Obtain prior authorization for listed services

Certain dental services require prior authorization (PA) for medical necessity, including periodontal surgery; space maintenance for children under 3 years of age or when permanent teeth are missing; orthodontics; dentures (complete and partial) and repairs/relines; frenulectomy for members 1 year of age or older (PA not required for members under 1 year for dates of service on/after Sept. 11, 2023); general anesthesia and IV sedation for members 21 years of age or older. PA does not override a noncovered status and does not guarantee payment.

Use correct PA submission method and form

Submit PA requests to the appropriate PA contractor via that contractor's provider portal, or by mailing or faxing the correct PA form: use the IHCP Prior Authorization Request Form (universal PA form) for orthodontics and the IHCP Prior Authorization Dental Request Form for all other dental PA requests.

Prior authorization required for dentures (all ages)

Prior authorization is required for dentures for all members effective Sept. 15, 2023; PA requests are reviewed for medical necessity and providers must maintain documentation in the patient chart to support the request, including clinical details about occlusion, bone/tissue changes, recent tooth loss, and whether a repair or reline will extend useful life.

• IHCP considers eight posterior teeth in occlusion (four maxillary and four mandibular) adequate for function.
• When submitting PA, complete all applicable information and include office telephone number for PA analyst follow-up.

Obtain PA for denture relines and repairs

Effective Sept. 15, 2023, providers must obtain PA for relines and repairs to complete or partial dentures for members of all ages; the PA request must state that the repair or reline will extend the useful life of the prosthesis and documentation of medical necessity must be maintained in the medical record.

• Use the specified CDT codes for repairs and relines when submitting claims and PA requests (e.g., D5511–D5520 for repairs to complete dentures; D5611–D5660 for repairs to partials; D5730–D5741 and D5750–D5761 for relines).
• Rebases (D5710–D5721) are not covered.

Get PA for immediate dentures (>=21 years only)

Prior authorization is required for immediate dentures, and coverage for immediate dentures is limited to members 21 years of age and older.

• IHCP waives the 60-day waiting period but does not reimburse additional charges related to furnishing dentures before the 60-day period unless documented and the patient was notified.

Prior authorization and documentation for frenulectomy

Prior authorization is required for frenulectomy (D7961, D7962) for members 1 year of age or older; for dates of service on or after Sept. 11, 2023, PA is not required for buccal/labial or lingual frenectomy procedures for members under 1 year.

• Medical necessity must be documented in the patient file, including a referral documenting significant feeding challenges and photos.
• Procedures limited to two units per day per member.

PA required for maxillofacial surgery; additional opinions may be requested

Prior authorization is required for maxillofacial surgery; IHCP may require a second or third opinion to substantiate medical necessity or the surgical approach regardless of surgical setting.

• Obtain PA from the appropriate PA contractor and be prepared to supply additional opinions or documentation if requested.

PA and frequency limits for SDF (D1354)

Prior authorization is required for silver diamine fluoride (CDT D1354) for members 21 years of age or older; reimbursement is limited to once per tooth per three months with the tooth number required and up to ten teeth allowed per date of service.

• Record and submit the tooth number on the claim and ensure frequency limits (one application per tooth per three months) are met.

Document medical necessity for frenulectomy in the patient file

For frenulectomy services, maintain documentation of medical necessity in the patient's file — including referral documenting significant feeding challenges and photos — for all ages when PA is required.

• Ensure records include the referring provider's documentation and photographs supporting the clinical need.

Be prepared to supply second/third opinions for maxillofacial surgery PA

When requesting PA for maxillofacial surgery, be aware IHCP may require second or third opinions to substantiate medical necessity or approach; failure to provide requested opinions or documentation may affect approval.

• Obtain and retain any additional consults or opinions the IHCP requests to support the PA.

PA and criteria for oral appliance therapy (D5999, D9947)

Prior authorization for oral appliance therapy (maxillofacial prosthesis D5999 and custom sleep apnea appliance D9947) is required; PA must include a face-to-face evaluation before the sleep test, qualifying sleep test results (AHI/RDI thresholds and CPAP trial/failure where applicable), a physician referral to the dentist, device ordered by provider after sleep test review, and the dental provider must maintain sleep study results in the patient's file. PA is not required for adjustment (D9948) or repair (D9949).

• Qualifying sleep-test thresholds: AHI/RDI >=5 and <15, or >=15 and <30 with CPAP trial/failure, or >=30 with CPAP trial/failure as applicable.
• Maintain the sleep study report and referral documentation in the dental record.

Submit orthodontic PA with complete treatment plan; one PA per phase

Prior authorization is required for all orthodontic services (covered only for members 20 and younger for craniofacial deformities). Use the universal PA form for orthodontics and include a treatment plan; phased treatment requires one PA per phase and must include a step-by-step treatment plan with time frames and expectations.

• PA requests for orthodontics must include diagnostic records and meet the medical necessity criteria outlined in the policy.
• IHCP reimburses a maximum of two phases: one limited and one comprehensive; one PA issued per phase.

PA required for anesthesia, IV sedation, and certain space maintenance

Prior authorization is required for general anesthesia and IV sedation for members 21 years of age or older; space maintenance for children under 3 and space maintenance for missing permanent teeth also require PA and will be reviewed case-by-case.

• Documentation for general anesthesia must explain why the individual cannot receive necessary dental services without anesthesia and must be retained in the member's file.
• PA is required for IV sedation for members 21 and older when applicable.