Covered and Noncovered Services : Prosthodontics (Removable)

An Overview

Coverage of removable prosthodontic services includes:

• Complete dentures
• Partial dentures
• Repairs to complete dentures
• Repairs to partial dentures
• Denture reline procedures
• Maxillofacial prosthetics

Wisconsin Medicaid reimburses dental providers for allowable removable prosthodontic services identified by BadgerCare Plus.

When submitting claims for partial and complete dentures, the following requirements must be met:

• Providers may use the date of final impressions as the DOS, but may not submit claims to BadgerCare Plus until the prosthesis is inserted.
• Members must be eligible on the date the final impressions are made in order for the denture service to be covered. If eligibility issues arise, providers will be asked to verify this date through treatment progress notes.

Custom Preparation of Maxillofacial Prosthetics

The custom preparation of maxillofacial prosthetics is used to artificially replace the loss or absence of facial tissue or teeth due to disease, trauma, surgery, or a congenital defect.

ForwardHealth covers the custom preparation of maxillofacial prosthetics with PA when rendered in an office setting by oral surgeons, orthodontists, pediatric dentist or prosthodontists.

Coverage is limited to once per six months.

Allowable Procedure Codes

Providers are required to indicate custom preparation of maxillofacial prosthetics on PA requests and claims using the most appropriate CPT procedure code listed below:

• 21076 (Impression and custom preparation; surgical obturator prosthesis)
• 21077 (Impression and custom preparation; orbital prosthesis)
• 21079 (Impression and custom preparation; interim obturator prosthesis)
• 21080 (Impression and custom preparation; definitive obturator prosthesis)
• 21081 (Impression and custom preparation; mandibular resection prosthesis)
• 21082 (Impression and custom preparation; palatal augmentation prosthesis)
• 21083 (Impression and custom preparation; palatal lift prosthesis)
• 21084 (Impression and custom preparation; speech aid prosthesis)
• 21085 (Impression and custom preparation; oral surgical splint)
• 21086 (Impression and custom preparation; auricular prosthesis)
• 21087 (Impression and custom preparation; nasal prosthesis)
• 21088 (Impression and custom preparation; facial prosthesis)
• 21089 (Unlisted maxillofacial prosthetic procedure)

Denture Repair Services

BadgerCare Plus requests that dentists use discretion with denture repairs. Old, worn dentures with severely worn teeth or fractures due to age should be replaced. A PA request with appropriate documentation must be submitted for replacement dentures.

Providers are required to indicate an area of the oral cavity modifier (01, maxillary or 02, mandibular).

Wisconsin Medicaid reimburses a maximum amount per member, per denture, per six-month period for the repair of complete or partial dentures.

If laboratory costs exceed the maximum reimbursement allowed, dentists may submit a claim or adjustment request with laboratory bills.

Complete Denture Repairs

Complete denture repairs include the following:

• Repair of broken complete denture base
• Replacement of missing or broken teeth

Partial Denture Repairs

Repairs to partial dentures include the following:

• Repair of resin denture base.
• Repair of cast framework.
• Repair or replace a broken clasp.
• Replace broken teeth.
• Add tooth to existing partial denture.
• Add clasp to existing partial denture.
• Replace all teeth and acrylic on cast metal framework.

Noncovered Repairs

The following repairs are not covered by BadgerCare Plus:

• Extensive repairs of marginally functional dentures
• Repairs to a denture when a new denture would be better for the health of the member

Edentulous Members

If a member has been edentulous for more than five years and has never worn a prosthesis, then no denture is ordinarily approved unless the dentist submits the following:

• A favorable prognosis
• An analysis of the oral tissue status (e.g., muscle tone, ridge height, muscle attachments, etc.)
• Justification indicating why a member has been without a prosthesis

If a member has not worn an existing prosthesis for three years, no new prosthesis will usually be authorized unless unusual mitigating circumstances and medical necessity are documented and verified by a physician.

