For Dates of Service Before January 1, 2018

BadgerCare Plus/Medicaid Prosthodontics, Maxillofacial Prosthetics, Maxillofacial Surgery, and Orthodontics

The following procedure codes are covered under BadgerCare Plus and Medicaid.

D5000-D5899 Prosthodontics, Removable

Covered removable prosthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization	Limitations and Requirements
Complete Dentures (Including Routine Post-Delivery Care)
D5110	Complete denture — maxillary	Yes	Allowed once per five years.^{1, 2}
D5120	Complete denture — mandibular	Yes	Allowed once per five years.^{1, 2}
Partial Dentures (Including Routine Post-Delivery Care)
D5211	Maxillary (upper) partial denture; resin base (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
D5212	Mandibular (lower) partial denture; resin base (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
D5213	Maxillary partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2} Reimbursement is limited to reimbursement for D5211. Upgraded partial denture. No dentist is obligated to complete this type of partial.
D5214	Mandibular partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2} Reimbursement is limited to reimbursement for D5212. Upgraded partial denture. No dentist is obligated to complete this type of partial.
D5225	Maxillary partial denture — flexible base (including any clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
D5226	Mandibular partial denture — flexible base (including any clasps, rests and teeth)	Yes	Allowed once per five years.^{1, 2}
Repairs to Complete Dentures
D5510	Repair broken complete denture base	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
D5520	Replace missing or broken teeth — complete denture (each tooth)	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
Repairs to Partial Dentures
D5610	Repair resin denture base	No	Limited to once per DOS. Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
D5620	Repair cast framework	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
D5630	Repair or replace broken clasp — per tooth	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. Requires tooth numbers on claim submission.
D5640	Replace broken teeth — per tooth	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
D5650	Add tooth to existing partial denture	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
D5660	Add clasp to existing partial denture — per tooth	No	Combined maximum reimbursement limit per six months for repairs. Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form. Requires tooth numbers on claim submission.
D5670	Replace all teeth and acrylic on cast metal framework (maxillary)	Yes	Combined maximum reimbursement limit per six months for repairs. Requires area of oral cavity code 01=Maxillary in the appropriate element of the claim form.
D5671	Replace all teeth and acrylic on cast metal framework (mandibular)	Yes	Combined maximum reimbursement limit per six months for repairs. Requires area of oral cavity code 02=Mandibular in the appropriate element of the claim form.
Denture Reline Procedures
D5750	Reline complete maxillary denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.
D5751	Reline complete mandibular denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.
D5760	Reline maxillary partial denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.
D5761	Reline mandibular partial denture (laboratory)	No	Allowed once per three years.¹ Retain documentation of medical necessity.

¹ Frequency limitation may be exceeded in exceptional circumstances with written justification on PA request.
² Healing period of six weeks required after last extraction prior to taking impressions for dentures, unless shorter period approved in PA.

21076-21089, D5900-D5999 Maxillofacial Prosthetics

Covered maxillofacial prosthetics are identified by the allowable procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
21076	Impression and custom preparation; surgical obturator prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21077	Impression and custom preparation; orbital prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21079	Impression and custom preparation; interim obturator prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21080	Impression and custom preparation; definitive obturator prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21081	Impression and custom preparation; mandibular resection prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21082	Impression and custom preparation; palatal augmentation prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21083	Impression and custom preparation; palatal lift prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21084	Impression and custom preparation; speech aid prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21085	Impression and custom preparation; oral surgical splint	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21086	Impression and custom preparation; auricular prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21087	Impression and custom preparation; nasal prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21088	Impression and custom preparation; facial prosthesis	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
21089	Unlisted maxillofacial prosthetic procedure	Yes	Allowed once per six months. Must be in an office setting. Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist. Medical necessity as determined by defect and prognosis must be demonstrated. Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.
D5932	Obturator prosthesis, definitive	No	Allowed once per six months.¹ Retain documentation of medical necessity.
D5955	Palatal lift prosthesis, definitive	No	Allowed once per six months.¹ Retain documentation of medical necessity.
D5991	Topical medicament carrier	No
D5999	Unspecified maxillofacial prosthesis, by report	Yes	For medically necessary removable prosthodontic procedures. Use this code only if a service is provided that is not accurately described by other HCPCS or CPT procedure codes.

¹ Frequency limitation may be exceeded in exceptional circumstances with written justification on PA request.

