Update: New York State Medicaid Program Dental Policy

and Procedure Code Manual

The Department of Health has updated the following sections of the Dental Policy and Procedure
Code Manual:
• Section II Dental Services - Services Not Within the Scope of the Medicaid Program
• Section V Dental Procedure Codes – (3) “Essential” Services, III. Restorative D2000 –
D2999, IV. Endodontics D3000 – D3999, V. Periodontics D4000-D4999, VI.
• Prosthodontics D5000 – D5899, and VIII Implant Services D6000 - D6199

These updates are effective January 31, 2024 and replace existing language. New language is
indicated in a purple font. The New York State Department of Health will be hosting a webinar which
will explain the new policies and criteria guidance on January 2, 2024. The updates will be published
in the Dental Policy and Procedure Code Manual found online at https://www.emedny.org
/ProviderManuals/Dental/index.aspx shortly.

Required forms for prior authorization, titled “Justification of Need for Replacement Prosthesis” and
“Evaluation of the Dental Implant Patient”, are included with this notice. These forms do not need to
be notarized, and Managed Care Organizations (MCOs) and Fee-for-Service (FFS) providers cannot
impose additional criteria other than what is provided on these forms.

Services Not Within the Scope of the Medicaid Program

These services include but are not limited to:
• Fixed bridgework, except for cleft palate stabilization, or when a removeable prosthesis would
be contraindicated;
• Immediate full or partial dentures;
• Crown lengthening, except when associated with medically necessary crown or endodontic
treatment;
• Dental work for cosmetic reasons or because of the personal preference of the member of
provider;
• Periodontal surgery, except when associated with implants or implant related services;
• Gingivectomy or gingivoplasty, except for the sole correction of severe hyperplasia or
hypertrophy associated with drug therapy, hormonal disturbances, or congenital defects;
• Adult orthodontics, except in conjunction with, or as a result of, approved orthognathic surgery
necessary in conjunction with an approved course of orthodontic treatment or the on-going
treatment of clefts;
• Placement of sealants for members under 5 or over 15 years of age; and
• Improper use of panoramic images (D0330) along with intraoral complete series of images
(D0210).

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Section V Dental Procedure Codes
3 “Essential” Services
When reviewing requests for services the following guidelines will be used: Caries index, periodontal
status, recipient compliance, dental history, medical history and the overall status and prognosis of
the entire dentition, among other factors, will be taken into consideration when determining medical
necessity. Treatment is considered appropriate where the prognosis of the tooth is favorable.
Treatment may be appropriate where the total number of teeth which require or are likely to require
treatment is not considered excessive or when maintenance of the tooth is considered essential or
appropriate in view of the overall dental status of the recipient.

Treatment of deciduous teeth when exfoliation is reasonably imminent will not be routinely
reimbursable. Claims submitted for the treatment of deciduous cuspids and molars for children ten
(10) years of age or older, or other deciduous incisors in children five (5) years of age or older will be
pended for professional review. As a condition for payment, it may be necessary to submit, upon
request, radiographic images, and other information to support the appropriateness and necessity of
these restorations. Extraction of deciduous teeth will only be reimbursed if injection of a local
anesthetic is required.

As utilized in this Manual eight (8) posterior points of contact refers to four (4) maxillary and four (4)
mandibular (molars/premolars) in natural or prosthetic functional contact with each other.

For the criteria to be used when determining medical necessity refer to the following specific sections
of the Manual:
• Crowns (Section III);
• Endodontics (Section IV);
• Prosthodontics (Section VI); and
• Implant Services (Section VIII)

III. Restorative D2000 – D2999

Unless otherwise specified, the cost of analgesic and anesthetic agents is included in the
reimbursement for the dental service.

The maximum fee for restoring a tooth with either amalgam or composite resin material will be the
fee allowed for placement of a four-surface restoration. With the exception of the placement of
reinforcement pins (use code D2951), fees for amalgam and composite restorations include tooth
preparation, all adhesives (including amalgam and composite bonding agents), acid etching, cavity
liners, bases, curing and pulp capping.

Caries index, periodontal status, and the overall status and prognosis of the entire dentition, as well
as recipient compliance, dental history, and medical history, among other factors, will be taken into
consideration when determining medical necessity. Treatment is considered appropriate where the
prognosis of the tooth is favorable. Treatment may be appropriate where the total number of teeth
which require or are likely to require treatment is not considered excessive or when maintenance of
the tooth is considered essential or appropriate in view of the overall dental status of the recipient.
Please review Scope of Program and Non-Reimbursable Services and Essential Services in Sections
II and III of the NYS Medicaid Dental Policy and Procedure Code Manual.

Restorations placed solely for the treatment of abrasion, attrition, erosion or abfraction and are not
associated with the treatment of any other pathology are beyond the scope of the program and will
not be reimbursed. Restorative procedures should not be performed without documentation of clinical

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necessity. Published “frequency limits” are general reference points on the anticipated frequency for
that procedure. Actual frequency must be based on the clinical needs of the individual member.

If a non-covered surgical procedure is required to properly restore a tooth, any associated restorative
or endodontic treatment will NOT be considered for reimbursement. Note, this provision does not
apply to crown lengthening, which will be considered for reimbursement when associated with any
medically necessary crown or endodontic treatment.

