For Dates of Service Before January 1, 2020

Services Requiring Prior Authorization

Dental Services

The following dental services require PA:

• Intraoral radiograph (D0210) and panoramic film (D0330), if frequency limitations are exceeded
• Molar root canal therapy (D3330) for members ages 21 and over
• Periodontal scaling, root planing, and periodontal maintenance (D4341, D4342, D4910)
• Full-mouth debridement (D4355) for members ages 12 and under
• Full and partial dentures (D5110, D5120, D5211-D5226)
• Repairs to partial dentures including replacement of all teeth and acrylic on cast metal framework (maxillary and mandibular) (D5670-D5671)
• Fixed prosthodontics (D6211-D6971, D6940-D6980)
• Orthodontic services (D8010-D8692, excluding D8660)

Oral Surgery Services

PA is required for members 21 years of age and older in a nonemergency situation. PA is never required when an emergency is indicated on the claim form.

Services That Do Not Require Prior Authorization

ForwardHealth does not require PA for the following services when they are provided by a pediatric dentist or an oral surgeon for a member less than 21 years of age on the DOS:

• D9222 (Deep sedation/general anesthesia — first 15 minutes)
• D9223 (Deep sedation/general anesthesia — each subsequent 15 minute increment)
• D9230 (Inhalation of nitrous oxide/analgesia, anxiolysis)
• D9243 (Intravenous moderate [conscious] sedation/analgesia — each subsequent 15 minute increment)
• D9248 (Non-intravenous conscious sedation)