D6200-D6999 Prosthodontics, Fixed

Covered fixed prosthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Fixed Partial Denture Pontics
D6211	Pontic — cast predominantly base metal	Yes	Permanent teeth only (tooth numbers 1-32 and 51-82 only).
D6241	Pontic — porcelain fused to predominantly base metal	Yes	Permanent teeth only (tooth numbers 1-32 and 51-82 only).
Fixed Partial Denture Retainers — Inlays/Onlays
D6545	Retainer; cast metal for resin bonded fixed prosthesis	Yes	Tooth numbers 1-32, 51-82 only.
Fixed Partial Denture Retainers — Crowns
D6751	Retainer crown — porcelain fused to predominantly base metal	Yes	Permanent teeth only (tooth numbers 1-32 and 51-82 only).
D6791	Retainer crown — full cast predominantly base metal	Yes	Permanent teeth only (tooth numbers 1-32 and 51-82 only).
Other Fixed Partial Denture Services
D6930	Recement fixed partial denture	No
D6940	Stress breaker	Yes	Copy of lab bill required.
D6980	Fixed partial denture repair, by report	Yes	Copy of lab bill required.
D6985	Pediatric partial denture, fixed	No	Allowable up to age 12. Retain documentation of medical necessity.

D7000-D7999 Oral and Maxillofacial Surgery

Covered oral and maxillofacial surgery services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care)
D7111	Extraction, coronal remnants — deciduous tooth	No	Allowed only once per tooth. Primary teeth only (tooth letters A-T and AS-TS only). Not payable same DOS as D7250 for same tooth letter.
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	No	Allowed only once per tooth (tooth numbers 1-32, A-T, 51-82 and AS-TS). Not payable same DOS as D7250 for same tooth number.
Surgical Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care)
D7210	Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1-32, A-T, 51-82 and AS-TS).¹ Not payable same DOS as D7250 for same tooth number.
D7220	Removal of impacted tooth — soft tissue	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1-32, A-T, 51-82 and AS-TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7230	Removal of impacted tooth — partially bony	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1-32, A-T, 51-82 and AS-TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7240	Removal of impacted tooth — completely bony	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1-32, A-T, 51-82 and AS-TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7241	Removal of impacted tooth — completely bony, with unusual surgical complications	No	Allowed only once per tooth. Covered when performing an emergency service or for orthodontia (tooth numbers 1-32, A-T, 51-82 and AS-TS).¹ Not payable same DOS as D7250 for the same tooth number.
D7250	Removal of residual tooth roots (cutting procedure)	No	Emergency only (tooth numbers 1-32, A-T, 51-82 and AS-TS).¹ Allowed only once per tooth. Not allowed on the same DOS as tooth extraction of same tooth number.
Other Surgical Procedures
D7260 or CPT²	Oroantral fistula closure	No	Operative report required.
D7261	Primary closure of a sinus perforation	No	Operative report required.
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth	No	Emergency only (tooth numbers 1-32, C-H, M-R, 51-82, CS-HS, and MS-RS).¹ Operative report required.
D7280	Exposure of an unerupted tooth	No	Not allowed for primary or wisdom teeth (tooth numbers 2-15, 18-31, 52-65, and 68-81 only). Allowable for members ages 0-20. Operative report required.
D7282	Mobilization of erupted or malpositioned tooth to aid eruption	No	Not allowed for primary or wisdom teeth (tooth numbers 2-15, 18-31, 52-65, and 68-81 only). Allowable for members ages 0-20. Operative report required.
D7283	Placement of device to facilitate eruption of impacted tooth	No	Not allowed for primary or wisdom teeth (tooth numbers 2-15, 18-31, 52-65, and 68-81 only). Allowable for members ages 0-20. Operative report required.
D7285 or CPT²	Incisional biopsy of oral tissue — hard (bone, tooth)	No	Once per DOS.³ Operative report required.
D7286 or CPT²	Incisional biopsy of oral tissue — soft	No	Once per DOS.³ Operative report required.
D7287 or CPT²	Exfoliative cytological sample collection	No	Once per DOS.³ Operative report required.
D7288	Brush biopsy — transepithelial sample collection	No	Once per DOS.³ Operative report required.
Alveoloplasty — Surgical Preparation of Ridge for Dentures
D7310	Alveoloplasty in conjuction with extractions — per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
D7311	Alveoloplasty in conjuction with extractions — one to three teeth or tooth spaces, per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
D7320	Alveoloplasty not in conjuction with extractions — per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
D7321	Alveoloplasty not in conjuction with extractions — one to three teeth or tooth spaces, per quadrant	No	Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right). X-ray, treatment notes and treatment plan required.
Surgical Excision of Soft Tissue Lesions
D7410 or CPT²	Excision of benign lesion up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7411 or CPT²	Excision of benign lesion greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7412 or CPT²	Excision of benign lesion, complicated	No	Once per DOS.³ Pathology report required.
D7413 or CPT²	Excision of malignant lesion up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7414 or CPT²	Excision of malignant lesion greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7415 or CPT²	Excision of malignant lesion, complicated	No	Once per DOS.³ Pathology report required.
Surgical Excision of Intra-Osseous Lesions
D7440 or CPT²	Excision of malignant tumor — lesion diameter up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7441 or CPT²	Excision of malignant tumor — lesion diameter greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7450 or CPT²	Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7451 or CPT²	Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
D7460 or CPT²	Removal of benign nonodontogenic cyst or tumor — lesion diameter up to 1.25 cm	No	Once per DOS.³ Pathology report required.
D7461 or CPT²	Removal of benign nonodontogenic cyst or tumor — lesion diameter greater than 1.25 cm	No	Once per DOS.³ Pathology report required.
Excision of Bone Tissue
D7471 or CPT²	Removal of lateral exostosis (maxilla or mandible)	Yes	Oral photographic image or diagnostic cast of arch required for PA.
D7472 or CPT²	Removal of torus palatinus	Yes	Oral photographic image or diagnostic cast of arch required for PA.
D7473 or CPT²	Removal of torus mandibularis	Yes	Oral photographic image or diagnostic cast of arch required for PA.
D7485 or CPT²	Surgical reduction of osseous tuberosity	No	Operative report required.