When a member has a history of an inability to tolerate and wear a prosthetic appliance due to psychological or physiological reasons, then a new prosthesis will not be approved.

Full Dentures with Few Remaining Teeth

Wisconsin Medicaid may reimburse for full dentures when a member has only one or two remaining teeth per arch if this treatment would maintain proper anchorage and if the denture could be converted to a full denture by a simple repair, in the event of tooth loss. The ForwardHealth dental consultant determines the appropriateness of this situation at the time prior authorization is requested.

Healing Period After Tooth Extraction

BadgerCare Plus requires a minimum of six weeks healing period after the last tooth extraction occurs in the arch in question before a final impression is made.

A PA request for dentures may be approved before teeth are removed. The six-week healing period must still take place. If the six-week waiting period does not take place, payment for dentures is denied or recouped.

Shorter Healing Period After Tooth Extraction

A shorter healing period after an extraction may be approved or no healing period may be required if the PA request demonstrates that such approval is appropriate due to medical necessity, an unusual medical condition, that only a few teeth are extracted, or that extracted teeth are in noncritical areas such as the opposing arch.

BadgerCare Plus may grant a shortened healing period or require no healing period in limited situations for members who are employed with job duties that require public contact. In this situation, a statement from the employer indicating the job duties that require public contact must be included in the PA request.

To have a shorter healing period, a provider must request the shorter period at the same time the PA request for dentures is made.

Immediate upper complete denture or upper complete denture with shorter healing period is authorized and billed using procedure code D5110. Immediate lower complete denture or lower complete denture with shorter healing period is authorized and billed using procedure code D5120.

Life Expectancy of Prostheses

Generally, given reasonable care and maintenance, a prosthesis should last at least five years. Coverage of removable prosthodontic services is limited to one new full or partial denture per arch per five years unless unusual circumstances are documented with the PA request. Providers and members should not expect to receive approval for a replacement prosthesis without adequate justification and documentation.

ForwardHealth assesses all cases that request early replacement of a prosthesis due to a member's poor adaptation to a new prosthesis, or poor quality workmanship by the provider.

Lost, Stolen, or Severely Damaged Prostheses

Removable prosthodontic services are provided at considerable expense to BadgerCare Plus. BadgerCare Plus does not intend to repeatedly replace lost, severely damaged, or stolen prostheses. PA requests for lost, severely damaged, or stolen prostheses are only approved when:

• The member has exercised reasonable care in maintaining the denture.
• The prosthesis was being used up to the time of loss or theft.
• The loss or theft is not a repeatedly occurring event.
• A reasonable explanation is given for the loss or theft of the prosthesis.
• A reasonable plan to prevent future loss is outlined by the member or the facility where the member lives.

In these situations, BadgerCare Plus will reimburse only for the first lost, damaged, or stolen prosthesis per arch. Subsequent lost, damaged, or stolen prostheses are payable by the member.

Prior Authorization Requirements

When submitting a PA request involving a lost, stolen, or severely damaged prosthesis, give special attention to the need for the prosthesis. The request must include a police report, accident report, fire report, or hospital, nursing home, or group home (community based residential facility) administrator statement or member statement on the loss. Such statements should include how, when, and where the prosthesis was lost or damaged, and what attempts were made to recover the loss and plans to prevent future loss.

Partial Dentures

Wisconsin Medicaid reimburses for partial dentures only for members with good oral health and hygiene, good periodontal health (AAP Stage I or II), and a favorable prognosis where continuous deterioration of teeth and periodontal health is not expected.

A member qualifies for a partial denture if any of the following criteria are met:

• One or more anterior teeth are missing.
• The member has less than two posterior teeth per quadrant in occlusion with the opposing quadrant.
• The member has at least six missing teeth per arch, including third molars.
• A combination of one or more anterior teeth are missing, and the member has less than two posterior teeth per quadrant in occlusion with the opposing quadrant.
• The member requires replacement of anterior teeth for employment reasons.
• Medically necessary for nutritional reasons documented by a physician.
• Unusual clinical situations where a partial is determined to be necessary based on a comprehensive review of the dental and medical histories.

