Dental Policy and Procedure Manual

NEW YORK STATE
MEDICAID PROGRAM
DENTAL
POLICY AND PROCEDURE CODE

MANUAL
Dental Policy and Procedure Code Manual
Table of Contents
SECTION I - REQUIREMENTS FOR PARTICIPATION IN MEDICAID .......................... 4
QUALIFICATIONS OF SPECIALISTS ............................................................................................................................. 4
GROUP PROVIDERS ................................................................................................................................................... 5
APPLICATION OF FREE CHOICE ................................................................................................................................. 5
CREDENTIAL VERIFICATION REVIEWS ...................................................................................................................... 5
SECTION II - DENTAL SERVICES................................................................................. 7
CHILDREN’S DENTAL SERVICES ................................................................................................................................ 7
STANDARDS OF QUALITY .......................................................................................................................................... 7
SCOPE OF HOSPITALIZATION SERVICES ..................................................................................................................... 7
CHILD/TEEN HEALTH PROGRAM ............................................................................................................................... 7
CHILD HEALTH PLUS PROGRAM ............................................................................................................................... 8
DENTAL MOBILE VAN .............................................................................................................................................. 8
REQUIREMENTS AND EXPECTATIONS OF DENTAL CLINICS ....................................................................................... 8
SERVICES NOT WITHIN THE SCOPE OF THE MEDICAID PROGRAM ............................................................................. 9
SERVICES WHICH DO NOT MEET EXISTING STANDARDS OF PROFESSIONAL PRACTICE ARE NOT REIMBURSABLE 10
OTHER NON-REIMBURSABLE SERVICES .................................................................................................................. 10
RECORD KEEPING ................................................................................................................................................... 11
LOCUM TENENS ARRANGEMENTS ........................................................................................................................... 12
MISCELLANEOUS ISSUES ......................................................................................................................................... 12
SECTION III - BASIS OF PAYMENT FOR SERVICES PROVIDED............................. 14
PAYMENT FOR SERVICES NOT LISTED ON THE DENTAL FEE SCHEDULE ................................................................. 14
PAYMENT FOR SERVICES EXCEEDING THE PUBLISHED FREQUENCY LIMITATIONS ................................................. 14
PAYMENT FOR ORTHODONTIC CARE ....................................................................................................................... 14
MANAGED CARE ..................................................................................................................................................... 14
DENTAL SERVICES INCLUDED IN A FACILITY RATE ................................................................................................ 15
PAYMENT IN FULL .................................................................................................................................................. 15
PREPAYMENT REVIEW ............................................................................................................................................ 16
THIRD-PARTY INSURERS ......................................................................................................................................... 16
UNSPECIFIED PROCEDURE CODES ........................................................................................................................... 17
PRIOR APPROVAL / PRIOR AUTHORIZATION REQUIREMENTS .................................................................................. 17
RECIPIENT RESTRICTION PROGRAM ........................................................................................................................ 19
UTILIZATION THRESHOLD ....................................................................................................................................... 20
SECTION IV - DEFINITIONS ........................................................................................ 21
ATTENDING DENTIST .............................................................................................................................................. 21
REFERRAL ............................................................................................................................................................... 21
SECTION V - DENTAL PROCEDURE CODES ............................................................ 22
GENERAL INFORMATION AND INSTRUCTIONS ......................................................................................................... 22
I. DIAGNOSTIC D0100 - D0999 ................................................................................... 27
II. PREVENTIVE D1000 - D1999 .................................................................................. 32
III. RESTORATIVE D2000 - D2999............................................................................... 37
IV. ENDODONTICS D3000 - D3999 ............................................................................. 40
V. PERIODONTICS D4000 - D4999 ............................................................................. 43
VI. PROSTHODONTICS (REMOVABLE) D5000 - D5899............................................ 45
Version 2020 (effective 1/1/2020) Page 2 of 83

VII. MAXILLOFACIAL PROSTHETICS D5900 - D5999 ............................................... 49

VIII. IMPLANT SERVICES D6000 - D6199................................................................... 50
IX. PROSTHODONTICS, FIXED D6200 - D6999 ......................................................... 55
X. ORAL AND MAXILLOFACIAL SURGERY D7000 - D7999 ..................................... 58
XI. ORTHODONTICS D8000 - D8999........................................................................... 67
XII. ADJUNCTIVE GENERAL SERVICES D9000 - D9999 .......................................... 77

Section I - Requirements for Participation in Medicaid

Dental providers must be licensed and currently registered by the New York State
Education Department (NYSED), or, if in practice in another state, by the appropriate
agency of that state, and must be enrolled as providers in the New York State Medicaid
program.
No provider who has been excluded from the Medicaid program may receive
reimbursement by the Medicaid program, either directly or indirectly, while such sanctions
are in effect.
Qualifications of Specialists
A specialist is one who:

• Is a diplomat of the appropriate American Board; or,
• Is listed as a specialist in the American Dental Directory of the American Dental
Association section on “character of practice”; or,
• Is listed as a specialist on the roster of approved dental specialists of the New York
State Department of Health (DOH).
All dental providers enrolled in the Medicaid program are eligible for reimbursement for
all types of services except for orthodontic care, dental anesthesia and those procedures
where a specialty is indicated. There is no differential in levels of reimbursement
between general practitioners and specialists.
• Orthodontic care is reimbursable only when provided by a board certified or board
eligible orthodontist or an Article 28 facility which have met the qualifications of the
DOH and are enrolled with the appropriate specialty code.
• General anesthesia, parenteral and enteral conscious sedation are reimbursable
only when provided by a qualified dental provider who has the appropriate level of
certification in dental anesthesia by the NYSED. The NYSED issues five separate
certificates:
i. General Anesthesia Certificate, which authorizes a licensed dentist to
employ conscious (moderate) sedation (enteral or parenteral route with or
without inhalation agents), deep sedation, and general anesthesia;
ii. Dental Parenteral Conscious (Moderate) Sedation for patients 13
years old and older, which authorizes a licensed dentist to employ
conscious (moderate) sedation (enteral or parenteral route with or without
inhalation agents) on all patients 13 years old and older;
iii. Dental Parenteral Conscious (Moderate) Sedation for patients 12
years old and younger, which authorizes a licensed dentist to employ
conscious (moderate) sedation (enteral or parenteral route with or without
inhalation agents) on all patients;

iv. Dental, Enteral Conscious (Moderate) Sedation for patients 13 years

old and older, which authorizes a licensed dentist to employ conscious
(moderate) sedation (enteral route only with or without inhalation agents)
on all patients 13 years old and older; and
v. Dental Enteral Conscious (Moderate) Sedation for patients 12 years
old and younger, which authorizes a licensed dentist to employ
conscious (moderate) sedation (enteral route only with or without
inhalation agents) on all patients.
Additional information is located on the New York State Education Department
website (NYSED.gov):
http://www.op.nysed.gov/prof/dent/dentanesthes.htm
Group Providers
A group of practitioners is defined in 18 NYCRR 502.2 as:
“…two or more health care practitioners who practice their profession at a
common location (whether or not they share common facilities, common
supporting staff, or common equipment).”
Regardless of the arrangement among practitioners (associates, employer-employee,
principal-independent contractor), practitioners who practice in a group setting are
required to enroll as a group and to comply with the requirements associated with group
practices.
Regardless of the nature of the practice (group, employer-employee, associate, etc.), the
name, NPI and other required information of the dentist actually providing the service
or treatment must be entered in the “Servicing Provider” or “Treating Dentist” field on all
claims and prior approval requests.
Initial and periodic exam (D0120, D0145, and D0150) frequency limitations will be applied
to a claim based on the member’s exam history within the group when the servicing
provider has a group affiliation.
Application of Free Choice

A Medicaid member is guaranteed free choice of a dental provider in obtaining the dental
care available under the New York State Medicaid program.
Credential Verification Reviews
Credential Verification Reviews (CVRs) are periodic onsite visits of a provider’s place of
business to ensure overall compliance with Medicaid regulations. These visits are
conducted by the Medicaid program and the Office of the Medicaid Inspector General
(OMIG), and assess such areas as:
• provider and staff identification and credentialing

• physical attributes of the place of business

• recordkeeping protocols and procedures regarding Medicaid claiming.
CVRs are conducted for such sites as:
• medical and dental offices
• pharmacies
• durable medical equipment retailers, and
• part time clinics.
CVRs are not performed at hospitals, nursing homes, etc.
Every effort is made to conduct these visits in a professional and non-obtrusive manner.
Investigators conducting these reviews will have a letter of introduction signed by the
Office of the Medicaid Inspector General and a photo identification card.
Should providers, or their staff, have questions regarding these Credential Verification
Reviews, they can contact:
The New York State Office of the Medicaid Inspector General
Bureau of Medicaid Investigations
(518) 402-1837

Section II - Dental Services

Dental Care in the Medicaid program shall include only ESSENTIAL SERVICES rather than
comprehensive care. The provider should use this Manual to determine when the
Medicaid program considers dental services "essential". The application of standards
related to individual services is made by the DOH when reviewing individual cases.
Children’s Dental Services
A child is defined as anyone under age 21 years.
Standards of Quality
Services provided must conform to acceptable standards of professional practice.
Quality of Services Provided
Dental care provided under the Medicaid program must meet as high a standard of quality
as can reasonably be provided to the community-at-large. All materials and therapeutic
agents used or prescribed must meet the minimum specifications of the American Dental
Association, and must be acceptable to the State Commissioner of Health. Experimental
procedures are not reimbursable in the Medicaid program.
Scope of Hospitalization Services
Medicaid members are provided a full range of necessary diagnostic, palliative and
therapeutic inpatient hospital care, including but not limited to dental, surgical, medical,
nursing, radiological, laboratory and rehabilitative services.
Limitations of Hospitalization
Medicaid utilization review (UR) agents are authorized to review the necessity and
appropriateness of hospital admissions and lengths of stay, and to determine Medicaid
benefit coverage. These review agents will review inpatient dental services both on a
pre-admission and retrospective basis. Emergency admissions may be reviewed
retrospectively for necessity and appropriateness.
If you have any questions regarding specific Medicaid hospital review requirements, you
may contact the DOH, Bureau of Hospital and Primary Care Services at:
(518) 402-3267
Child/Teen Health Program
Please refer to the New York Medicaid Child/Teen Health Program (C/THP) Provider
Manual Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) available at
the following website:
https://www.emedny.org/ProviderManuals/index.aspx

Child Health Plus Program
The goal of the Child Health Plus Program is to improve child health by increasing
access to primary and preventive health care through a subsidized insurance program.
A child eligible for Medicaid is not eligible for Child Health Plus.
For more information on benefits, contact the Child Health Plus Program at:
(800) 698-4543
Dental Mobile Van
The use of mobile vans to provide the operatories for the provision of dental services is
commonplace. All claims for services rendered in a mobile unit must have the
corresponding Place of Service code which identifies this type of location. That is, the
use of a mobile unit (POS - 15). The correct POS code must be reported on every claim.
Reporting the incorrect place of service could result in inaccurate payment, audit review
and/ or ensuing disallowances.
Please refer to the Centers for Medicare and Medicaid Services website (CMS.gov) for
additional information:
Place of Service Code Set - Centers for Medicare & Medicaid Services
Requirements and Expectations of Dental Clinics
 Dental clinics licensed under Article 28 reimbursed on a rate basis or through

APG’s (i.e., hospital outpatient departments, diagnostic and treatment centers, and
dental schools) are required to follow the policies stated in the Dental Policy and
Procedure Code Manual and should use this Manual to determine when dental
services are considered "essential" by the Medicaid program.
 Except for implants, implant related services and orthodontic treatment, clinics and
schools are exempt from the prior approval procedure because of internal quality
assurance processes that insure their compliance with existing Medicaid policy.
 The provision of dental care and services are limited to those procedures
presented in the Dental Policy and Procedure Code Manual and are to be provided
within the standards and criteria listed in the procedure code descriptions.
 Dental care provided under the Medicaid program includes only essential services
(rather than “comprehensive” services).
 Non-emergency initial visits should include a cleaning, radiographic images (if
required), and a dental examination with a definitive treatment plan. Generally,
this should be accomplished in one visit. However, in rare instances, a second
visit may be needed for completion of these services. A notation in the record to
indicate the necessity for a second visit should be made.