For codes D2140, D2330 and D2391, only a single restoration will be reimbursable per surface.
Occlusal surface restorations including all occlusal pits and fissures will be reimbursed as one-surface
restorations whether or not the transverse ridge of an upper molar is left intact. Codes D2150,
D2160, D2161, D2331, D2332, D2335, D2781, D2392, D2393, and D2394 are compound
restorations encompassing 2, 3, 4 or more contiguous surfaces. Restorations that connect contiguous
surfaces must be billed using the appropriate multi-surface restorative procedure code.

Amalgam Restorations (Including Polishing)

Code Description
D2140 Amalgam - one surface, primary or permanent (SURF/TOOTH) $50.50
D2150 Amalgam - two surfaces, primary or permanent (SURF/TOOTH) $67.67
D2160 Amalgam - three surfaces, primary or permanent $82.82
(SURF/TOOTH)
D2161 Amalgam - four or more surfaces, primary or permanent $98.98
(SURF/TOOTH)
Resin-Based Composite-Restorations Direct
Code Description
D2330 Resin-based composite - one surface, anterior (SURF/TOOTH) $50.50
D2331 Resin-based composite - two surfaces, anterior (SURF/TOOTH) $73.73
D2332 Resin-based composite - three surfaces, anterior (SURF/TOOTH) $87.87
Resin-based composite - four or more surfaces or involving incisal
D2335 $98.98
angle (anterior) (SURF/TOOTH)
D2390 Resin-based composite crown, anterior (TOOTH) $98.98
Resin-based composite; one surface, posterior (SURF/TOOTH)
$50.50
D2391 Used to restore a carious lesion into the dentin or a deeply eroded area
into the dentin. Not a preventive procedure
D2392 Resin-based composite - two surfaces, posterior (SURF/TOOTH) $67.67
D2393 Resin-based composite - three surfaces, posterior (SURF/TOOTH) $82.82
Resin-based composite – four or more surfaces, posterior
D2394 $98.98
(SURF/TOOTH)

Crowns – Single Restorations Only

The materials used in the fabrication of a crown (e.g., all-metal, porcelain, ceramic, resin) is at the
discretion of the provider. The crown fabricated must correctly match the procedure code approved
on the Prior Approval.

Crowns include any necessary core buildups.

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Crowns for members under the age of 21 will be covered when medically necessary. In determining
whether a requested crown is medically necessary, the following factors may be considered:
• The periodontal status, member compliance and overall status and prognosis of the tooth is
favorable.
• The tooth is not routinely restorable with a filling.

Crowns for members 21 years of age and over will be covered when medically necessary. In
determining whether a crown is medical necessary, the following factors may be considered:
• There is a documented medical condition which precludes extraction.
• The tooth is a critical abutment for an existing or proposed prosthesis.
• If the tooth is a posterior tooth, the following additional factors may be considered:
o The periodontal status, member compliance and overall status and prognosis of the tooth
is favorable.
o The tooth is not routinely restorable with a filling.
o There are eight (8) or more natural or prosthetic points of contact present.
o If the posterior tooth is a molar, treatment of the molar is necessary to maintain functional
or balanced occlusion of the patient’s dentition.
o Consideration for a third (3rd) molar will be given if the third (3rd) molar occupies the first
(1st) or second (2nd) molar position.
o Note: Requests for treatment on unopposed molars must include a narrative documenting
medical necessity.
• If the tooth is an anterior tooth, the following additional factors may be considered:
o The periodontal status, member compliance and overall status and prognosis of the tooth
is favorable.
o The tooth is not routinely restorable with a filling

Crowns - Single Restorations Only

Code Description
Crown – resin-based composite (indirect) (laboratory) (TOOTH) (PA
D2710 REQUIRED) Acrylic (processed) jacket crowns may be approved as $292.90
restorations for severely fractured anterior teeth.
D2720 Crown – resin with high noble metal (TOOTH) (PA REQUIRED) $505.00
D2721 Crown – resin with predominantly base metal (TOOTH) (PA REQUIRED) $505.00
D2722 Crown – resin with noble metal (TOOTH) (PA REQUIRED) $505.00
D2740 Crown – porcelain/ceramic (TOOTH) (PA REQUIRED) $505.00
D2750 Crown – porcelain fused to high noble metal (TOOTH) (PA REQUIRED) $505.00
Crown – porcelain fused to predominately base metal (TOOTH) (PA
D2751 $505.00
REQUIRED)
D2752 Crown – porcelain fused to noble metal (TOOTH) (PA REQUIRED) $505.00
Crown – porcelain fused to titanium and titanium alloys (TOOTH) (PA
D2753 $505.00
REQUIRED)
D2780 Crown – ¾ cast high noble metal (TOOTH) (PA REQUIRED) $404.00
D2781 Crown – ¾ cast predominantly base metal (TOOTH) (PA REQUIRED) $404.00
D2782 Crown – ¾ cast noble metal (TOOTH) (PA REQUIRED) $404.00
D2790 Crown – full cast high noble metal (TOOTH) (PA REQUIRED) $505.00
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D2791 Crown – full cast predominately base metal (TOOTH) (PA REQUIRED) $505.00
D2792 Crown – full cast noble metal (TOOTH) (PA REQUIRED) $505.00
D2794 Crown – Titanium and titanium alloys $505.00

Other Restorative Services

For all prefabricated crowns (D2930, D2931, D2932, D2933, D2934) there must be supporting
documentation substantiating the need for the crown (e.g., radiographic images).

