a large diastema between teeth, interferes with a prosthetic appliance, or is the etiology of periodontal tissue disease.

When performed on an infant for breastfeeding purposes the procedure is considered a medical benefit (not dental).

Part A: Automatic severe handicapping conditions

Covered when ANY of the following Part A conditions exist, otherwise Part B scoring applies:

Part A automatic qualifiers: Presence of any listed Part A conditions (e.g., cleft palate deformities; impacted anterior teeth not indicated for extraction and planned to be brought into occlusion; deep impinging overbite with tissue damage; anterior crossbite with tissue destruction; overjet >9 mm; reverse overjet >3.5 mm) qualifies as severe handicapping malocclusion and authorizes orthodontic treatment.

Photographic documentation required for tissue‑damage criteria.

Part B: Numeric HLD Index criteria

If no Part A condition qualifies, covered when ALL of the following Part B scoring criteria are met:

Part B numeric HLD Index criteria: Complete Part B items (7–13) on the HLD index, calculate total score. A total score of 26 or more qualifies for authorization.>=26

Do not score both anterior crowding and ectopic eruption for the same condition; photographic and radiographic support required.

Comprehensive orthodontic treatment coverage

Comprehensive orthodontic coverage conditions

Comprehensive treatment definition and limits: Comprehensive orthodontic treatment involves placement of bands or bonded brackets for at least a two‑year period to achieve proper occlusion; treatment ends when adult dentition (except third molars) is in proper occlusion. Adjunctive appliances may require separate PA and payment processed when appliance provided.

Units and age restrictions (e.g., <21 general; continuation rules for >20 with PA) apply to comprehensive codes.

Anesthesia and sedation coverage criteria

Anesthesia and sedation coverage conditions

Anesthesia eligibility: General anesthesia and IV sedation are limited to recipients under 21 and patients with special healthcare needs (including intellectual/developmental disability); anesthesia codes are payable in specified 15‑minute increments and anesthetic management is limited to one method per patient per day.

Providers must be able to submit a copy of their permit to administer anesthesia upon request.

Professional Consultation

Covered when used as intended:

Professional consultation (D9310): D9310 is covered when provided by a dentist or dental specialist other than the requesting provider to provide opinion or advice regarding evaluation/management of a specific problem and may initiate diagnostic or therapeutic services.

D9310 must not be used routinely by the treating dentist or in addition to routine exams (D0120, D0140, D0150).

House/Hospital Call Coverage

Covered with billing and limit conditions:

House/extended care facility calls (D9410): D9410 is covered for nursing home, long‑term care, hospice, institutions and mobile visits when billed with an appropriate CDT code for the service performed and when facility name/address is included on the claim; D9410 cannot be billed alone and is limited to a maximum of five visits per day per facility per provider.Maximum 5 visits/day/provider/facility

D0999 (non‑paying) should be used for interim denture fabrication steps; such billing is subject to post‑procedure review.

Hospital/ASC calls (D9420): D9420 is covered when providing treatment in a hospital or ambulatory surgical center and is reported in addition to appropriate procedure codes for the actual services performed.

Facility documentation requirements apply.

Drug and Miscellaneous Service Coverage

Covered drug and miscellaneous services with authorization rules:

Office‑administered drugs: D9610 (therapeutic parenteral drug, single administration) is covered without authorization; D9630 (drugs or medicaments dispensed in the office for home use) requires prior authorization.

Providers should follow authorization rules for D9630.

Miscellaneous services and authorization: D9910, D9930, and occlusal guard codes (D9944–D9946) are covered but generally require authorization; D9920 (behavior management) is covered without authorization but limited to one D9920 per provider per day and requires descriptive documentation.

Teledentistry codes D9995/D9996 are reported in addition to other procedures and have limitations on procedure codes used with teledentistry.

This manual contains multiple "Services Not Covered" and exclusion sections across diagnostic, preventive, restorative, prosthodontic, surgical, orthodontic and teledentistry topics; providers must consult the specific service sections below for detailed exclusions and applicability. Procedure codes not listed on the Medicaid Dental Fee Schedule are not covered and may be denied when submitted. Some categories are explicitly identified as non‑covered except when medically necessary for recipients under age 21 (examples include crowns, fixed bridges, implants and certain extensive periodontal or restorative procedures). See the radiographs, topical fluoride, sealant, amalgam/resin restoration, pulp therapy, prosthodontics and oral surgery sections below for specific rules and cross‑references to payment and documentation limits.

The manual also lists a set of procedures that are never considered emergencies (and therefore are not exempt from prior authorization or other non‑emergency rules). This list includes: appliances not related to immediate trauma, full or partial dentures, exostosis (tori) removal, flippers (stay plates), frenectomy/frenulectomy, gingivectomy/gingivoplasty, remake or repair of archwire, space maintainers, and tissue conditioning. Providers should not rely on an emergency exception to bypass PA or documentation requirements for these items.

The manual explicitly identifies certain procedures that are never considered emergency care and therefore are not exempt from prior authorization or standard coverage rules. Items on this list include appliances (unless related to immediate trauma/injury), dentures (full or partial), removal of exostoses (tori), flippers/stay plates, frenectomy/frenulectomy, gingivectomy/gingivoplasty, remake or repair of archwire, space maintainers, and tissue conditioning. Routine treatment of incipient decay is likewise not an emergency and will not qualify for emergency coverage.

Because these procedures are never emergency services, claims for them must meet the usual medical necessity, documentation, and authorization requirements described elsewhere in the manual; treating providers should not submit these codes expecting emergency exceptions to apply.

Procedure codes not listed on the Rhode Island Medicaid Dental Fee Schedule are not covered. In addition, the manual identifies broad categories of services that are excluded unless specifically deemed medically necessary for recipients under age 21. Examples include: crowns (ceramco, gold, full cast and porcelain‑fused‑to‑metal types), crowns for premolars and molars, fixed bridges, implants, occlusal equilibration, desensitization and root canal therapy for premolars and molars.

When clinical circumstances for a recipient under 21 meet the Medicaid medical necessity criteria, exceptional coverage may be considered — such cases require documentation and follow the prior authorization and evidence requirements set out in the applicable sections of this manual.

Radiograph policies limit frequency and combined imaging payments. A full intraoral series (D0210) and a panoramic radiograph (D0330) are each allowed once every 1,460 days (four years). Routine bitewing radiographs (D0270–D0274) are allowed once every calendar year with combination and per‑day limits (for example, D0274 cannot be performed with D0272 on the same day).

