| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Dental | | 07/20/2026 | Covered and Noncovered Services : Prosthodontics (Removable)Topic #3084 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)
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