Code Description
D2920 Re-cement or re-bond crown (TOOTH) $30.30

Claims for recementation of a crown by the original provider within one year of placement, or claims
for subsequent recementations of the same crown, will be pended for professional review.
Documentation to justify the need and appropriateness of such recementations may be required as
a condition for payment.

Code Description
D2930 Prefabricated stainless steel crown - primary tooth (TOOTH) $117.16
D2931 Prefabricated stainless steel crown - permanent tooth (TOOTH) $117.16
D2932 Prefabricated resin crown (TOOTH) $117.16

Must encompass the complete clinical crown and should be utilized with the same criteria as for full
crown construction. This procedure is limited to one occurrence per tooth within two years. If
replacement becomes necessary during that time, claims submitted will be pended for professional
review. To justify the appropriateness of replacements, documentation must be included as a claim
attachment. Placement on deciduous anterior teeth is generally not reimbursable past the age of five
(5) years of age, unless medically necessary based on the clinical needs of the individual member.

Code Description
Prefabricated stainless steel crown with resin window (TOOTH)
D2933 Restricted to primary anterior teeth, permanent maxillary bicuspids and first $131.30
molars.
Prefabricated esthetic coated stainless steel crown – primary tooth
D2934 $131.30
(TOOTH)
D2951 Pin retention - per tooth, in addition to restoration (TOOTH) $29.29

IV. Endodontics D3000 – D3999

All radiographic images taken during the course of root canal therapy and all post-treatment
radiographic images are included in the fee for the root canal procedure. At least one pre-treatment
radiographic image demonstrating the need for the procedure, and one post-treatment radiographic
image that demonstrates the result of the treatment, must be maintained in the member's record.

Surgical root canal treatment or apicoectomy may be considered appropriate and covered when the
root canal system cannot be acceptably treated non-surgically, there is active root resorption, or
access to the canal is obstructed. Treatment may also be covered where there is gross over or under

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extension of the root canal filling, periapical or lateral pathosis persists, or there is a fracture of the
root.

Pulp capping, either direct or indirect, is not reimbursable.

Root canal therapy for members under the age of 21 will be covered when medically necessary. In
determining whether a requested root canal is medically necessary, the following factors may be
considered:

• The periodontal status, member compliance and overall status and prognosis of the tooth is
favorable.
• The tooth is not routinely restorable with a filling

Root canal therapy for members 21 and over will be covered when medically necessary. In
determining whether requested endodontic treatment is medically necessary, the following factors
may be considered:
• There is a documented medical condition which precludes an extraction
• The tooth is a critical abutment for an existing or proposed prosthesis
• If the tooth is a posterior tooth, the following additional factors may be considered:
o The periodontal status, member compliance and overall status and prognosis of the
tooth is favorable
o There are eight or more natural or prosthetic posterior points of contact present
o If the posterior tooth is a molar, treatment of the molar is necessary to maintain
functional or balanced occlusion of the patient’s dentition
o Consideration for a third molar will be given if the third molar occupies the first or
second molar position
o Note: Requests for treatment on unopposed molars must include a narrative
documenting medical necessity
• If the tooth is an anterior tooth, the following additional factors may be considered:
o The periodontal status, member compliance and overall status and prognosis of the
tooth is favorable

Pulpotomy

Pulpotomy
Code Description
Therapeutic pulpotomy (excluding final restoration) - removal of pulp
D3220 coronal to the dentinocemental junction and application of $87.87
medicament (TOOTH)

To be performed on primary or permanent teeth up until the age of 21 years. This is not to be
considered as the first stage of root canal therapy. Pulp capping (placement of protective dressing or
cement over exposed or nearly exposed pulp for protection from injury or as an aid in healing and
repair) is not reimbursable. This procedure code may not be used when billing for an "emergency
pulpotomy", which should be billed as palliative treatment.

Endodontic Therapy on Primary Teeth

Endodontic therapy on primary teeth with succedaneous teeth and placement of resorbable
filling. This includes pulpectomy, cleaning, and filling of canals with resorbable material.

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 Endodontic Therapy on Primary Teeth
Code Description
Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding
D3230 $151.50
final restoration) (TOOTH) (PA REQUIRED)
Pulpal therapy (resorbable filling) – posterior, primary tooth
D3240 $237.35
(excluding final restoration) (TOOTH) (PA REQUIRED)

Endodontic Therapy (Including Treatment Plan, Clinical Procedures, and Follow-Up Care)
Includes primary teeth without succedaneous teeth and permanent teeth.