Public health programs in schools, Head-Start Centers, dental schools, clinics

treating those individuals identified with a recipient exception code of RE 81 (“TBI
Eligible”) or RE 95 (“OPWDD/Managed Care Exemption”) and other settings are
exceptions that may require more than one visit to complete the above mentioned
services.
 Quadrant dentistry should be practiced, wherever practicable, and the treatment
plan followed in normal sequence.
 Procedures normally requiring multiple visits (i.e., full dentures, partial dentures,
root canals, crowns, etc.) should be completed in a number of visits that would be
considered consistent with the dental community at large and the scope of practice
of the provider. If additional visits are required, a notation in the member’s
treatment record to indicate the necessity for each additional visit must be made.
 Procedures normally completed in a single visit (examination, prophylaxis, x-rays,
etc.) but which require additional visits must include a notation in the member’s
treatment record documenting the justification for the additional visit.
 When billing:
• Other than orthodontic services (D8000 – D8999) and implant and implant
related services (D6010 -D6199) there is NO FEE-FOR-SERVICE (FFS)
BILLING;
• Prior approval is required for orthodontic services and implants and implant
related services;
• Certify that the services were provided;
• For specific instructions, please refer to the Dental Billing Guidelines at:
https://www.emedny.org/ProviderManuals/Dental/index.aspx
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 removable
prosthesis would be contraindicated;
 Immediate full or partial dentures;
 Molar root canal therapy for members 21 years of age and over, except when
extraction would be medically contraindicated or the tooth is a critical abutment for
an existing serviceable prosthesis;
 Crown lengthening;
 Replacement of partial or full dentures prior to required time periods unless
appropriately documented and justified as stated in the Manual;

 Dental work for cosmetic reasons or because of the personal preference of the
member or 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;
 Improper usage of panoramic images (D0330) along with intraoral complete series
of images (D0210).
Services Which Do Not Meet Existing Standards of Professional

Practice Are Not Reimbursable
These services include but are not limited to:

 Partial dentures provided prior to completion of all Phase I restorative treatment
which includes necessary extractions, removal of all decay and placement of
permanent restorations;
 Other dental services rendered when teeth are left untreated;
 Extraction of clinically sound teeth;
 Treatment provided when there is no clinical indication of need noted in the
treatment record. Procedures should not be performed without documentation
of clinical 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;
 Restorative treatment of teeth that have a hopeless prognosis and should be
extracted;
 Taking of unnecessary or excessive radiographic images;
 Services not completed and,
 “Unbundling” of procedures.
Other Non-Reimbursable Services
 Treatment of deciduous teeth when exfoliation is reasonably imminent.

 Extraction of deciduous teeth without clinical necessity.

• Claims submitted for the treatment of deciduous cuspids and molars for
children ten (10) years of age or older, or for 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.
 Services associated with a non-approved procedure will not be considered for
reimbursement.
Record Keeping
Health professionals are required to maintain records for each patient that accurately
reflect the evaluation and treatment of the patient according to section 29.2(a)(3) of the
Rules of the Board of Regents. Recipient medical histories should be updated
periodically (annually at a minimum) and be maintained as part of the recipient’s dental
records. The treating practitioner should refer to the recipient’s medical/dental history and
treatment record to avoid unnecessary repetition of services. Please refer to NYSED.gov
for further information:
NYS Rules of the Board of Regents: Part 29
The patient’s Dental Record is to include:

 Medical History;
 Dental History (including dated treatment plans, identification of all pathology
present);
 Dental Charting;
 Radiographs;
 Study Models (if taken);
 Copies of all prescriptions and invoices (pharmacy / lab);
 All correspondences;
 Consultation and referral reports; and,
 Signed consent and HIPAA forms.
Treatment notes are to include the following for each dental appointment:
 Detailed description of all services rendered including the identification of the
healthcare professional providing the service(s);

 Date (and time when appropriate) of visit and signature or initials of the team
member writing the entry;
 Instructions to the patient;
 Drugs administered / prescription (includes all anesthesia provided);
 Unusual reactions;
 Cancellations / missed appointments;
 Telephone conversations (date and time);
 Patient comments and complaints;
 Referrals made;
 Referrals not followed or refused; and,
 General anesthesia / I.V. sedation reports.
Note: Reports must include start and stop times for:
 Anesthetic provided; and,
 Operative treatment provided.
Locum Tenens Arrangements

Federal law requires that payment for services be made to the provider of service. An
exception to this requirement may be made when one dentist arranges for another
dentist to provide services to his/her patients under a locum tenens arrangement.
The law allows such locum tenens arrangements:
• On an informal, reciprocal basis for periods not to exceed 14 days, or;
• For periods of up to 90 days with a more formal agreement.
Record of either arrangement must be maintained in writing to substantiate locum

tenens payment.
Locum tenens arrangements should not be made with any dentists who are not enrolled
or have been disqualified by the New York State Medicaid program.
Miscellaneous Issues
 Radiographic images should be clear and allow for diagnostic assessment. They
are performed based on need, age, prior dental history and clinical findings. All
radiographic images, whether digitalized or conventional, must be of good
diagnostic quality, properly dated and positionally mounted including accurate
right/left orientation, and identified with the member's name and provider name
and address. The cost of all materials and equipment used shall be included in
the fee for the image.

Medicaid claims payment decisions for types, numbers and frequency of images
will be related to the needs of the individual member, dental age, past dental history
and, most importantly, clinical findings. Guidelines on the selection of members
for Dental radiographic examination can be obtained from the “American Dental
Association (ADA)” or the “U.S. Department of Health and Human Services, Food
and Drug Administration (FDA)”.
Good quality, diagnostic, duplicate radiographic images, must be made available
for review upon request of the Department of Health or the Office of the Medicaid
Inspector General. There is no reimbursement for duplication of images. If original
radiographs are submitted, they will be returned after each review. Other types of
images that can be readily reproduced will not be returned. All images must be
retained by the provider for a minimum of six years, or the minimum duration
prescribed by law, from the date of payment.
 Facilities should use the NYS Medicaid Exclusion List when checking and verifying
the credentials of the dental professionals that make up their staff. The NYS
Medicaid Exclusion List is currently available at NYS Office of the Medicaid
Inspector General (OMIG) website:
NYS Medicaid Exclusion List

Section III - Basis of Payment for Services Provided

It is the provider’s responsibility to verify each member’s eligibility at EVERY
appointment. Even when a service has been prior approved / prior authorized, the
provider must verify a member’s eligibility via the MEVS before the service is
provided and comply with all other service delivery and claims submission
requirements described in each related section of the provider manual.
Payment for dental services is limited to the lower of the usual and customary fee charged
to the general public or the fee developed by the DOH and approved by the New York
State Director of the Budget. The Dental Fee Schedule is available online:
http://www.emedny.org/ProviderManuals/Dental/index.aspx
Claims must be submitted when the product or service is completed and delivered to the
member with the appropriate procedure code using the date that the service is actually
completed and delivered as the date of service.
Payment for Services Not Listed on the Dental Fee Schedule
If an "essential" service is rendered that is not listed in the fee schedule, the fee will be
determined by the DOH, which will use the most closely related service or procedure in
the fee schedule as the basis for determining such fee.
Payment for Services Exceeding the Published Frequency Limitations
Reimbursement for services that exceed the published frequency limitations but that are
determined to be medically necessary following professional review may be considered.
Payment for Orthodontic Care
When Prior Approval is obtained for orthodontic care for severe physically handicapping
malocclusions, the care will be reimbursed for an eligible member for a maximum of three
years of active orthodontic care plus one year of retention care. Cleft palate or approved
orthognathic surgical cases may be approved for additional treatment time. Treatment
not completed within the maximum allowed period must be continued to completion
without additional compensation from the NYS Medicaid program, the member or family.
Managed Care
If a member is enrolled in a managed care plan which covers the specific care or services
being provided, it is inappropriate to bill such services to the Medicaid program on a fee-
for-service basis whether or not prior approval has been obtained.

Dental Services Included in a Facility Rate
Article 28 facilities must adhere to the program policies as outlined in this manual.
 Hospital In-Patient; Ambulatory Surgery; Emergency Room
The “professional component” for dental services can be reimbursed on a fee-for-
service basis. Payment for those services requiring prior approval / prior
authorization is dependent upon obtaining approval from the Department of Health
or the Medicaid Managed Care Plan. Refer to the prior approval section of this
manual and the Prior Approval Guidelines located on the eMedNY.org website for
additional information on how to obtain prior approval:
eMedNY : Provider Manuals : Dental
 Out-Patient Clinic
Dental services rendered in outpatient clinics are reimbursed using an “Ambulatory
Patient Groups (APG)” payment methodology and include both the facility and
professional reimbursement. There is no fee-for-service billing allowed.
 OMH Psychiatric Centers
Dental services are included in the facility rates. Payment for services in such
facilities will not be made on a fee-for-service basis.
It is the responsibility of the facility to make arrangements for the provision of all
dental services listed in the Provider Manual either within the facility or with area
providers. Claims should not be submitted by either the provider(s) or facility for
covered dental services or for transportation.
 Intermediate Care Facilities (ICF)-DD
ICF-DD providers should contact OPWDD for guidance on billing for dental
services for their residents.
 Residential Health Care Facilities (RHCF’s)
In State
Dental services are included in the facility rates. Payment for services to
residents of such facilities will not be made on a fee-for-service basis.
It is the responsibility of the facility to make arrangements for the provision
of all dental services listed in the Provider Manual either within the facility
or with area providers. Claims should not be submitted by either the
provider(s) or facility for covered dental services or for transportation.
Out of State
It is the responsibility of the out-of-state RHCF to inform the provider if
dental services are included in the rate.
Payment in Full
Fees paid by the Medicaid program shall be considered full payment for services
rendered. Except for appropriate co-pay’s, no additional charge may be made by a
provider.
Medicaid members cannot be charged for broken or missed appointments.