Payment for multiple periapical and/or other intraoral radiographs cannot exceed the payment for a complete intraoral series (D0210); any combination of radiographs that exceeds the FMX maximum will be reimbursed at the D0210 rate. Medicaid may deny payment if multiple radiographs of the same tooth/area are judged excessive. Periapical images require tooth numbers and documented findings in the record.

Topical fluoride codes (D1206, D1208) are allowed twice every calendar year for recipients under 21. For recipients aged 21 and older, topical fluoride is covered only when the patient has medical or dental conditions that significantly interrupt saliva flow and create a high caries risk (examples: radiation therapy, certain tumors, or medications associated with hyposalivation); when used solely as a preventive measure for adults 21+, topical fluoride is not covered. For adult topical fluoride claims, a caries risk assessment code denoting high risk must be listed on the claim.

Sealants (D1351) are covered only for permanent molars in patients younger than 21 years, limited to one treatment per tooth every five years. When billing for sealants, the occlusal surface must be reported on the claim form. Payment is not allowed when an occlusal restoration exists, and sealant payment is not permitted on teeth #1, 16, 17 or 32.

Providers must confirm tooth eligibility and the absence of occlusal restorations before billing sealant codes to avoid post‑payment review or denial.

The manual disallows replacement of non‑carious or non‑defective amalgam restorations for esthetic reasons or perceived health benefits. Specifically, removal and replacement of intact amalgam restorations with composite solely for esthetics or perceived benefit is not a covered benefit and is subject to post‑procedural review. In addition, resin‑based restorations may not be performed as a preventive procedure and may not be used to replace existing non‑carious amalgam restorations.

Resin restorations (composite) are covered only when restoring tooth structure lost to caries, trauma, or other pathology and must not be provided for purely esthetic concerns (e.g., closing diastemas, superficial color improvement) or to replace sound amalgam restorations.

Direct and indirect pulp capping are included in the restoration fee; no additional payment will be made for pulp capping procedures. Providers should not bill a separate code or expect separate reimbursement for direct or indirect pulp cap services provided in conjunction with a restoration.

When planning restorative and endodontic care, note that pulp capping is considered part of the restorative service and any billing must reflect that inclusion to avoid inappropriate separate payment.

Therapeutic pulpotomy (D3220) and root canal therapy codes exclude the final restoration from their reimbursement — the endodontic codes cover the endodontic procedure only and the final coronal restoration is billed separately. D3220 is allowed only for calcium hydroxide pulpotomy on permanent teeth with vital exposed pulps and incompletely formed apices or formocresol pulpotomy on deciduous teeth, and recipients are limited to one pulpotomy per deciduous tooth per lifetime. D3220 has an age limitation of 21 years and cannot be billed in conjunction with root canal therapy codes (D3310, D3320, D3330).

Root canal therapy (D3310/D3320/D3330) is limited to one procedure per tooth per recipient per lifetime, generally limited to permanent teeth and payable only when the treatment will lead to a favorable prognosis. Providers must bill the definitive restoration (crown/other) separately from endodontic codes, and applicable age and tooth‑type limitations for root canal codes must be observed.

CDT Codes, Frequency Limits, and Coding Rules

CDT referencemixed

No codes listed

Billing forms and code setmixed

CDT	Current Dental Terminology procedure codes used by Medicaid for dental claims
ADA 2019	ADA 2019 dental claim form required for paper submissions

Teledentistry documentation codesCPT

D9995	Synchronous teledentistry (documentation code, nonpaying)
D9996	Asynchronous teledentistry (documentation code, nonpaying)

Covered CDT Codes (selected)CPTCovered

D0120	Periodic oral evaluation
D0140	Limited oral evaluation — problem focused
D0145	Oral evaluation for a patient under the age of three years
D0150	Comprehensive oral evaluation — new or established patient
D0160	Detailed and extensive oral evaluation
D0180	Comprehensive periodontal evaluation — new or established patient
D0190	Screening of a patient
D0191	Assessment of a patient
D0210	Intraoral-complete series
D0220	Intraoral periapical — first radiographic image

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Intraoral and extraoral radiograph codesCPTCovered

D0210	Intraoral comprehensive series
D0220	Intraoral periapical — first radiographic image
D0230	Intraoral periapical — each additional radiographic
D0240	Intraoral occlusal radiographic
D0250	Extra-oral 2D projection radiographic image created using a stationary radiation source

Bitewing radiograph codesCPTCovered

D0270	Bitewing — single radiographic image
D0272	Bitewing — two radiographic images
D0273	Bitewing — three radiographic images
D0274	Bitewing — four radiographic images

Panoramic/cephalometric and additional imagingCPTCovered

D0330	Panoramic radiographic image
D0340	2D cephalometric radiographic image acquisition, measurement
D0310	Sialography
D0320	Temporomandibular joint arthrogram, including injection
D0321	Other temporomandibular joint radiographic images, by report
D0322	Tomographic survey

Tests and laboratory examinations (priced individually)CPT

D0502	Other oral pathology procedures, by report
D0999	Unspecified diagnostic procedure, by report

Caries risk assessment codes (non-paying)CPT

D0601	Caries risk assessment and documentation, finding of low risk
D0602	Caries risk assessment and documentation, finding of medium risk
D0603	Caries risk assessment and documentation, finding of high risk

Prophylaxis codesCPTCovered

D1110	Prophylaxis — adult
D1120	Prophylaxis — child

Topical fluoride codesCPTCovered

D1206	Topical application of fluoride varnish
D1208	Topical application of fluoride — excluding varnish

Sealants and caries-arresting material codesCPTCovered

D1351	Sealant — per tooth
D1354	Interim caries-arresting material application — per tooth

Space maintenance codesCPTCovered

D1510	Space maintainer — fixed, unilateral (per quadrant)
D1516	Space maintainer — fixed, bilateral, maxillary
D1517	Space maintainer — fixed, bilateral, mandibular
D1520	Space maintainer — removable, unilateral (per quadrant)
D1526	Space maintainer — removable, bilateral, maxillary
D1527	Space maintainer — removable, bilateral, mandibular
D1551	Re-cement or re-bond bilateral space maintainer — maxillary
D1552	Re-cement or re-bond bilateral space maintainer — mandibular
D1553	Re-cement or re-bond unilateral space maintainer — per quadrant
D1556	Removal of fixed bilateral space maintainer — per quadrant

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Amalgam procedure codesCPTCovered

D2140	Amalgam — one surface, primary or permanent
D2150	Amalgam — two surfaces, primary or permanent
D2160	Amalgam — three surfaces, primary or permanent
D2161	Amalgam — four or more surfaces, primary or permanent