Endodontic Therapy
Code Description
Endodontic therapy – anterior tooth (excluding final restoration)
D3310 $252.50
(TOOTH) (PA REQUIRED)
Endodontic therapy – premolar tooth (excluding final restoration)
D3320 $303.00
(TOOTH) (PA REQUIRED)
Endodontic therapy – molar tooth (excluding final restoration)
D3330 $404.00
(TOOTH) (PA REQUIRED)

Endodontic Retreatment

Endodontic Retreatment
Code Description

D3346 Retreatment of previous root canal therapy – anterior (TOOTH) (PA $252.50
REQUIRED)
D3347 Retreatment of previous root canal therapy – premolar (TOOTH) (PA $303.00
REQUIRED)
D3348 Retreatment of previous root canal therapy – molar (TOOTH) (PA $404.00
REQUIRED)

Apexification / Recalcification Procedures

Apexification / Recalcification Procedures

Code Description
Apexification / recalcification - initial visit (apical closure/calcific
repair of perforations, root resorption, etc.) (TOOTH) Includes opening
D3351 tooth, pulpectomy, preparation of canal spaces, first placement of $82.82
medication and necessary radiographic images. (This procedure includes
first phase of complete root canal therapy.)
Apexification / recalcification - interim medication replacement
(TOOTH) For visits in which the intra-canal medication is replaced with
D3352 new medication. Includes any necessary radiographs. There may be $80.80
several of these visits. The published fee is the maximum reimbursable
amount regardless of the number of visits.
Apexification / recalcification - final visit (include completed root
D3353 $104.03
canal therapy – apical closure/calcific repair of perforations, root
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 resorption, etc.) (TOOTH) Includes the removal of intra-canal
medication and procedures necessary to place final root canal filling
material including necessary radiographs. (This procedure includes last
phase of complete root canal therapy.)

Apicoectomy
Periradicular surgery is a term used to describe surgery to the root surface (e.g., apicoectomy),
repair of a root perforation or resorptive defect, exploratory curettage to look for root fractures,
removal of extruded filling materials or instruments, removal of broken root fragments, sealing
of accessory canals, etc. This does not include retrograde filling material placement.
Performed as a separate surgical procedure and includes periapical curettage.

Apicoectomy
Code Description
D3410 Apicoectomy - anterior (TOOTH) (PA REQUIRED) $161.60
Apicoectomy - premolar (first root) (TOOTH) (PA REQUIRED)
D3421 $161.60
If more than one root is treated, see D3426
Apicoectomy - molar (first root) (TOOTH) (PA REQUIRED)
D3425 $181.80
If more than one root is treated, see D3426
D3426 Apicoectomy (each additional root) (TOOTH) (PA REQUIRED) $60.60
D3430 Retrograde filling - per root (TOOTH) (PA REQUIRED) $50.50

Other Endodontic Procedures

Code Description
D3999 Unspecified endodontic procedure, by report (Report Needed) (BR)

V. Periodontics D4000-D4999
Surgical Services (Including Usual Post-Operative Care)
D4210 and D4211 are reimbursable solely for the correction of severe hyperplasia or hypertrophy
associated with drug therapy, hormonal disturbances or congenital defects.
• The provider must keep in the treatment record detailed documentation describing the
need for gingivectomy or gingivoplasty including pretreatment photographs depicting the
condition of the tissues.

Clinical Crown Lengthening- hard tissue

Code Description
D4249 Clinical Crown Lengthening – hard tissue (PA REQUIRED) $75.00

• Crown lengthening requires reflection of a full thickness flap and removal of bone, altering the
crown to root ratio.
• The periodontal status, member compliance, and overall status and prognosis of the tooth
may be taken into consideration when determining medical necessity.

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 • Crown lengthening is reimbursable solely when associated with medically necessary crown
or root canal procedure.
• All requests for coverage of a crown lengthening should include a complete treatment plan
addressing all areas of pathology. The provider must keep in the treatment record detailed
documentation describing the need for crown lengthening including pretreatment
photographs depicting the condition of the tissues.
• Coverage of a crown lengthening should be requested at the same time as a request for
coverage of a crown and/or a root canal.
• If the need for crown lengthening is discovered during a procedure, then providers should
refer to Prior Approval Change Request information on page 18.

VI. Prosthodontics
Full and/or partial dentures are covered by Medicaid when they are determined to be medically
necessary, including when necessary to alleviate a serious condition or one that is determined to
affect employability. This service requires prior approval.

Complete dentures and partial dentures, whether unserviceable, lost, stolen, or broken will not be
replaced for a minimum of eight (8) years from initial placement except when determined to be
medically necessary by the Department or its agent. Prior approval requests for replacement dentures
prior to eight (8) years must include a completed Justification of Need for Replacement Prosthesis
form signed by the patient’s dentist, explaining the specific circumstances that necessitates
replacement of the denture. If replacement dentures are requested within the eight (8) year period
after they have already been replaced once, then the dentist’s supporting documentation must include
an explanation of preventative measures instituted to alleviate the need for further replacements.

