SECTION II DENTAL SERVICES (Continued) – Procedure Codes Treatment Plan Justification Category Required Documentation (Check all that apply.) (Check all that apply.) Periodontal D4341 Member 13 years of age and older Periodontal charting Services D4342 Early bone loss Comprehensive (Continued) Moderate bone loss periodontal treatment plan At least one pocket five or more millimeters deep on Full mouth X-rays with three or more teeth current bitewing X-rays Oral hygiene (Check one.) Clinical notes indicating member education on Good Fair Poor periodontal disease Full-mouth debridement completed in last 12 months Documentation of Date of service for D4355 (MM/DD/CCYY). debridement and/or routine dental care D4355 Excess calculus on X-ray Bitewing or full mouth (For members who are AAP I or II age 13 and older, PA is No dental treatment in multiple years Calculus must be visible not required.) on X-rays Oral hygiene (Check one.) Good Fair Poor Member under age 13 D4910 Recent history of periodontal scale / surgery Periodontal charting Oral hygiene (Check one.) Comprehensive periodontal treatment plan Good Fair Poor Allowed once per 12 Years requested (Check one.) months 1 2 3 Prosthodontic D5110 Initial placement of dentures (year) New dentures limited to Services one per five years, per D5120 Max Mand arch. Dentures Age of existing denture(s) (years) Six weeks healing period required unless special Max Mand circumstances New denture request because of the following (Check documented. all that apply.) Document reasons for not Worn base / broken teeth wearing dentures or for Poor fit not having ever had Vertical dimension dentures. Date(s) last teeth extracted (MM/DD/CCYY) Submit medical Reason for edentulation documentation to support special requests. Document loss and plan Lost / stolen / broken dentures for prevention of future Reline / repair not appropriate mishaps. Has not worn existing dentures for more than three Explanation to exceed years frequency limitation. Edentulous more than five years without dentures Additional justification Frequency limitation must be exceeded Continued PRIOR AUTHORIZATION / DENTAL ATTACHMENT 1 (PA/DA1) 3 of 4 F-11010 (01/2019) SECTION II DENTAL SERVICES (Continued) – Procedure Codes Treatment Plan Justification Category Required Documentation (Check all that apply.) (Check all that apply.)
SECTION II – DENTAL SERVICES (Continued) Category Procedure Codes (Check all that apply.) Treatment Plan Justification (Check all that apply.) Required Documentation Periodontal Services (Continued) D4341 D4342 Member 13 years of age and older Early bone loss Moderate bone loss At least one pocket five or more millimeters deep on three or more teeth Oral hygiene (Check one.) Good Fair Poor Full-mouth debridement completed in last 12 months Date of service for D4355 (MM/DD/CCYY). Periodontal charting Comprehensive periodontal treatment plan Full mouth X-rays with current bitewing X-rays Clinical notes indicating member education on periodontal disease Documentation of debridement and/or routine dental care D4355 (For members who are age 13 and older, PA is not required.) Excess calculus on X-ray AAP I or II No dental treatment in multiple years Oral hygiene (Check one.) Good Fair Poor Member under age 13 Bitewing or full mouth Calculus must be visible on X-rays D4910 Recent history of periodontal scale / surgery Oral hygiene (Check one.) Good Fair Poor Years requested (Check one.) 1 2 3 Periodontal charting Comprehensive periodontal treatment plan Allowed once per 12 months Prosthodontic Services Dentures D5110 D5120 Initial placement of dentures (year) Max Mand Age of existing denture(s) (years) Max Mand New denture request because of the following (Check all that apply.) Worn base / broken teeth Poor fit Vertical dimension Date(s) last teeth extracted (MM/DD/CCYY) Reason for edentulation Lost / stolen / broken dentures Reline / repair not appropriate Has not worn existing dentures for more than three years Edentulous more than five years without dentures Additional justification Frequency limitation must be exceeded New dentures limited to one per five years, per arch. Six weeks healing period required unless special circumstances documented. Document reasons for not wearing dentures or for not having ever had dentures. Submit medical documentation to support special requests. Document loss and plan for prevention of future mishaps. Explanation to exceed frequency limitation. Continued PRIOR AUTHORIZATION / DENTAL ATTACHMENT 1 (PA/DA1) 3 of 4 F-11010 (01/2019) SECTION II – DENTAL SERVICES (Continued) Category Procedure Codes (Check all that apply.) Treatment Plan Justification (Check all that apply.) Required Documentation
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