Resin-based restorationsCPTCovered

D2330	Resin-based composite — one surface, anterior
D2331	Resin-based composite — two surfaces, anterior
D2332	Resin-based composite — three surfaces, anterior
D2335	Resin-based composite — four or more surfaces (anterior)
D2390	Resin-based composite crown, anterior
D2391	Resin-based composite — one surface, posterior
D2392	Resin-based composite — two surfaces, posterior
D2393	Resin-based composite — three surfaces, posterior
D2394	Resin-based composite — four or more surfaces, posterior

Crown and prefabricated crown codesCPTCovered

D2710	Crown — resin-based composite (indirect)
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
D2790	Crown — full cast high noble metal
D2791	Crown — full cast predominantly base metal

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Other restorative servicesCPTCovered

D2910	Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration
D2920	Re-cement or re-bond crown
D2950	Core buildup, including any pins when required
D2951	Pin retention — per tooth, in addition to restoration
D2952	Post and core in addition to
D2954	Prefabricated post and core in addition to crown
D2980	Crown repair, by report
D2999	Unspecified restorative procedure, by report

Endodontic codesCPTCovered

D3220	Therapeutic pulpotomy (excluding final restoration)
D3310	Endodontic therapy — anterior tooth (excluding final restoration)
D3320	Endodontic therapy — premolar tooth (excluding final restoration)
D3330	Endodontic therapy — molar tooth (excluding final restoration)

Pulp cappingmixedNot Covered

pulp capping (no separate code listed)

Direct and indirect pulp caps are included in the restoration fee; no additional payment will be made.

PulpotomyCPTCovered

D3220

Therapeutic pulpotomy (excluding final restoration)

Root canal therapyCPTCovered

D3310	Endodontic therapy — anterior tooth (excluding final restoration)
D3320	Endodontic therapy — premolar tooth (excluding final restoration)
D3330	Endodontic therapy — molar tooth (excluding final restoration)

Apexification/RecalcificationCPTCovered

D3351	Apexification/recalcification — initial visit
D3352	Apexification/recalcification — interim medication replacement
D3353	Apexification/recalcification — final visit

Apicoectomy/Periradicular servicesCPTCovered

D3421	Apicoectomy — premolar (first root)
D3425	Apicoectomy — molar (first root)
D3426	Apicoectomy — each additional root
D3430	Retrograde filling — per root
D3450	Root amputation — per root

Other endodontic proceduresCPT

D3920	Hemisection (including any root removal), not including root canal therapy
D3999	Unspecified endodontic procedure, by report

Periodontal servicesCPTCovered

D4210	Gingivectomy or gingivoplasty — four or more contiguous teeth per quadrant
D4211	Gingivectomy or gingivoplasty — one to three teeth per quadrant
D4322	Splint — intra-coronal natural teeth or prosthetic crowns
D4323	Splint — extra-coronal natural teeth or prosthetic crowns
D4341	Periodontal scaling and root planing — four or more teeth per quadrant
D4342	Periodontal scaling and root planing — one to three teeth per quadrant
D4346	Scaling in presence of inflammation — full mouth
D4355	Full mouth debridement to enable comprehensive periodontal diagnosis
D4381	Localized delivery of chemotherapeutic agents via controlled release vehicle
D4910	Periodontal maintenance

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Removable prosthodonticsmixedCovered

removable partial/complete dentures (no CPT listed)

Removable prosthodontics coverage rules for partial and complete dentures

Other periodontal servicesCPTCovered

D4910	Periodontal maintenance
D4999	Unspecified periodontal procedure, by report

Complete DenturesCPTCovered

D5110	Complete denture — maxillary
D5120	Complete denture — mandibular

Partial DenturesCPTCovered

D5211	Maxillary partial denture — resin base
D5212	Mandibular partial denture — resin base
D5213	Maxillary partial denture — cast metal framework with resin bases
D5214	Mandibular partial denture — cast metal framework with resin bases

Immediate DenturesCPTCovered

D5130	Immediate denture — maxillary
D5140	Immediate denture — mandibular
D5221	Immediate maxillary partial denture — resin base
D5222	Immediate mandibular partial denture — resin base

Denture AdjustmentsCPTCovered

D5410	Adjust complete denture — maxillary
D5411	Adjust complete denture — mandibular
D5421	Adjust partial denture — maxillary
D5422	Adjust partial denture — mandibular

Repairs to Complete DenturesCPTCovered

D5511	Repair broken complete denture base — mandibular
D5512	Repair broken complete denture base — maxillary
D5520	Replace missing or broken teeth — complete denture (each tooth)

Repairs to Partial DenturesCPTCovered

D5611	Repair resin denture base — mandibular
D5612	Repair resin denture base — maxillary
D5621	Repair cast partial framework — maxillary
D5622	Repair cast partial framework — mandibular
D5630	Repair or replace broken clasp
D5640	Replace broken teeth — per tooth
D5650	Add tooth to existing partial denture
D5660	Add clasp to existing partial denture

Denture Rebase ProceduresCPTCovered

D5710	Rebase complete maxillary denture
D5711	Rebase complete mandibular denture
D5720	Rebase maxillary partial denture
D5721	Rebase mandibular partial denture

Denture Reline ProceduresCPTCovered

D5730	Reline complete maxillary denture
D5731	Reline complete mandibular denture (direct)
D5740	Reline maxillary partial denture
D5741	Reline mandibular partial denture (direct)
D5750	Reline complete maxillary denture (indirect)
D5751	Reline complete mandibular denture (indirect)
D5760	Reline maxillary partial denture (indirect)
D5761	Reline mandibular partial denture

Other Removable Prosthetic ServicesCPTCovered

D5862	Precision attachment, by report
D5899	Unspecified prosthodontic removable procedure, by report

FQHC billing note (no codes listed)mixed

No codes listed

Other removable prosthetic services (continued)CDT

D5862	Precision attachment, by report
D5899	Unspecified prosthodontic removable procedure, by report

Denture fabrication encounter billingCDT

D0999

Unspecified diagnostic procedure, by report (used for fabrication encounters)

Implant servicesmixedNot Covered

No codes listed

Prior Authorization, Documentation & Billing Rules

Prior Authorization

Some services require prior authorization

Some services require prior authorization and certain services are reviewed by Medicaid; prior authorization details and lists of PA‑required codes are in the manual and provider instructions. Providers must follow the Medicaid dental PA process when a code is designated as “Authorization Required.”

Prior Authorization

PA required for certain procedures and all hospitalizations

Prior authorization is required for some dental procedures and is required for all inpatient or outpatient hospitalization except life‑threatening emergencies or traumatic injuries; PA requests must include clinical justification and the facility name. Providers remain responsible for verifying eligibility on the date of service.