General Guidelines for All Removable Prosthesis:

• Requests for partial dentures will be reviewed based on the presence/absence of eight (8)
points of natural or prosthetic posterior occlusal contact and/or one (1) missing maxillary
anterior or two (2) missing mandibular teeth.
• Complete and/or partial dentures will be approved only when the existing prosthesis is not
serviceable and cannot be relined or rebased. Reline or rebase of an existing prosthesis will
not be reimbursed when such procedures are performed in addition to a new prosthesis for
the same arch within six (6) months of the delivery of a new prosthesis. Only “tissue
conditioning” (D5850 or D5851) is payable within six (6) months prior to the delivery of new
prosthesis.
• Six (6) months of post-delivery care from the date of insertion is included in the reimbursement
for all newly fabricated prosthetic appliances. This included rebasing, relining, adjustments,
and repairs.
• Cleaning of removable prosthesis or soft tissue not directly related to natural teeth or implants
is not a covered service. Prophylaxis and/or scaling and root planning is only payable when
performed on natural dentition.
• “Immediate” prosthetic appliances are not a covered service. An appropriate length of time for
healing should be allowed before taking final impressions. Generally, it is expected that tissue
will need a minimum of four (4) to six (6) weeks for healing. Claims for denture insertion
occurring within four (4) weeks of extraction(s) will pend for professional review.
• Claims are not to be submitted until the denture(s) are completed and delivered to the
member. The “date of service” used on the claim is the date that the denture(s) are delivered.
If the prosthesis cannot be delivered or the member has lost eligibility following the date of the
“decisive appointment” claims should be submitted following the guidelines for “Interrupted
Treatment”.
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 • Medicaid payment is considered payment in-full. Except for members with a “spend down,”
members cannot be charged beyond the Medicaid fee. Deposits, down-payments, or advance
payments are prohibited.
• All treatment notes, radiographic images, laboratory prescriptions and laboratory invoices
should be made part of the member's treatment record to be made available upon request in
support of any treatment provided, and;
• The total cost of repairs should not be excessive and should not exceed 50% of the cost of a
new prosthesis. If the total cost of repairs and/or relines is to exceed 50% of the cost of a new
prosthesis, a prior approval request for a new prosthesis should be submitted with a detailed
description of the existing prosthesis including why any replacement would be necessary
per Medicaid guidelines and would be more appropriate than repair of the existing prosthesis.

Complete Dentures (Including Routine Post-Delivery Care)

Radiographs are not routinely required to obtain prior approval for full dentures. The guidelines
published by the ADA and the U.S. Department of Health and Human Services on the use of x-rays
should be followed. Additional information is found here: The Selection of Patients for Dental
Radiographic Examinations | FDA.

Complete Dentures (Including Routine Post-Delivery Care)

Code Description
D5110 Complete denture – maxillary (PA REQUIRED) $565.60
D5120 Complete denture – mandibular (PA REQUIRED) $565.60

Partial Dentures (Including Routine Post-Delivery Care)

Caries index, periodontal status, recipient compliance, dental history, medical history and the overall
status and prognosis of the entire dentition, among other factors, will be taken into consideration
when determining medical necessity. Scope of Program and Non-Reimbursable Services and
Essential Services in Sections II and III of the NYS Medicaid Dental Policy and Procedure Code
Manual.

Requirements for the placement of partial dentures are:

• All phase I restorative treatment which includes extractions, removal of all decay and
restoration with permanent filling materials, endodontic therapy, crowns, etc. must be
completed prior to taking the final impressions(s) or partial dentures(s).
• Partial dentures can be considered for ages 15 years and above; an “Interim Prosthesis”
(procedure codes D5820 and/or D5821) can be considered for individuals 5 to 15 years of
age.

Partial Dentures (Including Routine Post-Delivery Care)

Code Description
Maxillary partial denture - resin base (including retentive/clasping
D5211 $353.50
materials, rests, and teeth) (PA REQUIRED)
Mandibular partial denture - resin base (including retentive/clasping
D5212 $353.50
materials, rests, and teeth) (PA REQUIRED)
Maxillary partial denture – cast metal framework with resin denture base
D5213 (including retentive/clasping materials, rests, and teeth) (PA $565.60
REQUIRED)

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 Mandibular partial denture – cast metal framework with resin denture
D5214 bases (including retentive/clasping materials, rests, and teeth) (PA $565.60
REQUIRED)
Maxillary partial denture – flexible base (including retentive/clasping
D5225 $565.60
materials, rests and teeth) (PA REQUIRED)
Mandibular partial denture – flexible base (including retentive/clasping
D5226 $565.60
materials, rests, and teeth) (PA REQUIRED)

Adjustments to Dentures
Adjustments within six months of the delivery of the prosthesis are considered part of the payment
for the prosthesis. Adjustments (procedure codes D5410, D5411, D5421, and D5422) are not
reimbursable on the same date of service as the initial insertion of the prosthetic appliance OR; on
the same date of service as any repair, rebase, or reline procedure code.

Adjustments to Dentures
Code Description
D5410 Adjust complete denture – maxillary $25.25
D5411 Adjust complete denture – mandibular $25.25
D5421 Adjust partial denture – maxillary $25.25
D5422 Adjust partial denture – mandibular $25.25

Prosthetic Appliance Repairs

Limitation: The total cost of repairs should not be excessive and should not exceed 50% of the cost
of a new prosthesis. If the total cost of repairs is to exceed 50% of the cost of a new prosthesis, a
prior approval request for a new prosthesis should be submitted with a detailed description of the
existing prosthesis and why any replacement would be necessary per Medicaid guidelines and would
be more appropriate than repair of the existing prosthesis.

