Prior Authorization

Prior Authorization A. The Division of Medicaid requires prior authorization, except for emergencies, from the Utilization Management/Quality Improvement Organization (UM/QIO) of the following dental services: 1. Surgical access of an unerupted tooth, 2. Radical resection of mandible with tooth bone graft, 3. Arthrotomy, 4. Complicated suture greater than five (5) cm, 5. Osteoplasty – for orthognathic deformities, 6. Osteotomy – mandibular rami, 7. Osteotomy – mandibular rami with bone graft, includes obtaining the graft, 8. Osteotomy – segmented or subapical – per sextant or quadrant, 9. Osteotomy –body of mandible, 10. Lefort I (maxilla – total), 11. Lefort I (maxilla – segmented), 12. Lefort II or Lefort III (osteoplasty of facial bones for midface hypoplasia), 13. Repair of maxillofacial soft and hard tissue defect, 14. Closure of salivary fistula, 15. Coronoidectomy, 16. All procedures billed under unspecified dental procedure codes, and 17. The following types of analgesia and sedation for dental office-based procedures: a. Analgesia, anxiolysis, inhalation of nitrous oxide, b. Non-Intravenous conscious sedation, c. Deep sedation/general anesthesia, and d. Intravenous conscious sedation/analgesia. B. In the case of an emergency, documentation justifying the medical necessity for the urgent or emergency procedure must be provided to the UM/QIO to receive a Treatment Authorization Number (TAN) for billing purposes. C. The prior authorization will apply only to those procedures on the treatment plan which were approved.