Providers are prohibited from charging any additional amount for a service billed to the
Medicaid program.
A dentist may enter into a private pay agreement with a Medicaid member. This
agreement must be in writing and mutually agreed upon prior to the start of treatment;
these guidelines must be followed:
 The member must be informed of alternative treatment plans, including
procedures covered by the Medicaid Program or procedures that require prior
authorization by the NYS DOH or Medicaid Managed Care Plan, the advantages
and disadvantages of each, as well as the expense and financial responsibilities
of each (If any of the procedures in the treatment plan require prior approval from
the Medicaid Program, the provider is encouraged to submit the necessary forms
and documentation for review and determination, which may eliminate the need
for a private payment agreement and Medicaid could cover the procedure(s) in
full);
 The NYS DOH (Medicaid Program) will not review a prior approval request, or
render any opinion, associated with a private pay agreement after treatment has
been started;
 The member must have full understanding and consent that there may be
service(s) or alternatives that could be provided through Medicaid coverage
without any expense to them;
 The member is responsible for 100% of the entire fee. There cannot be any
payment from Medicaid;
 The provision of this service might alter future benefits available through
Medicaid (e.g. if payment is made through a private payment agreement for root
canal(s) therapy, the member might not qualify for a partial denture and/or crowns
for these teeth either now or in the future that they might otherwise be eligible for);
and,
 The member may be responsible for any subsequent or associated expenses.
Prepayment Review
The DOH and OMIG reserve the right to pend any claim(s) for review prior to payment
without notification.
Third-Party Insurers
Third-party insurers (including Medicare) provide reimbursement for various dental

procedures. Since Medicaid is the payer of last resort, the provider must bill the
member’s third-party payers prior to requesting payment from Medicaid.
If the third party is a commercial plan, Medicaid will reimburse the difference only if the
total third-party payment(s) is (are) less than the lesser of the provider’s fee charged to
the general public or the fee developed by the DOH for the specific procedure code. If
the third party is a Medicare Advantage plan, Medicaid will reimburse eighty-five percent
(85%) of the patient responsibility. Prior to initiating treatment which has been approved
by a third-party insurance plan, the provider should obtain a prior approval from

Medicaid to ensure that the treatment plan falls within the current guidelines of the
Medicaid Program. Failure to do so may result in the denial of Medicaid benefits for
these services.
Unspecified Procedure Codes
Unspecified procedure codes at the end of each section of the fee schedule are
miscellaneous codes applicable to procedures within the scope of the Medicaid program,
but for which suitable procedure codes do not currently exist.
Prior Approval / Prior Authorization Requirements
Prior approval / prior authorization does not ensure payment. The provider must
verify a member’s eligibility before every appointment and comply with all other
service delivery and claims submission requirements described in each related
section of the provider manual.
Claims for fixed and removable prosthetics (including implant related prosthetics) and
endodontics are not to be submitted until the approved procedure code is completed.
Prior authorization is required through the use of the Dispensing Validation System (DVS)
when specified. These specifications are indicated after the procedure code description
by the following: (DVS REQUIRED)
When DVS is required providers must place the DVS prior authorization number on the
claim. If DVS rejects the request due to service limits exceeded, a prior approval is
required. The prior approval request must include medical documentation as to why the
service limit needs to be exceeded. Prior approval requests received where the provider
has not requested prior authorization through DVS will be rejected and returned to the
provider.
Procedures that require prior approval, or where a DVS over-ride is required, must not
begin until the provider has received approval from the DOH. When any portion of a
treatment plan requires prior approval, the complete treatment plan listing all necessary
procedures, whether or not they require prior approval, must be listed and coded on the
prior approval request form. Any completed treatment which is not evident on submitted
images should be noted. No treatment other than provision of symptomatic relief of pain
and/or infection is to be instituted until such time as cases have been reviewed and a
prior approval determination made.
All prior approval requests must include accurate pretreatment charting clearly
depicting all existing restorations and missing natural teeth. Any existing fixed or
removable prosthetic appliances should be noted and their current conditions described
and the date of initial placement noted. If applicable, a complete medical history,
nutritional assessment, certification of employment and any other pertinent information
that will assist in determining the necessity and appropriateness of the proposed
treatment plan should be submitted.

The approved treatment plan, in its entirety, must be adhered to. Any alteration of the
approved course of treatment may render the entire approval null and void and subject to
recoupment. Changes to an approved course of treatment should be submitted to the
DOH by using a “prior approval change request form”.
If a change is needed or there exists a disagreement with a prior approval review and you
would like to challenge a determination rendered by the DOH on an existing finalized prior
approval, a request may be submitted with supporting documentation and a detailed
report using a “Prior Approval Change Request Form”. This form may be submitted pre-
operatively or post-operatively. If the requested change is submitted post-operatively a
copy of the treatment notes should be included with the request.
The Prior Approval Change Request Form can be obtained by clicking on the link
below or by calling eMedNY at 1-800-343-9000.
eMedNY: Information: Paper Forms
The minimum number of pre-treatment radiographic images needed to clearly show

all current conditions and which allow for the proper evaluation and diagnosis of
the entire dentition must accompany all requests for prior approval. Radiographic
images are not routinely required to obtain prior approval for replacement full dentures,
sealants, denture re-base etc. The previously referenced guidelines on the selection of
members for radiographs should be followed.
Payment for multiple restorations which are placed in teeth subsequently determined to
need extraction as part of an approved prosthetic treatment plan is not acceptable if the
restorations were provided less than six months prior to the date of the prior approval
request for the prosthesis.
When a treatment plan has been denied, services that were a portion of that plan may
not be reimbursable, or subsequently prior approved.
For non-emergency treatment, the same prior approval guidelines apply when treatment
is being rendered by a specialist. If the member is referred to a specialist for treatment
requiring prior approval, the referring provider can obtain the prior approval for use by the
specialist, or the specialist can submit his/her own request.
When Prior Approval is required
For professional dental services, payment for those listed procedures where the
procedure code number is underlined and listed as (PA REQUIRED) is dependent upon
obtaining the approval of the Department of Health or the Medicaid Managed Care Plan
prior to performance of the procedure. If such prior approval is not obtained, no
reimbursement will be made. For information on completion and submission of prior
approval requests refer to the Prior Approval Guidelines:
Prior approval does not guarantee payment. It should be noted that:
• Prior approval requests will automatically be rejected if there is no response to
a request for additional information and the provider notified. The request will
be reactivated without submitting a new request provided that the information is

returned using the “Return Information Routing Sheet” provided with the original
request for information;
• Prior approval requests may be denied if there is incomplete or insufficient
response to a request for additional information;
• Dental providers may submit documents stored in a digitized format (x-rays,
treatment plans, charting, photographs, etc.) as electronic attachments to dental
prior approval requests when submitted through ePACES. This enhanced
feature is currently only available through ePACES. The following file formats
are currently supported: JPEG; TIF; PDF: PNG; and GIF.
For more information on ePACES, or to enroll, please contact the eMedNY Call
Center at (800) 343-9000;
• Back-dated prior approval can be issued on an exception basis, such as when
eligibility has been back-dated and treatment requiring prior approval has
already been rendered. The following guidelines apply:
o The request must be received within 90 days of the date of treatment;
o There is NO guarantee that the request will be approved or back-dated
even if treatment has already begun and / or completed;
o Treatment already rendered will NOT change the review criteria.
Approval will not be issued that wouldn't have been approved
otherwise;
o The same documentation must be submitted as any other request
(complete treatment plan, sufficient radiographic images to allow for
the evaluation of the entire dentition, charting etc.) as appropriate for
the case;
o Appropriate documentation must be submitted showing that
extenuating circumstances existed warranting back-dating of the
request as well as the date that the service(s) was (were) performed;
o Actions of either the provider or member do not commit the DOH to
any particular course of treatment;
o Approvals will NOT be issued for the convenience of the provider or
member, or because the provider forgot or didn't realize that prior
approval was required.
Emergency Treatment
The provider should refer to the billing guidelines on the eMedNY.org website for claim
submission instructions for emergency services when there is a severe, life threatening,
or potentially disabling condition that required immediate intervention:
Recipient Restriction Program

Medicaid members with any coverage type (i.e. managed care, fee-for-service) will be
reviewed and those who have been found to have a demonstrated pattern of abusive
behavior will be placed in the recipient restriction program in an effort to control the abuse.
Restricted members are monitored by the Office of the Medicaid Inspector General
(OMIG). When the member’s benefit is administered by a Managed Care Organization

(MCO), the MCO is responsible for identifying and restricting the member who is abusing
their Medicaid benefit. The MCO is required to report any new, re-restricted or modified
restrictions to OMIG for tracking. The recipient restriction program follows the member
when a member’s coverage changes. If a member is switched to a different managed
care plan OMIG will notify the new managed care plan of the existence of the restriction.
The restriction process does not force the member to be enrolled in a Medicaid Managed
Care Plan.
Utilization Threshold
With the implementation of HIPAA 5010 and D.0 transactions, the NYS Department of
Health (DOH) has eliminated the Service Authorization (SA - 278) process. This process
required providers to obtain UT service authorizations via the Medicaid Eligibility
Verification System (MEVS) prior to the payment of claims. Since service authorization
transactions are no longer being supported, the eligibility transaction process will provide
information when the member is at limit. Determining a Medicaid member’s UT status is
critical for accurate billing and payment purposes. The provider risks nonpayment if
eligibility is not verified. If a member has reached the Utilization Threshold limit for any
service category, the eligibility response will return an indication of “Limitations” for the
applicable Service Type(s).
If a “Limitations” message is returned, one of two options are available.
1. A Threshold Override Application (TOA) may be submitted to request an increase
in the member’s allowed services.
2. Services provided are exempt from the UT Program.
For a list of services exempt from the UT Program click on the
“Information” tab at the eMedNY.org website.

Section IV - Definitions
For the purposes of the Medicaid program and as used in this Manual, the following terms
are defined to mean:
Attending Dentist
The attending dentist is the dentist who is primarily and continuously responsible for the
treatment rendered.
Referral
A referral is the direction of a member to another provider for advice or treatment.