Repairs to Complete Dentures

Code Description
D5511 Repair broken complete denture base, mandibular $65.65
D5512 Repair broken complete denture base, maxillary $65.65
Replace missing or broken teeth – complete denture (each tooth)
D5520 $42.42
(TOOTH)

Repairs to Partial Dentures

Code Description
D5611 Repair resin partial denture base, mandibular $67.67
D5612 Repair resin partial denture base, maxillary $67.67
D5621 Repair cast partial framework, mandibular $121.20
D5622 Repair cast partial framework, maxillary $121.20
Repair or replace broken retentive/clasping materials-per tooth
D5630 $131.30
(TOOTH)
D5640 Replace broken teeth-per tooth (TOOTH) $60.60
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D5650 Add tooth to existing partial denture (TOOTH) $65.65
D5660 Add clasp to existing partial denture-per tooth (TOOTH) $103.02

Denture Rebase Procedures

Rebase procedures are not payable within six months prior to the delivery of a new prosthesis.
Only “tissue conditioning” (D5850 and D5851) is payable within six months prior to the delivery
of a new prosthesis.

Repairs to Complete Dentures

Code Description
D5710 Rebase - complete maxillary denture (PA REQUIRED) $171.70
D5711 Rebase - complete mandibular denture (PA REQUIRED) $171.70
D5720 Rebase – maxillary partial denture (PA REQUIRED) $175.74
D5721 Rebase – mandibular partial denture (PA REQUIRED) $175.74

Denture Reline Procedures

Reline procedures are not payable within six months prior to the delivery of a new prosthesis.
For cases in which it is impractical to complete a laboratory reline, prior approval for an office
(“chairside” or “cold cure”) reline may be requested with credible documentation which would
preclude a laboratory reline. Only “tissue conditioning” (D5850 and D5851) is payable within
six months prior to the delivery of a new prosthesis.

Denture Reline Procedures

Code Description
D5730 Reline complete maxillary denture (direct) (PA REQUIRED) $126.25
D5731 Reline complete mandibular denture (direct) (PA REQUIRED) $126.25
D5740 Reline maxillary partial denture (direct) (PA REQUIRED) $85.85
D5741 Reline mandibular partial denture (direct) (PA REQUIRED) $85.85
D5750 Reline complete maxillary denture (indirect) $171.70
D5751 Reline complete mandibular denture (indirect) $171.70
D5760 Reline maxillary partial denture (indirect) $126.25
D5761 Reline mandibular partial denture (indirect) $126.25

Interim Prosthesis
Reimbursement is limited to once per year and only for children between 5 and 15 years of age.
Codes D5820 and D5821 are not to be used in lieu of space maintainers. All claims will be
pended for professional review prior to payment.

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 Interim Prosthesis
Code Description
Interim partial denture (including retentive/clasping materials,
D5820 $175.74
rests, and teeth), maxillary
Interim partial denture (including retentive/clasping materials,
D5821 $175.74
rests, and teeth), mandibular

Other Removable Prosthetic Services

Codes D5850 and D5851 are for treatment reline using materials designed to heal unhealthy
ridges prior to more definitive final restoration. This is the ONLY type of reline reimbursable
within six (6) months prior to the delivery of a new prosthesis. Insertion of tissue conditioning
liners in existing dentures will be limited to once per denture unit. D5850 and D5851 are not
reimbursable under age 15 and should be billed one time at the completion of treatment,
regardless of the number of visits involved.

Other Removable Prosthetic Services

Code Description
D5850 Tissue conditioning, maxillary $25.25
D5851 Tissue conditioning, mandibular $25.25
Unspecified removable prosthodontic procedure, by report
D5899 (BR)
(REPORT NEEDED)

VIII. Implant Services D6000 - D6199

Dental implants, including single implants, and implant related services, will be covered by Medicaid
when medically necessary. Prior approval requests for implants must have supporting documentation
from the patient’s dentist. The patient’s dentist’s office must submit a completed Evaluation of the
Dental Implant Patient form documenting, among other things, the patient’s medical history, current
medical conditions being treated, list of all medications currently being taken by the patient,
explaining why implants are medically necessary and why other covered functional alternatives for
prosthetic replacement will not correct the patient’s dental condition, and certifying that the patient is
an appropriate candidate for implant placement. If the patient’s dentist indicates that the patient is
currently being treated for a serious medical condition, the Department may request further
documentation from the patient’s treating physician.

General Guidelines:
• The dentist’s explanation as to why other covered functional alternatives for prosthetic
replacement will not correct the patient’s dental condition will be reviewed based on the
presence/absence of eight (8) points of natural or prosthetic posterior occlusal contact and/or
one (1) missing maxillary anterior or two (2) missing mandibular teeth.
• A complete treatment plan addressing all phases of care is required and should include the
following:
o Accurate pretreatment charting;
o Complete treatment plan addressing all areas of pathology;
o Inter-arch distances;
o Number, type and location of implants to be placed;
o Design and type of planned restoration(s);

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 o Sufficient number of current, diagnostic radiographs and/or CT scans allowing for the
evaluation of the entire dentition.
• If bone graft augmentation is needed there must be a 4 to 6-month healing period before a
dental implant can be placed
• Dental implant code D6010 will be re-evaluated via intraoral radiographs or CT scans prior to
the authorization of abutments, crowns, or dentures four to six months after dental implant
placement.
• Treatment on an existing implant / implant prosthetic will be evaluated on a case- by-case
basis.
• Implant and implant related codes not listed will be considered on a case-by-case basis.
• Documentation must include a list of all medications currently being taken and all conditions
currently being treated.
• All cases will be considered based upon supporting documentation and current standard of
care.

