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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 147 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 • Codes beginning with D7220-D7999, soft tissue impactions and other oral surgery procedures requiring radiographs and narrative • Codes beginning with D73, alveoloplasty requiring radiographs and narrative • Codes 7510, 7511, incision and drainage of an abscess (will not be considered on the same date with extraction of tooth related to the I&D) requiring radiographs and narrative Endodontic Guidelines • Code 2950, core buildups, including pins • Code 2954, prefabricated post and cores • Code 3310, anterior routine endodontic therapy • Code 3320, bicuspid endodontic therapy • Code 3330, molar endodontic therapy • Code 3220, therapeutic pulpotomy • Code 3221, pulpal debridement on primary and permanent teeth • Code 3230, pupal therapy on primary anterior teeth (resorbable filling) • Code 3240, pupal therapy on primary teeth (resorbable filling) To refer to an Endodontic, preoperative radiographs are required for the following cases: • Code 3310, anterior endodontic therapy • Code 3320, bicuspid endodontic therapy • Code 3330, molar endodontic therapy • Codes 3346, 3347, 3348, retreatment of previous endodontic therapy • Codes 3351, 3352, 3353, apexification procedures • Code 3410, anterior apicoectomy • Teeth with existing crowns and bridgework • Teeth with atypical root morphology • Teeth with dilacerarted roots • Teeth with calcified canals or root perforations *Request for referrals for teeth with poor or guarded prognosis may result in a denial Endodontic Therapy Requirements: • Pre-authorization is required for all endodontic treatment. • Preoperative radiographs must be submitted with the pre-authorization. • Claims submitted for emergency services rendered without pre-authorization must be submitted with pre and post operative radiographs.