Prior Authorization

PA effective date change (May 1, 2025)

Policy Scope and Context

Background: Rhode Island Medicaid reimburses services that meet its definition of medical necessity. For eligible recipients under age 21, EPSDT (Early and Periodic Screening, Diagnostic and Treatment) provisions may provide broader coverage of dental services when medically necessary. Medical necessity determinations are made by Medicaid staff and contracted consultants and require appropriate documentation; providers should verify eligibility and follow the manual's documentation and prior authorization requirements where applicable.

Definitions and Terms

Medical necessity definition

DefinitionMedical necessity: Services required for prevention, diagnosis, cure or treatment of a health-related condition or to prevent detrimental change in medical/mental health status

DeterminationMedicaid determines medical necessity; services must be provided in a cost-effective manner

ImplicationServices denied by Medicare as not medically necessary are not reimbursable by Medicaid

Emergency Services definition

DefinitionEmergency Services: covered services requiring immediate treatment to control hemorrhage, relieve pain, and/or eliminate acute infection; includes immediate treatment of injuries to dentition/supporting structures but excludes permanent restorations

ScopeEmergency rule applies only to covered services; routine treatment of incipient decay is not emergency care

Document Revision History

2010-12manual_created

Initial Dental Services Coverage Manual published (version 1.0).

2016-01revision

Version 1.1 recorded (sections N/A).

2016-02revision

Version 1.2 recorded (sections N/A).

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyDental Services Coverage Manual — Dental services coverage for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation (radiographs, probing depths, HLD scoring, or letters) when required for listed procedures.

SourceLink

On This Page

All exams require recording of findings and dentist signature.

D0330: once/1460 days

Additional imaging often requires authorization.

Not payable with certain prophylaxis or gingivectomy codes on same date.

Oral surgery clinical limits: Oral surgery procedures (e.g., tooth replantation, biopsies, excision of hyperplastic tissue) are covered only for specific clinical indications; removal of asymptomatic impacted teeth (D7240, D7241) is not covered; certain procedures for recipients 21+ have additional restrictions.

Narrative of medical necessity and full‑mouth documentation required for some surgical extractions.

Fixed partial denture pontics and retainers (crowns)CDTCovered

D6211	Pontic — cast predominantly base metal
D6212	Pontic — cast noble metal
D6240	Pontic — porcelain fused to high noble metal
D6241	Pontic — porcelain fused to predominantly base metal
D6242	Pontic — porcelain fused to noble metal
D6250	Pontic — resin with high noble metal
D6251	Pontic — resin with predominantly base metal
D6252	Pontic — resin with noble metal
D6720	Crown — resin with high noble metal
D6721	Crown — resin with predominantly base metal

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Other fixed partial denture servicesCDT

D6999

Unspecified, fixed prosthodontic procedure, by report

Oral surgery and other surgical proceduresCDTCovered

D7270	Tooth re-implantation and/or stabilization of accidentally avulsed or displaced tooth
D7285	Incisional biopsy of oral tissue — hard (bone, tooth)
D7286	Incisional biopsy of oral tissue — soft
D7111	Extraction — coronal remnants, primary tooth
D7140	Extraction — erupted tooth or exposed root (elevation and/or forceps removal)
D7210	Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth
D7220	Removal of impacted tooth — soft tissue
D7230	Removal of impacted tooth — partially bony
D7240	Removal of impacted tooth — (unspecified)
D7241	Removal of impacted tooth — completely bony, with unusual surgical complications

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Other surgical procedures (continued)CDTCovered

D7410	Excision of benign lesion up to 1.25 cm
D7411	Excision of benign lesion greater than 1.25 cm
D7471	Removal of lateral exostosis (maxilla or mandible)
D7510	Incision and drainage of abscess — intraoral soft tissue
D7520	Incision and drainage of abscess — extraoral soft tissue
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue
D7540	Removal of reaction-producing foreign bodies — musculoskeletal system
D7550	Partial ostectomy/sequestrectomy for removal of non-vital bone
D7560	Maxillary sinusotomy for removal of tooth fragment or foreign body
D7670	Alveolus — closed reduction, may include stabilization of teeth

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Other surgical and soft-tissue CDT codesmixedCovered

D7260	Oroantral fistula closure
D7261	Primary closure of a sinus perforation
D7270	Tooth re-implantation and/or stabilization of accidentally avulsed or displaced tooth
D7280	Exposure of an unerupted tooth
D7285	Incisional biopsy of oral tissue — hard (bone, tooth)
D7286	Incisional biopsy of oral tissue — soft
D7320	Alveoloplasty not in conjunction with extractions — four or more teeth or tooth spaces, per quadrant
D7340	Vestibuloplasty — ridge extension
D7350	Ridge extension (including soft tissue grafts)
D7410	Excision of benign lesion up to 1.25 cm

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Orthodontic CDT codes and related recordsmixedCovered

D8010	Limited orthodontic treatment — primary dentition
D8020	Limited orthodontic treatment — transitional dentition
D8030	Limited orthodontic treatment — adolescent dentition
D8040	Limited orthodontic treatment — adult dentition
D8070	Comprehensive orthodontic treatment — transitional
D8080	Comprehensive orthodontic treatment — adolescent
D8090	Comprehensive orthodontic treatment — adult
D8071	Comprehensive orthodontic treatment — 1st 6 months (transitional)
D8081	Comprehensive orthodontic treatment — 1st 6 months (adolescent)
D8091	Comprehensive orthodontic treatment — 1st 6 months (adult)

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Comprehensive orthodontic treatment codes and interval unitsCPTCovered

D8070	Comprehensive orthodontic treatment — transitional dentition
D8080	Comprehensive orthodontic treatment — adolescent dentition
D8090	Comprehensive orthodontic treatment — adult dentition
D8071	Comprehensive orthodontic treatment — 1st 6 months (transitional)
D8081	Comprehensive orthodontic treatment — 1st 6 months (adolescent)
D8091	Comprehensive orthodontic treatment — 1st 6 months (adult)
D8072	Comprehensive orthodontic treatment — 2nd 6 months
D8082	Comprehensive orthodontic treatment — 2nd 6 months
D8092	Comprehensive orthodontic treatment — 2nd 6 months
D8073	Comprehensive orthodontic treatment — 3rd 6 months

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Other orthodontic services and appliance codesCPTCovered

D8210	Removable appliance therapy / tongue guard
D8220	Fixed appliance therapy / tongue guard
D8020	Orthodontic headgear therapy
D8030	Minor tooth movement with Hawley appliance
D8060	Maxillary expansion appliance
D8680	Orthodontic tooth retainer
D8660	Pre-orthodontic treatment examination to monitor growth and development
D8670	Periodic orthodontic treatment visit
D8695	Removal of fixed orthodontic appliances for reasons other than completion
D8999	Unspecified orthodontic procedure, by report