For procedure codes D6010 and D6013 the following must be submitted:
• Full mouth radiographs or a diagnostic panorex including periapicals of site requesting
dental implant(s).

Implant Services
Code Description
Surgical placement of implant body (TOOTH) (PA REQUIRED)
POST OPERATIVE CARE: 90 DAYS) Full mouth radiographs or diagnostic
D6010 $1010.00
panorex including periapicals of site requesting dental implant(s) must be
provided.
Surgical placement of mini implant (TOOTH) (PA REQUIRED)
(POST OPERATIVE CARE: 90 DAYS) Full mouth radiographs or
D6013 $505.00
diagnostic panorex including periapicals of site requesting dental
implant(s) must be provided.

For procedure codes D6055-D6057 the following must be submitted:

• Periapical radiograph of the integrated implant(s), and,
• Panorex of sufficient number of radiographs showing the complete arch and the placed
implant(s)

Code Description
Connecting bar – implant supported or abutment supported
D6055 $404.00
(ARCH) (PA REQUIRED)
Prefabricated abutment – includes modification and placement
D6056 $404.00
(TOOTH) (PA REQUIRED)
D6057 Custom fabricated abutment – includes placement $404.00

For procedure codes D6058 – D6067, D6094 the following must be submitted:
• Periapical radiograph of integrated implant with abutment
• Intra-oral photograph of healed abutment showing healthy gingiva

Code Description
Abutment supported porcelain/ceramic crown (TOOTH) (PA
D6058 $808.00
REQUIRED)

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 Abutment supported porcelain fused to metal crown (high noble
D6059 $808.00
metal) (TOOTH) (PA REQUIRED)
Abutment supported porcelain fused to metal crown (predominantly
D6060 $808.00
base metal) (TOOTH) (PA REQUIRED)
Abutment supported porcelain fused to metal crown (noble metal)
D6061 (TOOTH) (PA REQUIRED) $808.00
Abutment supported cast metal crown (high noble metal) (TOOTH)
D6062 (PA REQUIRED) $808.00
Abutment supported cast metal crown (predominately base metal)
D6063 (TOOTH) (PA REQUIRED) $808.00
Abutment supported cast metal crown (noble metal) (TOOTH) (PA
D6064 REQUIRED) $808.00

D6065 Implant supported porcelain/ceramic crown (TOOTH) (PA REQUIRED) $808.00

Implant supported crown - porcelain fused to high noble alloys
D6066 (TOOTH) (PA REQUIRED) $808.00

D6067 Implant supported crown - high noble alloys (TOOTH) (PA REQUIRED) $808.00
Scaling and debridement in the presence of inflammation or
mucositis of a single implant, including cleaning on the implant
surfaces without flap entry and closure (TOOTH) (REPORT NEEDED)
D6081 • Cannot bill for same date of service as D1110 or D4910. (BR)
• Cannot bill for same date of service and same quadrant as D4341,
D4342.

D6090 Repair implant supported prosthesis (ARCH) (REPORT NEEDED) (BR)

Replacement of replaceable part of semi-precision or precision
D6091 attachment (male or female component) of implant/abutment (BR)
supported prosthesis, per attachment (QUAD) (REPORT NEEDED)
Re-cement or re-bond implant/abutment supported crown
D6092 (BR)
(TOOTH) (REPORT NEEDED)
Re-cement or re-bond implant/abutment supported fixed partial
D6093 (BR)
denture (QUAD) (REPORT NEEDED)
D6094 Abutment supported crown – titanium and titanium alloys $808.00
(TOOTH) (PA REQUIRED)
D6095 Repair implant abutment (TOOTH) (REPORT NEEDED) (BR)
Remove broken implant retaining screw (TOOTH) (REPORT
D6096 (BR)
NEEDED)
Surgical Removal of Implant Body (TOOTH) (REPORT NEEDED) (POST
D6100 (BR)
OPERATIVE CARE: 10 DAYS)

For procedure codes D6101 – D6103 the following must be submitted:

• Pre-operative radiographic image of defect
• Detailed narrative
Intra-oral photograph of defect area

Code Description
Debridement of a peri-implant defect or defects surrounding a single $252.50
implant, and surface cleaning of the exposed implant surfaces,
D6101
including flap entry and closure (TOOTH) (PA REQUIRED) (POST
OPERATIVE CARE: 30 DAYS)
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 Debridement and osseous contouring of a peri-implant defect or $404.00
defects surrounding a single implant and includes surface cleaning
D6102
of the exposed implant surfaces, including flap entry and closure
(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 30 DAYS)
Bone graft for repair of peri-implant defect – does not include flap $202.00
D6103 entry and closure (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE:
30 DAYS)
D6104 Bone graft at time of implant placement (TOOTH) (PA REQUIRED)
(POST OPERATIVE CARE: 90 DAYS)
$252.50

For procedure codes D6110 – D6113 the following must be submitted:

• Periapical radiograph of integrated implant(s) with abutment placed
• IO photo of healed abutment showing healthy gingiva

