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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 150 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 • Any potential future damage to the adjacent tooth The following codes and documentation are required for approval: • Codes 7210, 7220, surgical removal of erupted tooth, radiographs and narrative. • Codes 7230, 7240, 7241, surgical removal of impacted teeth, radiographs and narrative. • Code 7250, surgical removal of residual roots, radiographs and narrative. • Code 7280, surgical access of unerupted tooth, radiographs and narrative. • Codes 7310, 7311, 7320, 7321, alveoplasty in conjunction with extraction, radiographs and narrative. • Codes 7510, 7511, incision and drainage of abscess, radiographs and narrative. (Will not be considered on the same date with extraction of tooth related to the incision and drainage)

Emergency pre-authorization requests for oral surgery procedures should not exceed two teeth per pre-authorization requests. Exceptions are made on a case by case basis.

Guidelines for the Pediatric Dentist • Pediatric Dentists have open access to see plan members from ages 0 – 8. • Children from ages 9 – 12 will need a referral from a General Dentist. • New patients and patients of record ages 13 and older will need to be seen by a General Dentist. Any referrals for children ages 13 and older will be handled on a case by case basis.

It is the responsibility of the pediatric dentist to obtain preauthorization for any of the following procedures: Procedure Code

Description 1510

space maintainer – fixed – unilateral 1515

space maintainer – fixed- bilateral 2930

stainless steel crown – primary tooth 2931

stainless steel crown – permanent tooth 2932

resin crown 3220

therapeutic pulpotomy 3221

pulpal debridement 3230 & 3240

pulpal therapy – resorbable filling 4341

periodontal scaling & root planing 4342

periodontal scaling & root planing 4355

full mouth debridement 7210, 7220

surgical removal of erupted tooth 7230, 7240, 7241

surgical removal of impacted teeth