Dental Prior Authorization Requests

Date: 10/01/24

Heritage Health (Medicaid):

Nebraska Total Care required documentation for dental prior authorization requests by code:

D2710, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2790, D2791, D2792 - pre-operative periapical x-rays and optional photos, completed RCT film for molars.

D4341, D4342- Full mouth series of x-rays to include posterior bitewings, full mouth periodontal charting, narrative of necessity, optional photographs.

D4910 - Narrative of medical necessity, scaling and root planing history.

D5110, D5120, D5130, D5140, D5214 - Pre-operative x-rays (should include panorex) and narrative of necessity.

D5520, D5640, D5650, D5765 – Narrative of necessity.

D5810, D5811 - Date and list of teeth to be extracted, narrative of medical necessity, and x-rays.

D5211, D5212, 5213, D5214, D5820, D5821 - List missing teeth and teeth to be extracted; age of existing partials, or statement identifying the prosthesis as an initial placement; X-rays showing missing teeth or teeth to be extracted.

D8020, D8080, D8090 - Rationale/treatment plan, completed NE HLD Form 471-000-406, complete set of diagnostic color photos (or OrthoCad equivalent), panoramic x-ray and lateral cephalometric radiograph.

D8999 - Narrative of medical necessity.

For further assistance please send all request to DentalProviderRelations@Centene.com.