Adjunctive general servicesCPTCovered

D9110

Palliative treatment of dental pain — per visit

Anesthesia and sedation codesCPTCovered

D9212	Trigeminal divisional block anesthesia
D9222	Deep sedation/general anesthesia — first 15 minutes
D9223	Deep sedation/general anesthesia — each subsequent 15-minute increment
D9230	Inhalation of nitrous oxide/analgesia, anxiolysis
D9239	IV moderate (conscious) sedation/analgesia — first 15 minutes
D9243	IV moderate (conscious) sedation/analgesia — each subsequent 15-minute increment

Professional consultation and mobile servicesCPTCovered

D9310	Consultation — diagnostic service by dentist or physician other than requesting provider
D9410	House call / extended care facility call
D9420	Hospital or ambulatory surgical center call
D0999	Non-paying code representing an interim denture step (referenced)

Professional ConsultationCPTCovered

D9310

Consultation — diagnostic service provided by dentist or physician other than requesting dentist or physician

House/Hospital Calls and related billingCPTCovered

D9410	House call / extended care facility call
D9420	Hospital or ambulatory surgical center call
D0999	Non-paying code representing an interim denture step

Drugs — drug codesCPTCovered

D9610	Therapeutic parenteral drug — single administration
D9630	Drugs or medicaments dispensed in the office for home use (authorization required)

Miscellaneous ServicesCPTCovered

D9910	Application of desensitizing medicament
D9920	Behavior management — by report
D9930	Treatment of complications (post-surgical) — unusual circumstances, by report
D9944	Occlusal guard — hard appliance, full arch
D9945	Occlusal guard — soft appliance, full arch
D9946	Occlusal guard — hard appliance
D9995	Teledentistry — synchronous; real-time encounter
D9996	Teledentistry — asynchronous; information stored and forwarded

Intraoral-complete series frequency

Allowed frequencyIntraoral-complete series (D0210) allowed once every 1460 days (4 years)

DocumentationFindings should be reported when D0210 is submitted

Payment cap noteTotal payment for periapical and/or other intraoral radiographs cannot exceed payment for a complete intraoral series (D0210)

Panoramic frequency

Allowed frequencyPanoramic radiographic image (D0330) limited to once every 1460 days (4 years)

Combination ruleMedicaid will not reimburse for both a full mouth series and panoramic radiograph in the same year

Additional imagingCertain additional imaging codes (e.g., cephalometric D0340) have separate age/PA rules and may require medical carrier billing

Bitewing frequency

Allowed frequencyBitewing radiographs (D0270–D0274) allowed once every calendar year per patient

Per-day limitOne of (D0270, D0272, D0273, D0274) per day per patient

Provider/location limitTwo of (D0270–D0274) per calendar year per provider or location

D0150 limit

LimitComprehensive oral evaluation (D0150) limited to one lifetime per provider or location

DocumentationD0150 requires review and analysis of concerns, clinical evaluation of intraoral and extraoral hard and soft tissues

Billing noteD0150 cannot be billed with certain other exams on same date by same provider or group

Intraoral complete series / panoramic frequency

Allowed frequencyFull intraoral series (D0210) or panoramic (D0330): once every 1460 days (4 years)

Payment capAny combination of intraoral radiographs exceeding FMX maximum reimbursed at the D0210 rate

DocumentationFindings should be reported for intraoral series submissions

Bitewing frequency

Allowed frequencyBitewing images (D0270–D0274): two per calendar year per provider/location; one per day per patient

Same-day restrictionD0274 cannot be performed with D0272 on the same day

Payment capCombinations exceeding FMX maximum reimbursed at D0210 rate

Restoration frequency limit

Per-tooth limitOne restoration (selected amalgam or resin-based codes) per tooth per calendar year (one per surface rule applies as listed)

Included itemsAdhesives, liners and bases are included in the restoration fee; pins reported separately (D2951)

Multisurface ruleRI Medicaid will not pay more than the multisurface rate for a restoration greater than one surface

Re-cementation frequency

Per-tooth frequencyRe-cementation of inlays and crowns (D2910 & D2920) allowed once per tooth per calendar year

Initial placement restrictionD2920 is not covered within 6 months of initial crown placement

DocumentationRe-cementation counts and limits apply per tooth; providers should document reason for re-cementation

Pulpotomy lifetime limit (deciduous)

Lifetime limitRecipients limited to one (1) pulpotomy per deciduous tooth per lifetime

Age and indicationD3220 limited to patients <21; allowed for calcium hydroxide pulpotomy on permanent teeth with incompletely formed apices and formocresol pulpotomy on deciduous teeth

Billing noteD3220 excludes final restoration and cannot be billed with root canal codes (D3310/D3320/D3330)

Periodontal pocket depth

Clinical thresholdPeriodontal scaling and root planing (D4341/D4342) require probing depths of 5 mm or greater

DocumentationPrior authorization requires full mouth probing depths and intraoral radiographs showing calculus or bone loss

FrequencyOne of D4341 or D4342 per patient per quadrant every 3 calendar years

Apexification treatment count

Maximum treatmentsApexification/Recalcification limited to a maximum of 5 treatments on permanent teeth

Age limitProcedures limited to recipients under age 21

CodesD3351 initial, D3352 interim medication replacement, D3353 final visit are covered

Immediate denture effect on replacement

Replacement impactPlacement of an immediate denture prevents coverage for replacement conventional dentures for 5 years from fabrication (1825 days)

Adjustment inclusionAdjustments, repairs, relines and rebases are included in the denture fee within the first 183 days (6 months) after delivery

Rebase/reline timingRebase allowed once every 24 months; reline allowed once per 12 months as medically necessary

Age limit for comprehensive orthodontic treatment

Age limit (general)Comprehensive orthodontic treatment codes generally limited to recipients < 21 years of age

Continuation ruleSubsequent 6-month units may be allowed up to < 23 if recipient >20 meets conditions: maintained Medicaid eligibility and PA approved and work initiated before 21st birthday

PA requirementComprehensive orthodontic procedure codes require prior authorization

HLD Index qualifying score

Qualifying scoreHLD Index total score of >= 26 qualifies for authorization under Part B

UseHLD (RI Mod) Index applied by board-qualified orthodontic consultants to determine medical necessity

DocumentationPhotographic and radiographic support required with PA submission

Reverse overjet threshold (Part A)