Section V - Dental Procedure Codes

General Information and Instructions
This section lists those procedure codes and nomenclature listed in the “Current Dental
Terminology (CDT®)” as published by the “American Dental Association (ADA®)” which
are covered services by the NYS Medicaid program. Some procedure descriptions are
included for clarification of Medicaid policy. The CDT should be referenced for a full
descriptor of each procedure.
The dental procedure codes are grouped into sections as follows:
Section Code Series
I. Diagnostic D0100-D0999
II. Preventive D1000-D1999
III. Restorative D2000-D2999
IV. Endodontics D3000-D3999
V. Periodontics D4000-D4999
VI. Prosthodontics, removable D5000-D5899
VII. Maxillofacial Prosthetics D5900-D5999
VIII. Implant Services D6000-D6199
IX. Prosthodontics, fixed D6200-D6999
X. Oral and Maxillofacial Surgery D7000-D7999
XI. Orthodontics D8000-D8999
XII. Adjunctive General Services D9000-D9999
Miscellaneous Procedures Q3014
Local anesthesia is considered to be part of the procedure(s) and is not payable

separately.
1. “(REPORT NEEDED)” / “BY REPORT (BR)” PROCEDURES:

Procedures that do not have a published fee are indicated as “(BR)”. Procedures
with or without a published fee that are listed as “(REPORT NEEDED)” require
professional review for validation and/or pricing. All claims for these procedures
must be submitted with supporting documentation.
Information concerning the nature, extent and need for the procedure or service,
the time, the skill and the equipment necessary, must be furnished. Appropriate
documentation (e.g., operative report, procedure description, and/or itemized
invoices and name/dosage of therapeutic agents) is required. To ensure
appropriate payment in the context of current Medicaid fees, bill your usual and
customary fee charged to the general public. Claims should only be submitted
AFTER treatment is completed.
Operative reports must include the following information:
a. Diagnosis;

b. Size, location and number of lesion(s) or procedure(s) where appropriate;

c. Major surgical procedure and supplementary procedure(s);
d. Whenever possible, list the nearest similar procedure by code number;
e. Estimated follow-up period;
f. Operative time;
g. Specific details regarding any anesthesia provided (this should include start
- stop times and all medications administered).
If documentation needs to be submitted in support of any “(REPORT NEEDED)” /
“By Report (BR)” procedure, the claim MUST be submitted on a paper claim form
‘A’ with the documentation as an attachment. Attachments must be on paper the
same size as the claim form. This documentation must be maintained in the
member’s record and made available upon request.
DO NOT SEND RADIOGRAPHIC IMAGES AS A CLAIM ATTACHMENT
If radiographs are needed DOH or OMIG will request that you submit them directly
to the reviewing unit.
Claim Form ‘A’ can be obtained from eMedNY by calling (800) 343-9000.
2. DENTAL SITE IDENTIFICATION:

Certain procedure codes require specification of surface, tooth, quadrant or arch
when billing. These specifications are indicated after the procedure code
description by the following abbreviations:
Specify surface: (SURF)
Specify tooth: (TOOTH)
Specify quadrant: (QUAD)
Specify arch: (ARCH)
 When more than one specification is required, both specifications are

included, for example: (SURF/TOOTH).
 Only the dental site information required should be provided. Prior approval
requests and/or claims may be rejected when extraneous or incorrect site
information is included. Multiple submission of codes that do not require
site designation should be entered on a single line with the site designation
(e.g. tooth, arch, quad) left blank and the number of times performed
entered. A report or narrative should be submitted where applicable.
 “Unspecified” procedure codes at the end of each section should not be
used for supernumerary teeth.
 Refer to the Dental Billing Guidelines, Appendix B, “Code Sets” found at
https://www.emedny.org/ProviderManuals/Dental/index.aspx for valid
values.

3. “ESSENTIAL” SERVICES:
When reviewing requests for services the following guidelines will be used:
Treatment will not be routinely approved when functional replacement with less
costly restorative materials, including prosthetic replacement, is possible.
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. Treatment is not considered appropriate
when the prognosis of the tooth is questionable or when a reasonable alternative
course of treatment would be extraction of the tooth and replacement. Treatment
such as endodontics or crowns will not be approved in association with an existing
or proposed prosthesis in the same arch, unless the tooth is a critical abutment for
a prosthesis provided through the NYS Medicaid program, or unless replacement
by addition to an existing prosthesis or new prosthesis is not feasible. If the total
number of teeth which require or are likely to require treatment would be
considered excessive or when maintenance of the tooth is not considered essential
or appropriate in view of the overall dental status of the recipient, treatment will not
be covered. 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 for 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.
Eight (8) posterior natural or prosthetic teeth (molars and/or bicuspids) in occlusion
(four (4) maxillary and four (4) mandibular teeth in functional contact with each
other) will be considered adequate for functional purposes. Requests will be
reviewed for necessity based upon the presence/absence of eight (8) points of
natural or prosthetic occlusal contact in the mouth (bicuspid/molar contact).
One (1) missing maxillary anterior tooth or two (2) missing mandibular anterior
teeth may be considered an esthetic problem that warrants a prosthetic
replacement.

4. INTERRUPTED TREATMENT:
Claims must be submitted when the product or service is completed and
delivered to the member with the appropriate procedure code using the date that
the service is actually completed and delivered as the date of service.
However, in those cases involving multiple appointments to complete the service
or product, and the service or product cannot be completed or delivered, or the
member loses eligibility prior to the completion of the service or delivery of the
product, then the appropriate billing code listed below may be used with the date
of the “decisive appointment” as the date of service.
If the "decisive appointment" (listed below) has not been met, or the member
was not eligible on the date of the "decisive appointment", no compensation
is available.
Medicaid Fee-For-Service Providers:
The "billing code" in the chart on page 26 can be used with the date of the "decisive
appointment" as the date of service if:
• The service is completed and delivered, but the member lost fee-for-service
Medicaid eligibility after the date of the "decisive appointment" (e.g. lost
Medicaid entirely or was switched to a managed care plan) but prior to the
date of delivery; or,
• The service is NOT completed and delivered (e.g. member died, detained
for an indefinite period, etc.) after the date of the decisive appointment. It
must be documented that every reasonable attempt was made to complete
and deliver the service.
All claims submitted using the interrupted treatment billing codes will be pended
for manual review. Payment in full may be considered if the supporting
documentation demonstrates that the service was completed and delivered.
Payment, either in full or pro-rated, may be considered if the service is NOT
completed and delivered. The amount of compensation will be determined based
on the documentation provided.
Managed Care Plans:
All Medicaid Managed Care plans, and Essential Plans offering dental services,
must continue to cover any remaining treatments required to complete the
procedures listed below if a managed care enrollee is disenrolled from the plan for
any reason (including, but not limited to, losing Medicaid eligibility, transferring to
another plan or voluntary disenrollment) after a decisive appointment. Such
coverage is required even if the member does not qualify for guaranteed eligibility.

Type of Service Approved Multiple Billing Decisive Appointment

Visit Procedures Code
Space Maintainers D1510, D1516, D0999 Tooth preparation
D1517, D1575
Crowns, Posts D2710-D2792 D2999 Tooth preparation or final post
D2794, D2952 pattern fabrication and final
impression
Root Canal Therapy D3310-D3348 D3999 Pulp extirpation or
debridement to at least the
apical 1/3 of all canals
Complete Dentures D5110-D5120 D5899 Final impression
Partial Dentures D5211-D5214 D5899 Final impression
D5225, D5226
Denture Repair D5510-D5660 D5899 Acceptance of the prosthesis
for repair
Denture Rebase or D5710-D5721 D5899 Final impression
Relining D5750-D5761
Other Prosthetic D5820-D5821 D5899 Final impression
Services
Maxillofacial D5911-D5988 D5999 Final impression
Prosthetics
Implant Services D6052-D6067, D6199 Final impression for the
D6094, D6095, specific procedure code
D6110- D6113
Implant Services D6090, D6091 D6199 Acceptance of prosthesis for
repair
Fixed Prosthetics D6210-D6252 D6999 Preparation and impression of
D6545-D6792 all abutment teeth
D6794
Orthodontic Retention D8680 D8999 Final impression
Occlusal Guards D9944, D9945, D9999 Final impression
D9946

CODE DESCRIPTION
I. DIAGNOSTIC D0100 - D0999

Fee
CLINICAL ORAL EVALUATIONS

The codes in this section recognize the cognitive skills necessary for patient evaluation.
The collection and recording of some data and components of the dental examination
may be delegated; however, the evaluation, which includes diagnosis and treatment
planning, is the responsibility of the dentist and must be documented in the treatment
record. As with all ADA procedure codes, there is no distinction made between the
evaluations provided by general practitioners and specialists. Report additional
diagnostic and/or definitive procedures separately.
Initial and periodic exam (D0120, D0145, and D0150) frequency limitations will be
applied to a claim based on the member’s exam history within the group when the
servicing provider has a group affiliation.
Includes charting, history, treatment plan, and completion of forms.
Orthodontist should ONLY use procedure code D8660 for examinations prior to starting
active care.
D0120 Periodic oral evaluation - established patient $25.00

An evaluation performed on a patient of record to determine any changes in the
patient’s dental and medical health status since a previous comprehensive or
periodic evaluation. This includes an oral cancer evaluation and periodontal
screening where indicated and may require interpretation of information acquired
through additional diagnostic procedures. Report additional diagnostic
procedures separately.
Reimbursement is limited to once per six-month period.
D0140 Limited oral evaluation - problem focused $14.00
Not used in conjunction with a regular appointment. Cannot be billed with any
other evaluation procedure, including but not limited to D9310 and D9430. Not
intended for follow-up care.
D0145 Oral evaluation for a patient under three years of age and $30.00
counseling with primary caregiver
Diagnostic services performed for a child under the age of three, preferably within
the first six months of the eruption of the first primary tooth, including recording
the oral and physical health history, evaluation of caries susceptibility,
development of an appropriate preventive oral health regimen and
communication with and counseling of the child’s parent, legal guardian and/or
primary caregiver.
D0150 Comprehensive oral evaluation – new or established patient $30.00
Can only be billed once per provider-member relationship.
D0160 Detailed and extensive oral evaluation - problem focused, (BR)
by report (REPORT NEEDED)
This procedure will not be reimbursed if performed within ninety days of a
consultation or any other evaluation by the same provider.

