Covered and Noncovered Services : Maxillofacial Prosthetics

An Overview

Wisconsin Medicaid reimburses dental providers for allowable maxillofacial prosthetics identified by ForwardHealth.

Obturators (D5932) for cleft palate and palatal lifts prostheses (D5955) are allowed once per six months. This frequency limitation may be exceeded in exceptional circumstances with written justification on a PA request. Providers are required to retain documentation of medical necessity of these procedures.

PA requests for maxillofacial prostheses should also include a request for a complete or removable partial denture when clinically appropriate. PA requests for unspecified maxillofacial prostheses must include laboratory bills and are approved based on documentation of medical necessity and appropriateness on a case-by-case basis.