Section 140.421  Limitations on Dental Services

Effective for dates of service on or after July 1, 2018:

a)         The Department shall impose prior approval requirements to determine the medical necessity of dental services listed in this Section.  Prior approval is required for:

1)         Crowns;

2)         Partial Pulpotomy;

3)         Periodontal services, except full mouth debridement for diagnostic purposes;

4)         Apexification and recalcification;

5)         Apicoectomy;

6)         Dentures, partial dentures and denture relines;

7)         Maxillofacial prosthetics;

8)         Prosthodontics;

9)         Removal of impacted teeth;

10)        Surgical removal of residual roots;

11)         Surgical exposure to aid eruption;

12)         Alveoloplasty;

13)         Incision and drainage of abscess;

14)         Removal of cysts or tumors;

15)         Frenulectomy;

16)         Orthodontics.  Effective January 1, 2017, medically necessary orthodontic treatment is approved only for patients under the age of 21 and is defined as:

A)        treatment necessary to correct a condition that scores 28 points or more on the Handicapping Labio-Lingual Deviation Index (HLD); or

B)        treatment necessary to correct the following conditions:

i)          Cleft palate;

ii)         Deep impinging bite with signs of tissue damage, not just touching palate;

iii)        Anterior crossbite with gingival recession;

iv)        Severe traumatic deviation (i.e., accidents, tumors, etc.; attach description); and

v)         Effective January 1, 2019, impacted maxillary central incisor;

17)         General anesthesia, conscious sedation or deep sedation;

18)         Therapeutic drug injection;

19)         Other drugs and medicaments;

20)         Unspecified miscellaneous adjunctive general services or procedures;

21)         Dental services not listed in Table D.

b)         The dentist may request post-approval when a dental procedure requiring prior approval is provided on an emergency basis.  Approval of the procedures shall be given if the dental procedure is medically necessary.

(Source:  Amended at 43 Ill. Reg. 1014, effective December 31, 2018)