ThresholdReverse overjet (mandibular protrusion) > 3.5 mm is a Part A automatic severe qualifying condition

Measurement methodMeasured from labial of lower incisor to labial of upper incisor and rounded to nearest millimeter

DocumentationIndicate an 'X' on the HLD score sheet and provide photographic documentation when tissue destruction present

Overjet threshold (Part A severe)

ThresholdOverjet > 9 mm (measured in centric relationship) is recorded as Part A severe and automatically qualifies

MeasurementRecord the greatest distance between an upper central incisor and corresponding lower incisor in millimeters

DocumentationPhotographic documentation required for tissue-damage criteria

Mobile visit limit (D9410)

Daily visit capD9410 (house/extended care facility call) limited to a maximum of five visits per day per facility per provider

Billing requirementD9410 must be billed with a CDT code indicating a service provided and cannot be billed alone; facility name/address required on claim

Denture-related noteMobile providers should use non-paying code D0999 for interim denture steps; subject to post-procedure review

Age limit for selected services

Age limitD9910, D9944, D9945, D9946 are limited to recipients < 21 years of age

AuthorizationD9910 requires authorization (per code table) and D9944–D9946 require authorization prior to payment

DocumentationD9920 (behavior management) requires descriptive documentation of illness/disability and services provided

Effective May 1, 2025, authorized dates for dental prior authorizations will begin the date the dental PA is reviewed and finalized by the dental consultant; providers should no longer include a date range on the PA form and must request retroactive dates on the PA form when needed.

Prior Authorization

Restricted or potentially prior‑authorized services

Certain services are restricted or require PA—e.g., pulp therapy is restricted to recipients under age 21, and many procedures listed as not covered (crowns, implants, root canal therapy for premolars/molars) are only allowable with medical necessity and may require prior authorization.

Documentation Required

Authorization and frequency limits on specific codes

Some codes have explicit benefit limitations and frequency restrictions — for example D0150 (comprehensive oral evaluation) is limited to one lifetime per provider/location and D0210/D0330 (full mouth/panoramic) are limited to once every 1,460 days (four years).

Prior Authorization

PA required for select additional imaging

Selected additional imaging procedures (D0310, D0320, D0321, D0322) require prior authorization and are anticipated to be billed via the medical carrier using CPT codes.

Prior Authorization

Authorization required for D2390

D2390 (resin‑based composite crown, anterior) requires authorization for full resin‑based composite coverage; D2390 is age‑limited (<21) per the code table.

Prior Authorization

PA and required documentation for D4341/D4342

Prior authorization is required for scaling and root planing (D4341/D4342) for adults; PA submissions must include full‑mouth probing depths and intraoral radiographs (recent bitewings and FMX or panorex within five years) documenting pocketing, calculus, and prognosis.

Prior Authorization

Authorization required for D3999

D3999 (unspecified endodontic procedure, by report) is marked as authorization required and must be submitted with supporting documentation as a 'by report' procedure.

Prior Authorization

Authorization required for unspecified/precision prosthodontics

Certain unspecified or precision prosthodontic procedures (e.g., D4999, D5862, D5899) are authorization required and must be submitted by report with supporting documentation when indicated.

Prior Authorization

PA required to add >4 teeth to partial denture (D5650)

Adding more than four teeth to an existing partial denture (D5650) requires prior authorization; PA requests must include a letter and available radiographs documenting the need.

Prior Authorization

PA required for specific prosthodontic codes

Several prosthodontic codes (for example D5862 precision attachment and D6999 unspecified fixed prosthodontic procedure) require prior authorization per the code tables and must be submitted with documentation when requested.

Prior Authorization

Prior authorization required for listed procedures

A broad set of listed procedures—including many oral surgery, limited and comprehensive orthodontic codes—require prior authorization as indicated in the code tables; comprehensive orthodontic units require PA.

Prior Authorization

PA for comprehensive orthodontics and appliances

Comprehensive orthodontic procedure codes and most orthodontic appliances require prior authorization; units and age limits (generally <21; some subsequent units may allow <23 under conditions) determine PA applicability.

Prior Authorization

PA for minor habit‑control and unspecified orthodontic procedures

Minor habit‑control therapies and unspecified orthodontic procedures (e.g., D8210, D8220, D8999) require authorization when provided for recipients under the stated age limits.

Prior Authorization

D9630 requires authorization

D9630 (drugs or medicaments dispensed in the office for home use) requires authorization prior to payment.

Prior Authorization

Authorization required for select miscellaneous services

Select miscellaneous services require authorization prior to payment—specifically D9910, D9930, and occlusal guard codes D9944–D9946 are authorization required per the code table.

Documentation Required

Minimize visits and document individualized treatment plan

When planning care, minimize the number of visits and create an individualized treatment plan that optimizes preventive and therapeutic care; indicate necessity of additional visits when multiple visits are required.

Documentation Required

Complete as much treatment as feasible per visit

Providers should perform as many treatment‑planned services as feasible during a visit, considering clinical circumstances and patient tolerance, to avoid inappropriate multiple visits.

Documentation Required

Caries risk assessment required to authorize preventive fluoride for adults

A caries risk assessment must be completed annually and a high‑risk caries assessment code must be listed on claims for topical fluoride when used for adults; caries risk assessment codes are used to authorize selected preventive procedures for medium/high‑risk patients.

Billing Rule

D9410 and denture fabrication billing (use D0999 for interim steps)

D9410 (house call/extended care facility call) guidance: use D0999 for interim denture fabrication encounters in mobile/denture fabrication contexts; when billing denture fabrication encounters include D0999 with a note indicating the encounter is for denture fabrication.

Documentation Required

Verify eligibility and follow retroactive billing rules

Verify recipient eligibility before providing services; procedures billed retrospectively for recipients with retroactive eligibility are valid only if billing conditions are met.

Documentation Required

Submit clinical documentation and radiographs for By‑Report procedures

For 'by report' procedures and when requested for utilization review, submit procedure descriptions, operative/clinical history reports and radiographs; failure to submit requested radiographs/clinical information may result in denial.

Documentation Required

Include clinical justification and facility on PA requests

Prior authorization requests must include clinical justification for hospitalization when applicable and the facility name; PA does not guarantee payment and providers must check eligibility on date of service.

Documentation Required

Provider signature and required record elements

Providers must sign and date patient records next to services performed (or use an identification number and initials) and record date of service, each service rendered, patient information, and any additional information required by RI Medicaid.

Billing Rule

Teledentistry billing: use D9995/D9996 plus applicable D codes

When using teledentistry, bill D9995 (synchronous) or D9996 (asynchronous) as documentation in addition to applicable D codes for the actual service; retain documentation that the dentist received and reviewed essential information comparable to an in‑person visit.