CODE DESCRIPTION
DIAGNOSTIC IMAGING
The following ADA / DOHHS recommendations for “prescribing dental radiographs”
should be followed:
http://www.ada.org/~/media/ADA/Publications/ADA%20News/Files/Dental_Radiograp
hic_Examinations_2012.pdf?la=en
All images taken should be medically necessary and of diagnostic quality, properly
identified and dated. Claims for dental radiographs may be pended for professional
review and are subject to denial unless there is a documented need of medical
necessity.
If you are ordering a CT, CTA, MRI, MRA, Cardiac Nuclear, or PET procedure, you or
your office staff are required to obtain an approval number through the radiology prior
approval program. For additional information refer to:
http://www.emedny.org/ProviderManuals/Radiology/index.html
Note: The radiology prior approval program does not include procedure code D0367,
cone beam computed tomography. For more information see description of D0367.
D0210 Intraoral - complete series of radiographic images $50.00
A radiographic survey of the whole mouth, usually consisting of 14-22 periapical
and posterior bitewing images intended to display the crowns and roots of all
teeth, periapical areas and alveolar bone.
D0220 Intraoral - periapical first radiographic image $8.00
To be billed only for the FIRST periapical image and ONLY when periapical
images are taken. Cannot be used in conjunction with any other type of images
on the same date of service (e.g. bitewing, occlusal, panoramic etc.). If another
type of radiograph is taken on the same day, all the periapical films must be
reported as D0230 (intraoral – periapical each additional radiographic image).
D0230 Intraoral - periapical each additional radiographic image $5.00
When periapical images are taken in conjunction with bitewing(s), occlusal or
panoramic images, use procedure code D0230 for ALL periapical images
including the first periapical image.
The total fee for ALL intraoral radiographic images (including the first
periapical image) may not exceed the total fee allowed for a complete
intraoral series.
D0240 Intraoral - occlusal radiographic image (ARCH) $15.00
One maxillary and one mandibular radiographic image are allowed within three
years. May be supplemented by necessary intraoral periapical or bitewing
images.
D0250 Extra-oral - 2D projection radiographic image created using $25.00
a stationary radiation source, and detector
These images include but are not limited to: Lateral Skull; Posterior-Anterior
Skull; Submentovertex; Waters; Reverse Tomes; Oblique Mandibular Body;
Lateral Ramus. Not reimbursable for Temporomandibular Joint images.

CODE DESCRIPTION
D0251 Extra-oral posterior dental radiographic image $12.00
Image is limited to exposure of complete posterior teeth in both dental arches.
This is a unique image that is not derived from another image.
Maximum of two images.
Not reimbursable for Temporomandibular Joint images.
Bitewings are allowed no more than once in six months for each member.
The procedure code is an indication of the number of images performed. Leave the
“Times Performed” on the claim form blank or enter “1”.
D0270 Bitewing – single radiographic image $8.00
D0272 Bitewings – two radiographic images $14.00
D0273 Bitewings – three radiographic images $20.00
D0274 Bitewings – four radiographic images $24.00
D0310 Sialography $41.00
D0320 Temporomandibular joint arthrogram, including injection $174.00
D0321 Other temporomandibular joint radiographic images, by $29.00
report (PER JOINT) (REPORT NEEDED)
D0330 Panoramic radiographic image $35.00
Reimbursable every three years if clinically indicated. For use in routine caries
determination, diagnosis of periapical or periodontal pathology only when
supplemented by other necessary radiographic intraoral images (bitewing
and/or periapical), completely edentulous cases, diagnosis of impacted teeth,
oral surgery treatment planning, or diagnosis of children with mixed dentition.
Postoperative panoramic images are reimbursable for post-surgical evaluation
of fractures, dislocations, orthognathic surgery, osteomyelitis, or removal of
unusually large and/or complex cysts or neoplasms. Panoramic radiographic
images are not required or reimbursable for post orthodontic documentation.
Panoramic images are not reimbursable when an intraoral complete series or
panoramic image has been taken within three years, except for the diagnosis
of a new condition (e.g. traumatic injury).
D0340 2D cephalometric radiographic image – acquisition, $55.00
measurement and analysis
Image of the head made using a cephalostat to standardize anatomic
positioning, and with reproducible x-ray beam geometry.
Reimbursable every three years if clinically indicated. Reimbursement is limited
to enrolled orthodontists or oral and maxillofacial surgeons for the diagnosing
and treatment of a physically handicapping malocclusion. Cephalometric
images are not required by the DOH for routine post-orthodontic documentation
and are not routinely reimbursable. A tracing and analysis are required and is
not payable separately. Use D0250 if a tracing and analysis is not performed.

CODE DESCRIPTION
D0350 2D oral/facial photographic image obtained intra-orally or $12.00
extra-orally
Photographs are reimbursable when associated with procedures described
under sections:
 VIII. IMPLANTS;
 XI. ORTHODONTICS;
 When requested by the Department Health; and,
 The fee includes all intra-oral and extra-oral images taken on the
same date of service.
CONE BEAM CT CAPTURE
 Includes axial, coronal and sagittal data.

 Includes all interpretation.
 There is no professional reimbursement for facility place of service.
Facility reimbursement is through APG.
 For treatment not involving implants or implant-related services, a
panoramic radiograph (D0330) or similar film, along with documentation
of medical necessity, must be submitted with requests for prior approval.
Approval is limited to those cases demonstrating significant risk for a
complication such as nerve injury or jaw fracture as well as pathology or
trauma workups.
 For treatment involving implants or implant-related services, refer to
section VIII. IMPLANTS.
D0364 Cone beam CT capture and interpretation with limited field $279.00
of view – less than one whole jaw (PA REQUIRED)
D0365 Cone beam CT capture and interpretation with field of view $279.00
of one full dental arch - mandibular (PA REQUIRED)
of one full dental arch – maxilla, with or without cranium
(PA REQUIRED)
of both jaws; with or without cranium (PA REQUIRED)
D0368 Cone beam CT capture and interpretation for TMJ series $279.00
including two or more exposures (PA REQUIRED)
D0470 Diagnostic casts $34.00

Reimbursement is limited to enrolled orthodontists or oral and maxillofacial
surgeons. Includes both arches when necessary.

CODE DESCRIPTION
ORAL PATHOLOGY LABORATORY
These are procedures generally performed in a pathology laboratory and do not include
the removal of the tissue sample from the patient. For removal of tissue sample, see
codes D7285 and D7286.
Reimbursement for procedure codes D0470, D0485 and D0502 are limited to enrolled
Oral Pathologists.
D0474 Accession of tissue, gross and microscopic examination, $87.00
including assessment of surgical margins for presence of
disease, preparation and transmission of written report.
D0485 Consultation, including preparation of slides from biopsy $87.00
material supplied by referring source
D0502 Other oral pathology procedures, by report (REPORT NEEDED) (BR)
D0999 Unspecified diagnostic procedure, by report (BR)
(REPORT NEEDED)

CODE DESCRIPTION
II. PREVENTIVE D1000 - D1999

DENTAL PROPHYLAXIS
Dental prophylaxis is reimbursable in addition to an initial dental examination and recall
examinations once per six (6) month period. Prophylaxis cannot be used in conjunction
with periodontal maintenance (D4910) or in conjunction with scaling and root planning
(D4341) on the same date of service.
D1110 Prophylaxis – adult $45.00
For members 13 years of age and older.
D1120 Prophylaxis – child $43.00
For members under 13 years of age.
An additional prophylaxis may be considered within a twelve-month period for those
individuals identified with a recipient exception code of RE 81 (“TBI Eligible”) or RE 95
(“OPWDD/Managed Care Exemption”). The additional prophylaxis should be submitted
using procedure code D1999. Documentation supporting necessity must be submitted
with the claim. Reimbursement will not be considered if performed within a four-month
interval of D1110, D1120, D1999 (used as an additional prophylaxis), or D4910.
TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE)
Topical fluoride treatment is reimbursable when professionally administered in
accordance with appropriate standards. Benefit is limited to gel, foam, and varnish.
There must be a minimum interval of three (3) months between all fluoride treatments
(D1206 and/or D1208).
Fluoride treatments that are not reimbursable under the program include:
 Treatment that incorporates fluoride with prophylaxis paste;
 Topical application of fluoride to the prepared portion of a tooth prior to
restoration;
 Fluoride rinse or “swish”; and,
 Treatment for desensitization.
D1206 Topical application of fluoride varnish $30.00
Reimbursable once per three (3) month period for members between 6 months
and 6 years of age (inclusive). For individuals 7 years of age and older D1206 is
only approvable for those individuals identified with a recipient exception code of
RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed Care Exemption”), or, in
cases where salivary gland function has been compromised through surgery,
radiation, or disease. Reimbursable to physicians and nurse practitioners under
CPT code 99188.
D1208 Topical application of fluoride – excluding varnish $14.00
Reimbursable once per six (6) month period for members between 1 and 20 years
of age (inclusive). Fluoride must be applied separately from prophylaxis paste.
For individuals 21 years of age and older D1208 is only approvable for those

CODE DESCRIPTION
individuals identified with a recipient exception code of RE 81 (“TBI Eligible”) or
RE 95 (“OPWDD/Managed Care Exemption”), or, in cases where salivary gland
function has been compromised through surgery, radiation, or disease.

CODE DESCRIPTION
OTHER PREVENTIVE SERVICES
D1320 Tobacco counseling for the control and prevention of oral $10.00
disease.
Tobacco prevention and cessation services reduce patient risks of developing
tobacco-related oral diseases and conditions and improves prognosis for
certain dental therapies.
Reimbursement for smoking cessation counseling (SCC) must meet the following
criteria:
• SCC must be provided face-to-face by either a dentist or by a
dental hygienist that is supervised by the dentist;
• SCC must be billed by either an office-based dental
practitioner or by an Article 28 clinic that employs a dentist;
• Dental practitioners can only provide individual SCC services,
which must be greater than three minutes in duration, NO
group sessions are allowed;
• Dental claims for SCC must include the CDT procedure code
D1320 (tobacco counseling for the control and prevention of
oral disease);
• In a dental office or an Article 28 clinic, SCC should only take
place during a dental visit as an adjunct when providing a
dental service and NOT billed as a stand-alone service;
• A dental practitioner will be allowed to provide two smoking
cessation counseling sessions to a Medicaid member within
any 12 continuous months;
• Smoking Cessation Counseling complements existing
Medicaid covered benefits for prescription and non-
prescription smoking cessation products including nasal
sprays, inhalers, Zyban (bupropion), Chantix (varenicline),
over-the counter nicotine patches and gum;
• To receive reimbursement for SCC services the following
information must be documented in the patient’s dental record:
 At least 4 of 5 A’s: smoking status and if yes,
willingness to quit;
 If willing to quit, offer medication as needed,
target date for quitting, and follow-up date (with
documentation in the record that the follow-up
occurred);
 If unwilling to quit, the patient’s expressed
roadblocks;
 Referrals to the New York State Smoker’s
Quitline and/or community services to address
roadblocks and for additional cessation
resources and counselling, if needed.