D7490 or CPT²	Radical resection of maxilla or mandible	No	Operative report required. Only allowable in hospital or ambulatory surgical center POS.
Surgical Incision
D7510 or CPT²	Incision and drainage of abscess — intraoral soft tissue	No	Operative report required. Not to be used for periodontal abscess — use D9110.
D7511 or CPT²	Incision and drainage of abscess — intraoral soft tissue — complicated (includes drainage of multiple fascial spaces)	No	Operative report required. Not to be used for periodontal abscess — use D9110.
D7520 or CPT²	Incision and drainage of abscess — extraoral soft tissue	No	Operative report required.
D7521 or CPT²	Incision and drainage of abscess — extraoral soft tissue — complicated (includes drainage of multiple fascial spaces)	No	Operative report required.
D7530 or CPT²	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue	No	Not allowed for removal of root fragments and bone spicules. (Use D7250 instead.) Operative report required.
D7540 or CPT²	Removal of reaction producing foreign bodies, musculoskeletal system	No	Not allowed for removal of root fragments and bone spicules. (Use D7250 instead.) Operative report required.
D7550 or CPT²	Partial ostectomy/sequestrectomy for removal of non-vital bone	No	Operative report required.
D7560 or CPT²	Maxillary sinusotomy for removal of tooth fragment or foreign body	No	Operative report required.
Treatment of Fractures — Simple
D7610 or CPT²	Maxilla — open reduction (teeth immobilized, if present)	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7620 or CPT²	Maxilla — closed reduction (teeth immobilized, if present)	No	Operative report required.
D7630 or CPT²	Mandible — open reduction (teeth immobilized, if present)	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7640 or CPT²	Mandible — closed reduction (teeth immobilized, if present)	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7650 or CPT²	Malar and/or zygomatic arch — open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7660 or CPT²	Malar and/or zygomatic arch — closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7670 or CPT²	Alveolus — closed reduction, may include stabilization of teeth	No	Operative report required.
D7671 or CPT²	Alveolus — open reduction, may include stabilization of teeth	No	Operative report required.
D7680 or CPT²	Facial bones — complicated reduction with fixation and multiple surgical approaches	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
Treatment of Fractures — Compound
D7710 or CPT²	Maxilla — open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7720 or CPT²	Maxilla — closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7730 or CPT²	Mandible — open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7740 or CPT²	Mandible — closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7750 or CPT²	Malar and/or zygomatic arch — open reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7760 or CPT²	Malar and/or zygomatic arch — closed reduction	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7770 or CPT²	Alveolus — open reduction stabilization of teeth	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7771 or CPT²	Alveolus — closed reduction stabilization of teeth	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7780 or CPT²	Facial bones — complicated reduction with fixation and multiple approaches	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions
D7810 or CPT²	Open reduction of dislocation	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7820 or CPT²	Closed reduction of dislocation	No	Once per DOS.³ Operative report required.
D7830 or CPT²	Manipulation under anesthesia	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7840 or CPT²	Condylectomy	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required.
D7850 or CPT²	Surgical discectomy, with/without implant	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required.
D7860 or CPT²	Arthrotomy	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required.
D7871 or CPT²	Non-arthroscopic lysis and lavage	Yes	Allowable only once per side (right and left) per three years.
D7899	Unspecified TMD therapy, by report	Yes	Use this code for billing TMJ assistant surgeon. Procedure must be included in PA request for the surgery itself. Only allowable in hospital or ambulatory surgical center POS.
Repair of Traumatic Wounds
D7910 or CPT²	Suture of recent small wounds up to 5 cm	No	Emergency only¹ — operative report required. Once per DOS.³
Complicated Suturing (Reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure)
D7911 or CPT²	Complicated suture — up to 5 cm	No	Covered for trauma (emergency) situations only.¹ Once per DOS.³ Operative report required.
D7912 or CPT²	Complicated suture — greater than 5 cm	No	Covered for trauma (emergency) situations only.¹ Once per DOS.³ Operative report required.
Other Repair Procedures
D7940 or CPT²	Osteoplasty — for orthognathic deformities	Yes	HealthCheck referral is required. Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required. Allowable age less than 21.
D7950 or CPT²	Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones — autogeneous or nonautogeneous, by report	Yes	Only allowable in hospital, office, or ambulatory surgical center POS. No operative report required.
D7951	Sinus augmentation with bone or bone substitutes	No
D7960 or CPT²	Frenulectomy (frenectomy or frenotomy) — separate procedure	No	Covered areas of the oral cavity are 01 and 02. The area of the oral cavity is required to be indicated on the claim. Up to two units of service per area of the oral cavity allowed per DOS. Total of four units per DOS. Note: An image of the obstructed frenum is not required to be submitted with claims but must be available in the medical or dental record. A dentist statement regarding the medical/dental need for the treatment is required to be available upon request. Refer to the Frenulectomy Procedures Online Handbook topic for limitations and requirements.
D7970 or CPT²	Excision of hyperplastic tissue per arch	Yes	No operative report required.
D7972 or CPT²	Surgical reduction of fibrous tuberosity	No	Operative report required.
D7980 or CPT²	Sialolithotomy	No	Only allowable in hospital, office, or ambulatory surgical center POS. Operative report required.
D7991 or CPT²	Coronoidectomy	Yes	Only allowable in hospital or ambulatory surgical center POS. No operative report required.
D7997 or CPT²	Appliance removal (not by dentist who placed appliance), includes removal of archbar	No	Operative report required.
D7999 or CPT²	Unspecified oral surgery procedure, by report	Yes	For medically necessary unspecified oral surgery procedure, by report. Use this code only if a service is provided that is not accurately described by other HCPCS or CPT procedure codes. Note: For occlusal guard use procedure code D9440.

