Ill. Admin. Code tit. 89 § 140.421

Current through Register Vol. 48, No. 45, November 8, 2024

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.

Ill. Admin. Code tit. 89, § 140.421

Amended at 27 Ill. Reg. 14799, effective September 5, 2003

Amended at 38 Ill. Reg. 23623, effective 12/2/2014

Amended at 41 Ill. Reg. 999, effective 1/19/2017

Amended at 42 Ill. Reg. 22352, effective 11/28/2018

Amended at 43 Ill. Reg. 1014, effective 12/31/2018