CODE DESCRIPTION
Smoking cessation services are included in the prospective payment system (PPS)
rate for those FQHCs that do not participate in APG reimbursement.
Dentists should be aware of the following guideline for smoking cessation

counseling:
The Clinical Practice Guideline, “Treating Tobacco Use and Dependence: 2008
Update” demonstrated that efficacious treatments for tobacco users exist and should
become a part of standard care giving.
This guideline recommends that a practitioner should follow the “5 A’s” of treating
tobacco dependence, which include:
1. Ask: Ask the patient about tobacco use at every visit and
document the response.
2. Advise: Advise the patient to quit in a clear and
personalized manner.
3. Assess: Assess the patient’s willingness to make a quit
attempt at this time.
4. Assist: Assist the patient to set a quit date and make a
quit plan; offer medication as needed.
5. Arrange: Arrange to follow-up with the patient within the
first week, either in person or by phone, and take
appropriate action to assist them.
For patients not ready to make a quit attempt, clinicians should use a brief
intervention designed to promote the motivation to quit. Content areas that should
be addressed can be captured by the “5 R’s”:
1. Relevance: Encourage the patient to state why quitting
is relevant to them, being as specific as possible.
2. Risks: Ask the patient to identify potential negative
consequences of their tobacco use, including acute,
environmental, and long-term risks.
3. Rewards: Ask the patient to identify potential benefits,
such as improved health, saving money, setting a good
example for children, and better physical performance.
4. Roadblocks: Ask the patient to identify barriers (e.g.,
fear of withdrawal, weight gain, etc.), and provide
treatment and resources to address them.
5. Repetition: The motivational intervention should be
repeated every time the patient is seen.
Research suggests that the “5 R’s” enhance future quit attempts. Additional
information is available in Chapter 3 of the guideline, titled Clinical Interventions for
Tobacco Use and Dependence.

CODE DESCRIPTION
D1351 Sealant – per tooth (TOOTH) (DVS REQUIRED) $35.00
Mechanically and/or chemically prepared enamel surface sealed to prevent
decay. Refer to the “Prior Approval/Prior Authorization Requirements” section for use of
DVS. Application of sealant is restricted to previously unrestored permanent first
and second molars that exhibit no signs of occlusal or proximal caries for
members between 5 and 15 years of age (inclusive). Buccal and lingual
grooves are included in the fee. The use of opaque or tinted sealant is
recommended for ease of checking bond efficacy. Reapplication, if necessary,
is permitted once every five (5) years.
SPACE MAINTENANCE (PASSIVE APPLIANCES)
Only fixed appliances are reimbursable. Documentation including pre-treatment images
to justify all space maintenance appliances must be available upon request. Space
maintenance should not be provided as an isolated service. All carious teeth must be
restored before placement of any space maintainer. The member should be practicing
a sufficient level of oral hygiene to ensure that the space maintainer will not become a
source of further carious breakdown of the dentition. All permanent teeth in the area of
space maintenance should be present and developing normally.
Space maintenance in the deciduous dentition (defined as prior to the interdigitation of
the first permanent molars) can generally be considered.
Space maintenance in the mixed dentition initiated within one month of the necessary
extraction will be reimbursable on an individual basis. Space maintenance in the mixed
dentition initiated more than one month after the necessary extraction, with minimum
space loss apparent, may be reimbursable.
D1510 Space maintainer – fixed, unilateral – per quadrant (QUAD) $116.00
Excludes a distal shoe space maintainer.
D1516 Space maintainer – fixed – bilateral, maxillary $174.00
D1517 Space maintainer – fixed – bilateral, mandibular $174.00
D1551 Re-cement or re-bond bilateral space maintainer - maxillary $19.00
D1552 Re-cement or re-bond bilateral space maintainer - $19.00
mandibular
D1553 Re-cement or re-bond unilateral space maintainer – per $19.00
quadrant (QUAD)
D1575 Distal shoe space maintainer – fixed, unilateral – per $116.00
quadrant (QUAD)
Fabrication and delivery of fixed appliance extending subgingivally and distally
to guide the eruption of the first permanent molar.
D1999 Unspecified preventive procedure, by report (BR)

CODE DESCRIPTION
III. RESTORATIVE D2000 - D2999

The cost of analgesic and anesthetic agents is included in the reimbursement for
the dental service. The administration of nitrous oxide is not separately reimbursable.
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.
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 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 (e.g. crown lengthening, D4249) is required to
properly restore a tooth, any associated restorative or endodontic treatment will NOT be
considered for reimbursement.
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)
D2140 Amalgam - one surface, primary or permanent (SURF/TOOTH) $50.00
D2150 Amalgam - two surfaces, primary or permanent (SURF/TOOTH) $67.00
D2160 Amalgam - three surfaces, primary or permanent $82.00
(SURF/TOOTH)
D2161 Amalgam - four or more surfaces, primary or permanent $98.00
(SURF/TOOTH)
RESIN-BASED COMPOSITE-RESTORATIONS DIRECT

D2330 Resin-based composite - one surface, anterior (SURF/TOOTH) $50.00
D2331 Resin-based composite - two surfaces, anterior $73.00
(SURF/TOOTH)
D2332 Resin-based composite - three surfaces, anterior $87.00
(SURF/TOOTH)
D2335 Resin-based composite - four or more surfaces or involving $98.00
incisal angle (anterior) (SURF/TOOTH)

CODE DESCRIPTION
D2390 Resin-based composite crown, anterior (TOOTH) $98.00
D2391 Resin-based composite; one surface, posterior (SURF/TOOTH) $50.00
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 $67.00
(SURF/TOOTH)
D2393 Resin-based composite - three surfaces, posterior $82.00
(SURF/TOOTH)
D2394 Resin-based composite - four or more surfaces, posterior $98.00
(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 will not be routinely approved for a molar tooth in those members age 21 and
over which has been endodontically treated without prior approval from the Department
of Health.
Crowns include any necessary core buildups.
D2710 Crown – resin-based composite (indirect) (laboratory) $290.00
(TOOTH) (PA REQUIRED)
Acrylic (processed) jacket crowns may be approved as restorations for
severely fractured anterior teeth.
D2720 Crown – resin with high noble metal (TOOTH) (PA REQUIRED) $500.00
D2721 Crown – resin with predominantly base metal (TOOTH) $500.00
(PA REQUIRED)
D2722 Crown – resin with noble metal (TOOTH) (PA REQUIRED) $500.00
D2740 Crown – porcelain/ceramic (TOOTH) (PA REQUIRED) $500.00
D2750 Crown – porcelain fused to high noble metal (TOOTH) $500.00
(PA REQUIRED)
D2751 Crown – porcelain fused to predominately base metal $500.00
D2752 Crown – porcelain fused to noble metal (TOOTH) $500.00
(PA REQUIRED)
D2753 Crown – porcelain fused to titanium and titanium alloys $500.00
D2780 Crown – ¾ cast high noble metal (TOOTH) (PA REQUIRED) $400.00
D2781 Crown – ¾ cast predominantly base metal (TOOTH) $400.00
(PA REQUIRED)
D2782 Crown – ¾ cast noble metal (TOOTH) (PA REQUIRED) $400.00
D2790 Crown – full cast high noble metal (TOOTH) (PA REQUIRED) $500.00
D2791 Crown – full cast predominately base metal (TOOTH) $500.00
(PA REQUIRED)
D2792 Crown – full cast noble metal (TOOTH) (PA REQUIRED) $500.00
D2794 Crown – Titanium and titanium alloys $500.00

CODE DESCRIPTION
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).
D2920 Re-cement or re-bond crown (TOOTH) $30.00
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.
D2930 Prefabricated stainless steel crown - primary tooth (TOOTH) $116.00
D2931 Prefabricated stainless steel crown - permanent tooth $116.00
(TOOTH)
D2932 Prefabricated resin crown (TOOTH) $116.00
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.
D2933 Prefabricated stainless steel crown with resin window $130.00
(TOOTH)
Restricted to primary anterior teeth, permanent maxillary bicuspids and first
molars.
D2934 Prefabricated esthetic coated stainless steel crown – $130.00
primary tooth (TOOTH)
D2951 Pin retention - per tooth, in addition to restoration (TOOTH) $29.00
Reimbursement is allowed once per tooth regardless of the number of pins
placed.
D2952 Post and core in addition to crown, indirectly fabricated $125.00
(TOOTH)
D2954 Prefabricated post and core in addition to crown (TOOTH) $125.00
There is no separate reimbursement for the core material.
D2955 Post removal (TOOTH) $95.00
D2980 Crown repair necessitated by restorative material failure (BR)
(TOOTH) (REPORT NEEDED)
D2999 Unspecified restorative procedure, by report (BR)
(REPORT NEEDED)

CODE DESCRIPTION
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 extension of the root canal filling, periapical
or lateral pathosis persists, or there is a fracture of the root.
If a non-covered surgical procedure (e.g. crown lengthening, D4249) is required to
properly restore a tooth, any associated restorative or endodontic treatment will NOT be
considered for reimbursement.
Pulp capping, either direct or indirect, is not reimbursable.
Molar endodontic treatment, retreatment or apical surgery is not approvable as a routine
procedure. Prior approval requests will be will only be considered for members under
age 21 who display good oral hygiene, have healthy mouths with a full complement of
natural teeth with a low caries index and/or who may be undergoing orthodontic
treatment. In those members age 21 and over, molar endodontic therapy will be
considered only in those instances where the tooth in question is a critical abutment for
an existing functional prosthesis and when the tooth cannot be extracted and replaced
with a new prosthesis, or; where there is a documented medical condition which
precludes extraction.
PULPOTOMY
D3220 Therapeutic pulpotomy (excluding final restoration) - $87.00
removal of pulp coronal to the dentinocemental junction
and application of 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.

CODE DESCRIPTION
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.
D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth $150.00
(excluding final restoration) (TOOTH) (PA REQUIRED)
D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth $235.00
(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.
D3310 Endodontic therapy – anterior tooth (excluding final $250.00
restoration) (TOOTH) (PA REQUIRED)
D3320 Endodontic therapy – premolar tooth (excluding final $300.00
D3330 Endodontic therapy – molar tooth (excluding final $400.00
ENDODONTIC RETREATMENT
D3346 Retreatment of previous root canal therapy - anterior $250.00
D3347 Retreatment of previous root canal therapy - premolar $300.00
D3348 Retreatment of previous root canal therapy - molar (TOOTH) $400.00
(PA REQUIRED)
APEXIFICATION / RECALCIFICATION PROCEDURES

D3351 Apexification / recalcification - initial visit (apical $82.00
closure/calcific repair of perforations, root resorption, etc.)
(TOOTH)
Includes opening tooth, pulpectomy, preparation of canal spaces, first placement
of medication and necessary radiographic images.
(This procedure includes first phase of complete root canal therapy.)
D3352 Apexification / recalcification - interim medication $80.00
replacement (TOOTH)
For visits in which the intra-canal medication is replaced with new medication.
Includes any necessary radiographs.
There may be several of these visits.
The published fee is the maximum reimbursable amount regardless of the
number of visits.

