SERVICES REQUIRING PRIOR AUTHORIZATION
Applicable to Pediatric Enrollees under Age 19
NOTE: Where Prior Authorization is required but not obtained, We can apply a penalty of up to 50% of
the charges that would otherwise be covered.
- Sealant replacement
- Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function.
Services will not be considered for cosmetic reasons, for teeth where other restorative materials will
be adequate to restore form and function or for teeth that are not in occlusion or function and have
a poor prognosis.
- Endodontic services other than Emergency Dental Services. Services will not be considered for teeth
that are not in occlusion or function and have poor long term prognosis.
- Periodontal services. Requires submission of diagnostic materials and documentation. Periodontal
root planning and scaling – with Prior Authorization, can be considered every six (6) months for a
Child with Special Health Care Needs.
- All dentures, fixed prosthodontics (fixed bridges) and maxillofacial prosthetics require Prior
- Denture rebase – following 12 months post denture insertion and subject to Prior Authorization,
denture rebase is covered and includes adjustments for first six (6) months following service. <.li>
- Pediatric partial denture – for select cases to maintain function and space for anterior teeth with
premature loss of primary anterior teeth, subject to Prior Authorization.
- Medically Necessary Orthodontic Services including continuation of transfer cases or cases started
outside the program (otherwise Orthodontic Services are not covered). Removal can be requested
by report as a separate service for Dentist that did not start case and requires Prior Authorization.
- Behavior management when exceeding the following thresholds based on place of service:
- One unit equals 15 minutes of additional time:
- Office or clinic – 2 units
- Inpatient/outpatient hospital – 4 units
- Skilled nursing/long term care – 2 units
- Dental services to be rendered in a hospital or ambulatory surgical center (documentation must
include the specific diagnosis and medical conditions that require admission to the hospital or
ambulatory surgical center).