Documentation Required

Document reasons and findings when services span multiple visits

When definitive services are split across appointments, chart notes must document why, include clinical findings and radiograph interpretations, and indicate tooth numbers where required.

Documentation Required

Radiograph retention and interpretation requirements

Radiographs must be diagnostic quality, properly identified and dated; originals must be retained by the dentist and interpretations documented.

Documentation Required

Radiograph findings and tooth number documentation

Report findings for intraoral radiographs and indicate tooth numbers for periapical images (D0220, D0230); documentation of variation from ADA guidelines must remain in the patient record.

Documentation Required

Annual caries risk assessment required for fluoride claims

Caries risk assessment must be completed one time per year and the appropriate high‑risk code listed on claims for topical fluoride (D1206/D1208); these caries risk codes are billed at $0 and support authorization for fluoride in adults.

Billing Rule

Sealant billing: report occlusal surface and respect exclusions

When billing for sealants, report the occlusal surface on the claim; payment is not allowed when an occlusal restoration exists and sealants are not payable on teeth #1, 16, 17, and 32.

Documentation Required

Amalgam management and population guidance

Follow FDA/ADA guidance for amalgam use and best management practices for amalgam separators and waste when amalgam is used; avoidance is recommended in certain populations listed in the manual.

Documentation Required

Specific periodontal PA documentation required (probing depths, radiographs)

Prior authorization for D4341/D4342 requires full‑mouth probing depths and intraoral radiographs (recent bitewings and FMX or panorex within five years) that demonstrate calculus on root surfaces or bone loss and a favorable prognosis.

Documentation Required

D3999: documentation required with PA

D3999 requires submission by report and supporting documentation when requested; authorization is required per the code table.

Documentation Required

Radiograph requirement for removable prosthodontics and PAs

Radiographs are required to assess abutment health for removable prosthodontics; include available films with PA requests and expect radiographs may be requested for post‑payment review.

Documentation Required

PA submission must include letter and radiographs for D5650 >4 teeth

Prior authorization requests to add more than four teeth to an existing partial denture (D5650) must include a letter and available radiographs documenting the need.

Documentation Required

Narrative and full‑mouth documentation for select surgical extractions

For certain surgical extractions (e.g., D7240) a narrative of medical necessity and full‑mouth documentation are required when the benefit limitation indicates.

Billing Rule

Denture fabrication encounters: bill D0999 with explanatory note

When billing additional denture fabrication encounters in FQHCs, include D0999 on the claim with a note indicating the encounter is for denture fabrication; appliance D codes must be billed only once on delivery date.

Documentation Required

Orthodontic PA must include full diagnostic records and treatment details

For full orthodontic PA, submit diagnosis, length and type of treatment, diagnostic casts, cephalometric and panoramic or complete intraoral radiographs, and diagnostic photographs; approve only when evidence of favorable prognosis and high probability of compliance is present.

Documentation Required

Required supporting documentation for orthodontic PA (HLD score, photos, radiographs)

Providers must submit HLD scoring, photographs, and supporting radiographs with orthodontic treatment requests; the performing provider must certify that the medical necessity information is true, accurate and complete.

Documentation Required

Anesthesia permit must be available on request

Providers must be able to submit a copy of their permit to administer anesthesia and/or sedation to Medicaid upon request.

Billing Rule

Include facility info on D9410 claims and bill D9410 with a service code

For mobile/house calls, include facility name and address on the claim narrative when billing D9410; D9410 must be billed with a CDT code indicating a service provided and cannot be billed alone.

Documentation Required

Documentation required for D9920 behavior management

For behavior management (D9920), include a description of the member's illness or disability and types of services furnished; indicate significant modifications to care when applicable.

DocumentationSome non-covered services may meet clinical emergency criteria but are not covered by policy

Investigative/Experimental definition

DefinitionInvestigative/Experimental: procedures not approved by appropriate regulatory body, under Phase I/II trials, subject to investigational protocols, or lacking demonstrated reliable evidence

Evidence standardDemonstrated reliable evidence includes peer-reviewed literature or final regulatory approval

ConsequenceInvestigational/experimental services are not covered by Medicaid

Emergency Services definition (alternate)

DefinitionEmergency Services: services to control hemorrhage, relieve pain, and/or eliminate acute infection; immediate treatment of dentition injuries; does not include permanent restorations

NoteEmergency rule applies only to covered services

ExclusionRoutine dental treatment of incipient decay is not considered emergency care

General Anesthesia definition

DefinitionGeneral Anesthesia: a controlled state of unconsciousness including inability to independently maintain an airway or respond purposefully

Presumed agentsCertain ultra-short acting barbiturates and agents like ketamine or etomidate are presumed to produce general anesthesia

ImplicationUsed where general anesthesia is clinically indicated and provider must document permit upon request

Sedation definition

DefinitionSedation: administration of a sedative drug intravenously, intramuscularly, submucosally, or subcutaneously

ContextIncludes IV moderate (conscious) sedation and sedation billing codes in anesthesia section

DocumentationProviders must be able to submit permit to administer anesthesia/sedation upon request

Restricted to individuals under age 21 or with I/DD definition

DefinitionRestriction: certain services limited to individuals under age 21 or adults with intellectual/developmental disability when medically necessary

ExamplesPulp therapy, many pediatric preventive services, selected prosthodontic codes

ImplicationCoverage outside these groups may require demonstration of medical necessity and prior authorization

Comprehensive Oral Evaluation (D0150) definition and limit

DefinitionComprehensive Oral Evaluation (D0150): the first exam for a new patient in the dental office; each recipient limited to one D0150 per lifetime per provider/location

Subsequent examsExams after the comprehensive are paid as periodic exams (D0120), and all exams require recording of findings signed by the dentist

Benefit limitD0150 limited to one lifetime per provider/location

Radiographs / Diagnostic imaging definition

DefinitionRadiographs/Diagnostic imaging: images appropriate only for clinical reasons as determined by a dentist; must be diagnostic quality, identified, dated, and originals retained

Frequency examplesD0210/D0330 once every 1460 days; bitewings once per calendar year

Payment capTotal payment for periapical/intraoral radiographs cannot exceed D0210 rate

Posterior restoration surface classification

DefinitionPosterior restoration surface classification: one-surface through four-or-more defined by involvement of mesial, distal, occlusal, lingual, facial surfaces

ApplicationUsed to determine appropriate CDT restoration code and benefit limitation (one restoration per tooth per year)

Payment ruleProgram will not pay more than multisurface rate for restoration greater than one surface