CODE DESCRIPTION
D3353 Apexification / recalcification - final visit (includes $103.00
completed root canal therapy – apical closure/calcific repair
of perforations, root 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.
D3410 Apicoectomy - anterior (TOOTH) (PA REQUIRED) $160.00
D3421 Apicoectomy - premolar (first root) (TOOTH) (PA REQUIRED) $160.00
If more than one root is treated, see D3426.
D3425 Apicoectomy - molar (first root) (TOOTH) (PA REQUIRED) $180.00
If more than one root is treated, see D3426.
D3426 Apicoectomy (each additional root) (TOOTH) (PA REQUIRED) $60.00
D3430 Retrograde filling - per root (TOOTH) (PA REQUIRED) $50.00
OTHER ENDODONTIC PROCEDURES
D3999 Unspecified endodontic procedure, by report (BR)
(REPORT NEEDED)

CODE DESCRIPTION
V. PERIODONTICS D4000 - D4999

For details regarding the “PERIODONTICS” codes that are associated with the implant
and implant related services benefit ONLY (D4245, D4266, D4267, D4273, D4275,
D4277, D4278, D4283, D4285), see section VIII. IMPLANTS.
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.
D4210 Gingivectomy or gingivoplasty – four or more contiguous $100.00

teeth or tooth bounded spaces per quadrant (QUAD)
(REPORT NEEDED)
D4211 Gingivectomy or gingivoplasty – one to three contiguous $65.00
teeth or tooth bounded spaces per quadrant (QUAD)
(REPORT NEEDED)
NON-SURGICAL PERIODONTAL SERVICES

D4341 Periodontal scaling and root planing – four or more teeth $45.00
per quadrant (QUAD)
D4342 Periodontal scaling and root planing – one to three teeth $30.00
per quadrant (QUAD)
For periodontal scaling and root planning (D4341 and D4342) to be considered, the
diagnostic materials must demonstrate the following, consistent with professional
standards:
 Clinical loss of periodontal attachment, and;
• Periodontal pockets and sub-gingival accretions on cemental surfaces in the
quadrant(s) being treated, and/or;
• Radiographic evidence of crestal bone loss and changes in crestal lamina
dura, and/or;
• Radiographic evidence of root surface calculus.
The provider must keep in the treatment record detailed documentation describing the
need for periodontal scaling and root planing, including a copy of the pre-treatment
evaluation of the periodontium, a general description of the tissues (e.g., color, shape,
and consistency), the location and measurement of periodontal pockets, the description

CODE DESCRIPTION
of the type and amount of bone loss, the periodontal diagnosis, the amount and location
of subgingival calculus deposits, and tooth mobility.
Treatment per quadrant is limited to once every two (2) years. For consideration of
more frequent treatment prior approval with supporting documentation is required.
Reimbursement for D4341 and/or D4342 is limited to no more than two quadrants on
a single date of service.
In exceptional circumstances, consideration may be given for reimbursement for more
than two quadrants on a single date of service (e.g. treatment under anesthesia). These
claims should be submitted using procedure code D4999 with documentation supporting
both the need for treatment and the exceptional circumstances present.
Prophylaxis or periodontal maintenance (e.g. D1110, D1120, D4910) will not be
reimbursed on the same date of service as periodontal scaling and root planning (D4341,
D4342).
OTHER PERIODONTAL SERVICES
D4910 Periodontal maintenance $45.00
This procedure is for members who have previously been treated for
periodontal disease with procedures such as scaling and root planing
(D4341 or D4342). D4910 cannot be used in conjunction with or billed
within six (6) months of any other prophylaxis procedure (e.g. D1110).
Reimbursement for D4910 is limited to once per six (6) months and
cannot be used in conjunction with D4341 or D4342 on the same date
of service.
D4999 Unspecified periodontal procedure, by report (BR)
(REPORT NEEDED)

CODE DESCRIPTION
VI. PROSTHODONTICS (Removable) D5000 - D5899

Full and /or partial dentures are covered by Medicaid when they are required to alleviate a
serious health condition or one that affects 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 years from initial placement except when determined
medically necessary by the Department or its agent. Prior approval requests for replacement
dentures prior to eight years must include a letter from the patient’s physician and dentist. A
letter from the patient’s dentist must explain the specific circumstances that necessitates
replacement of the denture. The letter from the physician must explain how dentures would
alleviate the patient’s serious health condition or improve employability. If replacement
dentures are requested within the eight-year period after they have already been replaced
once, then supporting documentation must include an explanation of preventative measures
instituted to alleviate the need for further replacements.
General Guidelines for All Removable Prosthesis:

 Complete and/or partial dentures will be approved only when the existing
prosthesis is not serviceable or 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 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 a 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 includes
rebasing, relining, adjustments and repairs.
 Cleaning of removable prosthesis or soft tissue not directly related to natural teeth
is not a covered service. Prophylaxis and/or scaling and root planing 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 any final impressions.
Generally, it is expected that tissues 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";
 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;

CODE DESCRIPTION
 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:
http://www.ada.org/~/media/ADA/Publications/ADA%20News/Files/Dental_Radiograph
ic_Examinations_2012.pdf?la=en
D5110 Complete denture – maxillary (PA REQUIRED) $560.00
D5120 Complete denture – mandibular (PA REQUIRED) $560.00
PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)
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 impression(s) for partial denture(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.
D5211 Maxillary partial denture - resin base (including $350.00
retentive/clasping materials, rests, and teeth) (PA REQUIRED)
D5212 Mandibular partial denture - resin base (including $350.00
retentive/clasping materials, rests, and teeth) (PA REQUIRED)
D5213 Maxillary partial denture - cast metal framework with resin $560.00
denture bases (including retentive/clasping materials, rests
and teeth) (PA REQUIRED)
D5214 Mandibular partial denture - cast metal framework with $560.00
resin denture bases (including retentive/clasping materials,
rests and teeth) (PA REQUIRED)
D5225 Maxillary partial denture - flexible base (including any $560.00
clasps, rests and teeth) (PA REQUIRED)
D5226 Mandibular partial denture - flexible base (including any $560.00
clasps, rests and teeth) (PA REQUIRED)

CODE DESCRIPTION
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.
D5410 Adjust complete denture - maxillary $25.00
D5411 Adjust complete denture - mandibular $25.00
D5421 Adjust partial denture - maxillary $25.00
D5422 Adjust partial denture - mandibular $25.00
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
D5511 Repair broken complete denture base, mandibular $65.00
D5512 Repair broken complete denture base, maxillary $65.00
D5520 Replace missing or broken teeth - complete denture (each $42.00
tooth) (TOOTH)
REPAIRS TO PARTIAL DENTURES

D5611 Repair resin partial denture base, mandibular $67.00
D5612 Repair resin partial denture base, maxillary $67.00
D5621 Repair cast partial framework, mandibular $120.00
D5622 Repair cast partial framework, maxillary $120.00
D5630 Repair or replace broken retentive/clasping materials- per $130.00
tooth (TOOTH)
D5640 Replace broken teeth - per tooth (TOOTH) $60.00
D5650 Add tooth to existing partial denture (TOOTH) $65.00
D5660 Add clasp to existing partial denture - per tooth (TOOTH) $102.00
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.
D5710 Rebase - complete maxillary denture (PA REQUIRED) $170.00
D5711 Rebase - complete mandibular denture (PA REQUIRED) $170.00
D5720 Rebase - maxillary partial denture (PA REQUIRED) $174.00

CODE DESCRIPTION
D5721 Rebase - mandibular partial denture (PA REQUIRED) $174.00
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.
D5730 Reline complete maxillary denture (chairside) (PA REQUIRED) $125.00
D5731 Reline complete mandibular denture (chairside) $125.00
(PA REQUIRED)
D5740 Reline maxillary partial denture (chairside) (PA REQUIRED) $85.00
D5741 Reline mandibular partial denture (chairside) (PA REQUIRED) $85.00
D5750 Reline complete maxillary denture (laboratory) $170.00
D5751 Reline complete mandibular denture (laboratory) $170.00
D5760 Reline maxillary partial denture (laboratory) $125.00
D5761 Reline mandibular partial denture (laboratory) $125.00
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.
D5820 Interim partial denture (maxillary) $174.00
D5821 Interim partial denture (mandibular) $174.00
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.
D5850 Tissue conditioning, maxillary $25.00
D5851 Tissue conditioning, mandibular $25.00
D5899 Unspecified removable prosthodontic procedure, by report (BR)
(REPORT NEEDED)

CODE DESCRIPTION
VII. MAXILLOFACIAL PROSTHETICS D5900 - D5999

D5911 Facial moulage (sectional) (REPORT NEEDED) $116.00
D5912 Facial moulage (complete) (REPORT NEEDED) $174.00
D5913 Nasal prosthesis (REPORT NEEDED) (BR)
D5914 Auricular prosthesis (REPORT NEEDED) (BR)
D5915 Orbital prosthesis (REPORT NEEDED) $957.00
D5916 Ocular prosthesis (REPORT NEEDED) $957.00
D5919 Facial prosthesis (REPORT NEEDED) (BR)
D5922 Nasal septal prosthesis (REPORT NEEDED) (BR)
D5923 Ocular prosthesis, interim (REPORT NEEDED) $435.00
D5924 Cranial prosthesis (REPORT NEEDED) (BR)
D5925 Facial augmentation implant prosthesis (REPORT NEEDED) (BR)
D5926 Nasal prosthesis, replacement (REPORT NEEDED) (BR)
D5927 Auricular prosthesis, replacement (REPORT NEEDED) (BR)
D5928 Orbital prosthesis, replacement (REPORT NEEDED) (BR)
D5929 Facial prosthesis, replacement (REPORT NEEDED) (BR)
D5931 Obturator prosthesis, surgical (REPORT NEEDED) (BR)
D5932 Obturator prosthesis, definitive (REPORT NEEDED) (BR)
D5933 Obturator prosthesis, modification (REPORT NEEDED) (BR)
D5934 Mandibular resection prosthesis with guide flange (BR)
(REPORT NEEDED)
D5935 Mandibular resection prosthesis without guide flange (BR)
(REPORT NEEDED)
D5936 Obturator prosthesis, interim (REPORT NEEDED) (BR)
D5937 Trismus appliance (not for TMD treatment) (REPORT NEEDED) $145.00
D5951 Feeding aid (REPORT NEEDED) $435.00
D5952 Speech aid prosthesis, pediatric (REPORT NEEDED) (BR)
D5953 Speech aid prosthesis, adult (REPORT NEEDED) (BR)
D5954 Palatal augmentation prosthesis (REPORT NEEDED) (BR)
D5955 Palatal lift prosthesis, definitive (REPORT NEEDED) (BR)
D5958 Palatal lift prosthesis, interim (REPORT NEEDED) (BR)
D5959 Palatal lift prosthesis, modification (REPORT NEEDED) (BR)
D5960 Speech aid prosthesis, modification (REPORT NEEDED) (BR)
D5982 Surgical stent (REPORT NEEDED) (BR)
D5983 Radiation carrier (REPORT NEEDED) (BR)
D5984 Radiation shield (REPORT NEEDED) (BR)
D5985 Radiation cone locator (REPORT NEEDED) (BR)
D5986 Fluoride gel carrier (per arch) (ARCH) $10.00
D5987 Commissure splint (REPORT NEEDED) (BR)
D5988 Surgical splint (REPORT NEEDED) (BR)
D5999 Unspecified maxillofacial prosthesis, by report (BR)
(REPORT NEEDED)