Code Description
Implant/abutment supported removable denture for edentulous arch –
D6110 $1010.00
maxillary (PA REQUIRED)
Implant/abutment supported removable denture for edentulous arch –
D6111 $1010.00
mandibular (PA REQUIRED)
Implant/abutment supported removable denture for partially
D6112 $909.00
edentulous arch – maxillary (PA REQUIRED)
Implant/abutment supported removable denture for partially
D6113
edentulous arch – mandibular (PA REQUIRED) $909.00
Radiographic/surgical implant index, by report (ARCH) (REPORT
D6190 (BR)
NEEDED)
Semi-precision abutment - placement (TOOTH) (PA REQUIRED) This
D6191 procedure is the initial placement, or replacement, or a semi-precision $202.00
abutment on the implant body.
Semi-precision attachment – placement (TOOTH) (PA REQUIRED) This
D6192 procedure involves the luting of the initial, or replacement, semi-precision $50.50
Attachment to the removable prosthesis
Unspecified implant procedure, by report (REPORT NEEDED) The
following procedure codes are a covered benefit only when associated with
D6199 (BR)
an implant or an implant-related service D4245, D4266, D4267, D4273,
D4278, D4283, D4285

Code Description
Apically positioned flap (TOOTH (PA REQUIRED) (POST OPERATIVE
CARE: 14 DAYS) Procedure is used to preserve keratinized gingiva in
conjunction with osseous resection and second stage implant procedure.
D4245 $126.25
Procedure may also be used to preserve keratinized/attached gingiva
during surgical exposure of labially impacted teeth and may be used
during treatment of peri-implantitis.
Guided tissue regeneration – resorbable barrier, per site (TOOTH) (PA
REQUIRED) (POST OPERATIVE CARE: 14 DAYS) This procedure does
not include flap entry and closure, or, when indicated, wound
D4266 $126.25
debridement, osseous contouring, bone replacement grafts, and
placement of biologic materials to aid in osseous regeneration. This
procedure can be used for periodontal defects around natural teeth.
Guided tissue regeneration – non-resorbable barrier, per site (includes
D4267 $151.50
membrane removal) (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE:

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 14 DAYS) This procedure does not include flap entry and closure, or,
when indicated, wound debridement, osseous contouring, bone
replacement grafts, and placement of biologic materials to aid in
osseous regeneration. This procedure can be used for periodontal
defects around natural teeth.
Autogenous connective tissue graft procedure (including donor and
recipient surgical sites) first tooth, implant or edentulous tooth position
in graft (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)
D4273 There are two surgical sites. The recipient site utilizes a split thickness $303.00
incision, retaining the overlapping flap of gingiva and/or mucosa. The
connective tissue is dissected from a separate donor site leaving an
epithelialized flap for closure
Non-autogenous connective tissue graft (including recipient site and
D4275 donor material) – first tooth, implant, or edentulous tooth position in $404.00
graft (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)
Free soft tissue graft procedure (including recipient and donor surgical
sites) first tooth, implant, or edentulous tooth position in graft (TOOTH)
(PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS) There is only a
D4277 $404.00
recipient surgical site utilizing split thickness incision, retaining the
overlaying flap of gingiva and/or mucosa. A donor surgical site is not
present.
Free soft tissue graft procedure (including recipient and donor
surgical sites) each additional contiguous tooth, implant, or
D4278 $303.00
edentulous tooth position in same graft site (TOOTH) (PA REQUIRED)
(POST OPERATIVE CARE: 14 DAYS) Used in conjunction with D4277
Autogenous connective tissue graft procedure (including donor and
recipient surgical sites) – each additional contiguous tooth, implant
D4283 or edentulous tooth position in same graft site (TOOTH) (PA $202.00
REQUIRED) (POST OPERATIVE CARE: 14 DAYS) Used in conjunction
with D4273.
Non-autogenous connective tissue graft procedure (including
recipient surgical site and donor material) – each additional
D4285 contiguous tooth, implant or edentulous tooth position in same graft $303.00
site. (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)
Used in conjunction with D4275.

The following procedure codes are a covered benefit only when associated with an implant or an
implant-related service: D7951, D7952, D7953.

Code Description
Sinus augmentation with bone or bone substitutes via a lateral open
approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)
The augmentation of the sinus cavity to increase alveolar height for
D7951 reconstruction of edentulous portions of the maxilla. This procedure is $808.00
performed via a lateral open approach. This includes obtaining the bone or
bone substitutes. Placement of a barrier membrane if used should be
reported separately
Sinus augmentation with bone or bone substitutes via a vertical
approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE: 14 DAYS)
The augmentation of the sinus to increase alveolar height by vertical
D7952 $808.00
access through the ridge crest by raising the floor of the sinus and
grafting as necessary. This includes obtaining the bone or bone
substitutes
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 Bone replacement graft for ridge preservation – per site (TOOTH) (PA
REQUIRED) (POST OPERATIVE CARE: 10 DAYS) Graft is placed in an
extraction or implant removal site at the time of extraction or removal to
D7953 preserve ridge integrity (e.g., clinically indicated in preparation for $252.50
implant reconstruction or where alveolar contour is critical to planned
prosthetic reconstruction) Does not include obtaining graft material.
Membrane if used should be reported separately.

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