¹ Retain records in member files regarding nature of emergency.
² Providers who are enrolled in Wisconsin Medicaid as oral surgeons or oral pathologists and who choose CPT billing must use a CPT code to bill for this procedure. Refer to the Dental Maximum Allowable Fee Schedule for allowable CPT procedure codes.
³ Frequency limitation may be exceeded if a narrative on the claim demonstrates medical necessity for additional services.

D8000-D8999 Orthodontics

Covered orthodontic services are identified by the allowable CDT procedure codes listed in the following table. Medicaid reimbursement is allowable only for services that meet all program requirements. This includes documenting the medical necessity of services in the member's medical record.

Code	Description of Service	Prior Authorization?	Limitations and Requirements
Limited Orthodontic Treatment
D8010	Limited orthodontic treatment of the primary dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
D8020	Limited orthodontic treatment of the transitional dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
D8030	Limited orthodontic treatment of the adolescent dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
D8040	Limited orthodontic treatment of the adult dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
Interceptive Orthodontic Treatment
D8050	Interceptive orthodontic treatment of the primary dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
D8060	Interceptive orthodontic treatment of the transitional dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
Comprehensive Orthodontic Treatment
D8070	Comprehensive orthodontic treatment of the transitional dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
D8080	Comprehensive orthodontic treatment of the adolescent dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
D8090	Comprehensive orthodontic treatment of the adult dentition	Yes	HealthCheck referral is required. Allowable age less than 21.
Minor Treatment to Control Harmful Habits
D8210	Removable appliance therapy	Yes	HealthCheck referral is required. Allowable age less than 21.
D8220	Fixed appliance therapy	Yes	HealthCheck referral is required. Allowable age less than 21.
Other Orthodontic Services
D8660	Pre-orthodontic treatment visit	No	HealthCheck referral is required. Allowable age less than 21. Includes exam, diagnostic tests and consult.
D8670	Periodic orthodontic treatment visit (as part of contract)	Yes	HealthCheck referral is required. Allowable age less than 21. Used for monthly adjustments.
D8680	Orthodontic retention (removal of appliances, construction and placement of retainer[s])	Yes	HealthCheck referral is required. Allowable age less than 21.
D8692	Replacement of lost or broken retainer	Yes	Allowable age less than 21.
D8693	Rebonding or recementing; and/or repair, as required, of fixed retainers	No