If placement of a partial denture in an arch provides at least two posterior teeth (posterior teeth are bicuspids and molars only) per quadrant in occlusion with the opposing quadrant, the opposing partial, if requested, may not be authorized unless the member also has an anterior tooth missing in that arch.

Prior Authorization Requirements

PA requests are required for the following:

• Complete dentures
• Partial dentures
• Replacement of all teeth and acrylic on cast metal frame work
• Unspecified maxillofacial prosthesis
• Frequency limitations for dentures, partials, and relines

Complete and Partial Dentures

PA requests for a removable prosthesis should explain the individual needs of the member and include the following information:

• The age of existing prosthesis (if applicable).
• The date(s) of surgery, edentulation, or date the last tooth or teeth were extracted.
• The adaptability of the member. When appropriate, specifically document why a member is not wearing an existing prosthesis, and why a new prosthesis will eliminate the problem.
• The appropriateness of repairing or relining the existing prosthesis.
• Any misutilization practice of the member.
• Documented loss or damage of prosthesis requiring replacement, if applicable, and how future loss will be prevented.

Partial Dentures

Complete periodontal charting and X-rays sufficient to show entire arch in question; the BadgerCare Plus consultant may request additional information such as diagnostic casts on a case-by-case basis.

PA requests for partial dentures must include the following information:

• Periodontal status (AAP Type I-V)
• Verification that all abscessed or non-restorable teeth have been extracted or are scheduled to be extracted
• Verification that all remaining teeth are decay-free or the member is scheduled for all restorative procedures
• Success potential for proper completion and long-term maintenance of the partial denture
• Verification that no tooth requires root canal therapy or that the member is responsible for any necessary root canals

BadgerCare Plus may request additional documentation including a physician's statement to verify the following for complete or partial dentures:

• The medical necessity and appropriateness of the PA request.
• The prosthesis is necessary for proper nourishment and digestion.
• The member is physically and psychologically able to wear and maintain the prosthesis.
• The previous dentures have become unserviceable or lost.

Unspecified Maxillofacial Prostheses

Unspecified maxillofacial prostheses (D5999) require PA. PA requests for unspecified maxillofacial prostheses are approved based on medical necessity and appropriateness on a case-by-case basis. A laboratory bill and narrative must be included with the claim form.

Upgraded Partial Dentures

Wisconsin Medicaid reimburses dentists for providing upgraded partial dentures (D5213 and D5214), according to the following guidelines:

• PA is always required.
• Reimbursement is at the maximum fee for the "standard" resin-base partial denture (D5211 and D5212).
• Reimbursement must be accepted as payment in full.
• Each dental office that provides the service must have written criteria based on medical necessity to determine who receives the upgraded service.
• All criteria must be applied consistently to all BadgerCare Plus members.

No provider is obligated to provide upgraded partial dentures.

Prostheses Care Instructions

As part of any removable prosthetic service, dentists are expected to instruct the member on the proper care of the prostheses. Six months of post-insertion follow-up care is included in the reimbursement for complete and partial dentures and relining complete and partial dentures.

Providers performing denture and partial denture adjustments after six months of post-insertion follow-up care may submit claims to ForwardHealth using procedure code D9110 for these services.

Reline Services

Relining complete and partial upper and lower dentures is limited to once every three years, per arch, when an existing denture is loose or ill fitting or there is considerable amount of tissue shrinkage or weight loss. Six months of post-insertion follow-up care is included in reimbursement for complete and partial dentures and relining complete and partial dentures.

The frequency limitation for relines may be exceeded in exceptional circumstances. Written justification must be included with the PA request.

Note: Chair-side reline services are not covered by BadgerCare Plus.

Traumatic Loss of Teeth for Members Under Age 21

When a child experiences a traumatic loss of an anterior tooth or teeth (tooth numbers 6-11, 22-27), removable prostheses may be provided by backdating a PA request.