§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)