Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11010 (10/08)

STATE OF WISCONSIN HFS 107.07(2), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / DENTAL ATTACHMENT 1 (PA/DA1) CHECK BOX FORMAT
The requested identifying information will only be used to process the prior authorization (PA) request. Failure to supply any of the requested information may result in denial of the PA.
Member Identification Number Billing Provider's National Provider Identifier (NPI) Rendering Provider's NPI

CATEGORY Diagnostic Services

PROCEDURE CODES (Check All That Apply) D0210 D0330 D0470 (Prior authorization only required in certain circumstances.) D2390 Tooth No. D2932 D2933 (For members ages 0-20, PA is not required.)

TREATMENT PLAN JUSTIFICATION (Check All That Apply) Frequency limitation to be exceeded (D0210 and D0330) Member over age 20 (D0470) Department of Health Services request Date of models (MM/DD/CCYY)

REQUIRED DOCUMENTATION · Explanation to exceed frequency limitation. · Document number and type of Xrays taken (for D0210 and D0330). · One periapical X-ray. · Explanation to exceed frequency limitation. · D2933 is not allowed on teeth numbers 22-27.

Restorative Services

Endodontic Services

D3310 D3320 D3330 (For members ages 0-20, PA is not required.)

Tooth No.

Tooth numbers 6-11, 22-27, D-G, supernumerary (56-61, 72-77) Successful endodontic treatment More than 50 percent tooth involved in trauma / caries Cannot be restored with composite American Association of Periodontists (AAP) I or II Frequency limitation to be exceeded Member over age 20 Involves root canal therapy on four or more teeth (PA not required for three or fewer teeth)

Tooth No.

AAP I or II Evidence visible on radiographs that at least 50 percent of the clinical crown is intact Restorative treatment completed Restorative treatment in process Extractions completed in last three years (Indicate tooth number, date, and reason for any extractions) Pathology, describe Involves root canal therapy on four or more teeth (PA not required for three or fewer teeth)

All documentation listed below and a treatment plan that indicates all indicated teeth meet clinical criteria. · Full-mouth series X-rays to include bitewing X-rays. · Intra-oral charting. · Document pathology, abcesses, carious exposure, non-vital, etc.

Periodontic Services

D4210 D4211

Medication-induced hyperplasia Irritation from orthodontic bands Hyperplasia More than 25 percent crown involved Other

· Periodontal charting. · Comprehensive periodontal treatment plan. · Include Area of Oral Cavity code(s) on PA/DRF: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right). · Periodontal charting. · Comprehensive periodontal treatment plan. · Include Area of Oral Cavity code(s) on PA/DRF: 10 (upper right), 20 (upper left), 30 (lower left), and 40 (lower right). · Bitewing or full mouth X-rays. · Calculus must be visible on Xrays. · Periodontal charting. · Comprehensive periodontal treatment plan. · Allowed once per 12 months. Continued

D4341 D4342

D4355 (For members ages 13 and older, PA is not required.) D4910

Member over age 12 -- pockets 4 to 6 mm History of periodontal abcess Early bone loss Moderate bone loss AAP II or III Oral hygiene (choose one) -- Good Fair Poor Full-mouth debridement completed in last 12 months. Date of service for D4355 (MM/DD/CCYY) ___________________ Excess calculus on X-ray AAP I or II No dental treatment in multiple years Oral hygiene (choose one) -- Good Fair Poor Member under age 13 Recent history of periodontal scale / surgery Oral hygiene (choose one) -- Good Fair Poor Years requested (check one) -- 1 2 3

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PRIOR AUTHORIZATION / DENTAL ATTACHMENT 1 (PA/DA1) F-11010 (10/08) Member Identification Number Billing Provider's NPI

Page 2 of 2 Rendering Provider's NPI

CATEGORY Prosthodontic Services -- Complete Dentures

PROCEDURE CODES (Check All That Apply) D5110 D5120

TREATMENT PLAN JUSTIFICATION (Check All That Apply) Initial placement of dentures (year) Max _____ Mand ____ Age of existing denture(s) (years) Max _____ Mand _____ New denture request because of the following (choose all that apply) Worn base / broken teeth Poor fit Vertical dimension Date(s) last teeth extracted (MM/DD/CCYY) ______________ Reason for edentulation______________________________ _________________________________________________ Lost / stolen / broken dentures Reline / repair not appropriate Has not worn existing dentures for more than three years Edentulous more than five years without dentures Additional justification _______________________________ ___________________________________________________ Frequency limitation must be exceeded. Initial placement of dentures (year) Max _____ Mand _____ Age of existing denture(s) (years) Max _____ Mand _____ New denture partial request because of the following (choose all that apply) Worn base / broken teeth Poor fit Vertical dimension Date(s) last teeth extracted ___________________________ Tooth numbers extracted ____________________________ Missing at least one anterior tooth and/or has fewer than two posterior teeth in any one quadrant in occlusion with opposing arch Has at least six missing teeth per arch AAP I or II Nonrestorable teeth have been extracted Restorative procedures scheduled Restorative procedures completed Unusual clinical circumstances -- must be documented (e.g., needed for employment) Lost / stolen / broken dentures Reline / repair not appropriate Additional justification Frequency limitation must be exceeded. Loose or ill fitting Tissue shrinkage or weight loss Member is wearing denture Age of the denture or partial __________________________ Frequency limitation must be exceeded. Behavior Disability (describe) _________________________________ Geriatric Physician consult Complicated medical history __________________________ Extensive restoration Maxillofacial surgery (describe) ________________________ Three or more extractions in more than one quadrant.

REQUIRED DOCUMENTATION · New dentures limited to one per five years, per arch. · Six weeks healing period required unless special circumstances documented. · Document reasons for not wearing dentures, or for not having ever had dentures. · Submit medical documentation to support special requests. · Document loss and plan for prevention of future mishaps. · Explanation to exceed frequency limitation.

Prosthodontic Services -- Partial Dentures

D5211 D5212 D5213 D5214 D5225 D5226 D5670 D5671

· X-rays to show entire arch. · Periodontal charting. · New partials limited to one per five years, per arch. · Six weeks healing period required unless special circumstances documented. · Document reasons for not wearing partial dentures, or reasons for not having ever had partial dentures. · Submit medical documentation to support special requests. · Document loss and plan for prevention of future mishaps. · Explanation to exceed frequency limitation.

Prosthodontic Services -- Denture Reline

D5750 D5751 D5760 D5761

Adjunctive General Services -- Anesthesia

D9220 D9241 D9248 (Prior authorization not required for the following: · Services performed in a hospital or ambulatory surgery center. · Services for members ages 0-20 when performed by a pediatric dentist or oral surgeon.) D0999 D2999 D4999 D9999

· Relines limited to one per three years, per arch. · Document special circumstances. · Explanation to exceed frequency limitation. Submit medical documentation to support special circumstances.

HealthCheck Other Services

Periodic oral evaluation (additional) Single unit crown. Tooth number ____________________ Surgical procedure Non-surgical procedure

· Submit medical documentation to support special requests. · HealthCheck referral required.

Additional Comments

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