Prior Authorization : Services Requiring Prior Authorization

Occlusal Guards

ForwardHealth covers occlusal guards with PA.

Prior Authorization Criteria for Members 20 Years of Age and Younger

Initial Occlusal Guard

Members 20 years of age and younger must meet the following criteria in order for a PA request for an initial occlusal guard to be approved:

• The member has a para-functional habit (e.g., clenching, bruxism), per the provider's statement.
• The member is able to tolerate the prosthesis, per the provider's statement and the consultant's review.

Subsequent Occlusal Guard

Members 20 years of age and younger must meet the following criteria in order for a PA request for a subsequent occlusal guard to be approved:

• The member has a para-functional habit (e.g., clenching, bruxism), per the provider's statement.
• The member is able to tolerate the prosthesis, per the provider's statement and the consultant's review.
• The existing prosthesis cannot be repaired, per the provider's statement.

Prior Authorization Criteria for Members 21 Years of Age and Older

Initial Occlusal Guard

Members 21 years of age and older must meet all of the following criteria in order for a PA request for an initial occlusal guard to be approved:

• The member has been medically diagnosed with a permanent physical, developmental, or intellectual disability, or has a documented medical condition that impairs their ability to maintain oral hygiene. (Refer to Wis. Admin. Code § DHS 101.03[122m] and 101.03[41] for definitions of physical disability and developmental disability).
• The member has a para-functional habit (e.g., clenching, bruxism), per the provider's statement.
• The member is able to tolerate the prosthesis, per the provider's statement and the consultant's review.

Subsequent Occlusal Guard

Members 21 years of age and older must meet all of the following criteria in order for a PA request for a subsequent occlusal guard to be approved:

• The member has been medically diagnosed with a permanent physical, developmental, or intellectual disability, or has a documented medical condition that impairs their ability to maintain oral hygiene. (Refer to Wis. Admin. Code § DHS 101.03[122m] and 101.03[41] for definitions of physical disability and developmental disability).
• The member has a para-functional habit (e.g., clenching, bruxism), per the provider's statement.
• The member is able to tolerate the prosthesis, per the provider's statement and the consultant's review.
• The existing prosthesis cannot be repaired, per the provider's statement.