Anterior proximal restoration classification

DefinitionAnterior proximal restoration classification: one- to four-or-more surface definitions based on extension beyond line angles and incisal involvement

ApplicationGuides selection of D2330–D2335 codes for anterior composite restorations

Benefit limitSubject to same one-restoration-per-tooth-per-year limit as posterior restorations

Resin-based composite/restoration definition

DefinitionResin-based composite/restoration: broad category including bonded composite, light-cured composite, glass ionomer; tooth preparation, acid etching, adhesives included in restoration fee

Clinical useCovered when restoring damage from decay, trauma, or pathology and not for purely esthetic reasons

LimitBenefit limitation: one restoration per tooth per calendar year per business per surface includes resin-based codes

Noble metal classification definition

DefinitionNoble metal classification: alloys defined by percentage of noble metal content (high noble, noble, predominantly base)

High noble>60% noble metals with at least 40% gold (Au)

UseApplied to crown and fixed prosthodontic coding and payment rules

Periodontal scaling and root planing definition

DefinitionPeriodontal scaling and root planing (D4341/D4342): instrumentation of crown and root surfaces to remove plaque and calculus; therapeutic, not prophylactic

IndicationIndicated for periodontal disease with pocketing and radiographic evidence; requires probing depths and radiographs for PA

FrequencyAllowed once every 3 years per quadrant; pockets must be >=5 mm

Therapeutic pulpotomy (D3220) definition

DefinitionTherapeutic pulpotomy (D3220): removal of pulp coronal to dentinocemental junction and application of medicament; includes calcium hydroxide pulpotomy on permanent teeth and formocresol pulpotomy on deciduous teeth

Age/TeethD3220 age limitation <21; covers teeth 1–32, A–T

LimitOne pulpotomy per deciduous tooth per lifetime; cannot be billed with root canal therapy

Rebase definition

DefinitionRebase: process of refitting a denture by replacing the base material

FrequencyOne of D5710/D5730/D5750 per 24 months per patient; included in denture fee within first 6 months

DocumentationFee for denture includes relines/rebases necessary within 6 months of dispensing date

Provisional prosthesis definition

DefinitionProvisional prosthesis: a provisional prosthesis designed for use over a limited period, to be replaced by a definitive restoration

ExamplesUsed in removable prosthetic services and may require authorization (D5899/D5862) for certain cases

InclusionPayment and age/authorization rules vary by specific code

Provisional prosthesis alternate entry

DefinitionProvisional prosthesis: provisional appliance for limited period prior to definitive restoration

CodingMay be reported with D5899 or D5862 when applicable

PASome precision/unspecified prosthodontic procedures require prior authorization

Noble metal classification (alternate)

DefinitionNoble metal classification (alternate): high noble >60% (at least 40% Au), noble >25%, predominantly base <25%

ContextUsed for classification of crown and fixed partial denture alloys

PaymentApplied when adjudicating prosthodontic claims involving metal alloys

Handicapping Malocclusion / HLD (RI Mod) Index definition

DefinitionHandicapping Malocclusion / HLD (RI Mod) Index: scoring tool applied by board-qualified orthodontic consultants to determine medical necessity for orthodontic treatment

PartsIncludes Part A automatic qualifiers (severe conditions) and Part B numeric scoring (items 7–13)

Qualifying scoreA Part B total score of 26 or more qualifies for authorization

Dentition categories

DefinitionDentition categories: Primary, Transitional (Mixed), Adolescent, and Adult — used to assign orthodontic code categories

ApplicationDetermines which orthodontic procedure codes and age rules apply

Treatment implicationComprehensive treatment ends when adult dentition is placed in proper occlusion

Comprehensive orthodontic treatment definition

DefinitionComprehensive orthodontic treatment: placement of bands or bonded brackets for at least a two-year period with adjustments to achieve proper occlusion

End pointEnds when entire adult dentition (except third molars) is in proper occlusion

PA & unitsComprehensive codes (D8070/D8080/D8090 and subsequent 6-month units) require prior authorization and have age/unit rules

HLD Index (summary)

SummaryHLD Index (RI Mod): Part A automatic qualifiers plus Part B numeric scoring; Part B score >=26 qualifies for authorization

DocumentationPhotographs and radiographs required with PA; performing provider must certify information

UseApplied by Board-qualified orthodontic consultants for medical necessity determinations

D9310 definition (consultation)

DefinitionD9310: Consultation — diagnostic service provided by a dentist or physician other than the requesting provider; may initiate diagnostic/therapeutic services

Use restrictionShould not be used routinely by treating dentist or in addition to routine exams (D0120/D0140/D0150)

AuthorizationAuthorization not required for D9310

D9410 definition (house call)

DefinitionD9410: House call/extended care facility call — includes nursing home and long-term care visits; must be billed with a CDT code for an actual service provided

LimitMaximum of five visits per day per facility per provider for mobile services

Billing requirementFacility name and address must be on claim narratives; D9410 cannot be billed alone

D9995 / D9996 teledentistry definitions

DefinitionD9995/D9996: Teledentistry — D9995 synchronous (real-time), D9996 asynchronous (store-and-forward); reported in addition to other procedures

LimitationLimitations apply to the procedure code used with teledentistry; teledentistry codes are non-paying documentation codes

BillingD9995/D9996 reported in addition to applicable D codes for actual services performed

2017-12revision

Version 1.3 recorded (sections N/A).

2018-01revision

Version 1.4 recorded (sections N/A).

2018-07policy_change

Version 1.5 updated Periodontal Services (policy change).

2019-02policy_change

Version 1.6 updated Other Preventative Services – Space Maintenance and Miscellaneous (policy change).

2019-09revision

Version 1.7 updated Occlusal Guards (sections revised).

2022-10manual_update

Version 2.0 manual-wide update (All Sections).

2023-07policy_update

Version 2.1 updated Adjustments (policy update).

2023-11revision

Version 2.2 recorded (sections N/A).

2024-02policy_change

Version 2.3 revised Clinical Oral Examinations (policy change).

2024-04benefit_limitation

Version 2.4 revised Topical Fluoride Treatment implementing a benefit limitation.

2024-08policy_update

Version 2.5 updated Periodontal scaling and root planing (policy update).

2025-06revision

Version 2.6 noted revisions including Periodontal scaling and root planing, Relines, and Caries Arresting Material.

2025-10revision

Version 2.7/2.8 entries record revisions including anesthesia and Dental Amalgam updates and CDT copyright additions in late 2025.

2026-04revisionLatest

Version 2.9 recorded with CDT copyright additions and prior authorization changes for certain CDT codes (document version date May 2026).