CODE DESCRIPTION
VIII. IMPLANT SERVICES D6000 - D6199

Dental 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 physician and dentist. A letter from the patient’s
physician must explain how implants will alleviate the patient’s medical condition. A
letter from the patient’s dentist must explain why other covered functional alternatives
for prosthetic replacement will not correct the patient’s dental condition and why the
patient requires implants.
General Guidelines:
 A complete treatment plan addressing all phases of care is required and should
include the following:
• Accurate pretreatment charting;
• Complete treatment plan addressing all areas of pathology;
• Inter-arch distances;
• Number, type and location of implants to be placed;
• Design and type of planned restoration(s);
• 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.
 Physician’s 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).
D6010 Surgical placement of implant body (TOOTH) (PA $1000.00
REQUIRED) (POST OPERATIVE CARE: 90 DAYS)
Full mouth radiographs or diagnostic panorex including periapicals of
site requesting dental implant(s) must be provided.
D6013 Surgical placement of mini implant (TOOTH) (PA REQUIRED) $500.00
(POST OPERATIVE CARE: 90 DAYS)

CODE DESCRIPTION
Full mouth radiographs or diagnostic panorex including periapicals of site
requesting dental implant(s) must be provided.
For procedure codes D6052 – D6057 the following must be submitted:
 Periapical radiograph of the integrated implant(s); and,
 Panorex or sufficient number of radiographs showing the
complete arch and the placed implant(s)
D6052 Semi-precision attachment abutment (ARCH or TOOTH) (PA $250.00
REQUIRED)
D6055 Connecting bar – implant supported or abutment supported $400.00
(ARCH) (PA REQUIRED)
D6056 Prefabricated abutment – includes modification and placement $400.00
D6057 Custom fabricated abutment – includes placement $400.00
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
D6058 Abutment supported porcelain/ceramic crown $800.00
D6059 Abutment supported porcelain fused to metal crown (high noble $800.00
metal) (TOOTH) (PA REQUIRED)
D6060 Abutment supported porcelain fused to metal crown $800.00
(predominantly base metal) (TOOTH) (PA REQUIRED)
D6061 Abutment supported porcelain fused to metal crown (noble metal) $800.00
D6062 Abutment supported cast metal crown (high noble metal) (TOOTH) $800.00
(PA REQUIRED)
D6063 Abutment supported cast metal crown (predominately base metal) $800.00
D6064 Abutment supported cast metal crown (noble metal) (TOOTH) (PA $800.00
REQUIRED)
D6065 Implant supported porcelain/ceramic crown (TOOTH) (PA REQUIRED) $800.00
D6066 Implant supported crown - porcelain fused to high noble alloys $800.00
D6067 Implant supported crown - high noble alloys (TOOTH) (PA REQUIRED) $800.00
D6081 Scaling and debridement in the presence of inflammation or (BR)
mucositis of a single implant, including cleaning on the implant
surfaces, without flap entry and closure (TOOTH) (REPORT NEEDED)
 Cannot bill for same date of service as D1110 or D4910.
 Cannot bill for same date of service and same quadrant
as D4341, D4342.
D6090 Repair implant supported prosthesis (ARCH) (REPORT NEEDED) (BR)

CODE DESCRIPTION
D6091 Replacement of semi-precision or precision attachment (male or (BR)
female component) of implant/abutment supported prosthesis, per
attachment (QUAD) (REPORT NEEDED)
D6092 Re-cement or re-bond implant/abutment supported crown (TOOTH) (BR)
(REPORT NEEDED)
D6093 Re-cement or re-bond implant/abutment supported fixed partial (BR)
denture (QUAD) (REPORT NEEDED)
D6094 Abutment supported crown – titanium and titanium alloys (TOOTH) $800.00
(PA REQUIRED)
D6095 Repair implant abutment (TOOTH) (REPORT NEEDED) (BR)
D6096 Remove broken implant retaining screw (TOOTH) (REPORT NEEDED) (BR)
D6100 Implant removal (TOOTH) (REPORT NEEDED) (POST OPERATIVE CARE: 10 (BR)
DAYS)
 Pre-operative radiographic image of defect
 Detailed narrative
 Intra-oral photograph of defect area
D6101 Debridement of a peri-implant defect or defects surrounding a $250.00
single implant, and surface cleaning of the exposed implant
surfaces, including flap entry and closure (TOOTH) (PA REQUIRED)
D6102 Debridement and osseous contouring of a peri-implant defect or $400.00
defects surrounding a single implant and includes surface cleaning
of the exposed implant surfaces, including flap entry and closure
(TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 30 DAYS)
D6103 Bone graft for repair of peri-implant defect – does not include flap $200.00
entry and closure (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 30
DAYS)
D6104 Bone graft at time of implant placement (TOOTH) (PA REQUIRED) (POST $250.00
OPERATIVE CARE: 90 DAYS)

 Periapical radiograph of integrated implant(s) with abutment
placed
 IO photo of healed abutment showing healthy gingiva
D6110 Implant/abutment supported removable denture for edentulous $1000.00
arch – maxillary (PA REQUIRED)
D6111 Implant/abutment supported removable denture for edentulous $1000.00
arch – mandibular (PA REQUIRED)
D6112 Implant/abutment supported removable denture for partially $900.00
edentulous arch – maxillary (PA REQUIRED)
D6113 Implant/abutment supported removable denture for partially $900.00
edentulous arch – mandibular (PA REQUIRED)
D6190 Radiographic/surgical implant index, by report (ARCH) (REPORT (BR)
NEEDED)
D6199 Unspecified implant procedure, by report (REPORT NEEDED) (BR)

CODE DESCRIPTION
The following procedure codes are a covered benefit only when associated with an
implant or an implant-related service: D4245, D4266, D4267, D4273, D4275, D4277,
D4278, D4283, D4285.
D4245 Apically positioned flap (TOOTH) (PA REQUIRED) (POST $125.00

Procedure is used to preserve keratinized gingiva in conjunction with
osseous resection and second stage implant procedure. 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.
D4266 Guided tissue regeneration – resorbable barrier, per $125.00
site (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 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 and peri-
implant defects.
D4267 Guided tissue regeneration – non-resorbable barrier, per site $150.00
(includes membrane removal) (TOOTH) (PA REQUIRED)
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 and peri-
implant defects.
D4273 Autogenous connective tissue graft procedure $300.00
(including donor and recipient surgical sites) first
tooth, implant or edentulous tooth position in graft
There are two surgical sites. The recipient site utilizes a split thickness
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.
D4275 Non-autogenous connective tissue graft (including $400.00
recipient site and donor material) – first tooth, implant, or
edentulous tooth position in graft (TOOTH) (PA REQUIRED)
D4277 Free soft tissue graft procedure (including recipient and $400.00
donor surgical sites) first tooth, implant, or edentulous
tooth position in graft (TOOTH) (PA REQUIRED) (POST
There is only a recipient surgical site utilizing split thickness incision,
retaining the overlaying flap of gingiva and/or mucosa. A donor surgical
site is not present.

CODE DESCRIPTION
D4278 Free soft tissue graft procedure (including recipient and donor $300.00
surgical sites) each additional contiguous tooth, implant, or
edentulous tooth position in same graft site (TOOTH) (PA
Used in conjunction with D4277.
D4283 Autogenous connective tissue graft procedure (including $200.00
donor and recipient surgical sites) – each additional
contiguous tooth, implant or edentulous tooth position in
same graft site (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14
DAYS)
D4285 Non-autogenous connective tissue graft procedure (including $300.00
recipient surgical site and donor material) – each additional
contiguous tooth, implant or edentulous tooth position in
same graft site. (TOOTH) (PA REQUIRED) (POST OPERATIVE CARE: 14
DAYS)
The following procedure codes are a covered benefit only when associated with an
implant or an implant-related service: D7951, D7952, D7953.
D7951 Sinus augmentation with bone or bone substitutes via a lateral $800.00
open approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE: 14
DAYS)
The augmentation of the sinus cavity to increase alveolar height for
reconstruction of edentulous portions of the maxilla. This procedure
is 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.
D7952 Sinus augmentation with bone or bone substitutes via a $800.00
vertical approach (QUAD) (PA REQUIRED) (POST OPERATIVE CARE: 14
DAYS)
The augmentation of the sinus to increase alveolar height by vertical
access through the ridge crest by raising the floor of the sinus and
grafting as necessary. This includes obtaining the bone or bone
substitutes.
D7953 Bone replacement graft for ridge preservation – per site $250.00
Graft is placed in an extraction or implant removal site at the time of
the extraction or removal to preserve ridge integrity (e.g., clinically
indicated in preparation for 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.

CODE DESCRIPTION
IX. PROSTHODONTICS, FIXED D6200 - D6999

Fixed bridgework is generally considered beyond the scope of the NYS
Medicaid program. The placement of a fixed prosthetic appliance will only
be considered for the anterior segment of the mouth in those exceptional
cases where there is a documented physical or neurological disorder that
would preclude placement of a removable prosthesis, or in those cases
requiring cleft palate stabilization. In cases other than for cleft palate
stabilization, treatment would generally be limited to replacement of a single
maxillary anterior tooth or replacement of two adjacent mandibular teeth.
The fabrication of a fixed bridge is generally considered for members with no
recent caries activity (no initial restorations placed during the past year), no
unrestored carious lesions, no significant periodontal bone loss in the same
arch and no posterior tooth loss with replaceable space in the same arch.
The replacement of a missing tooth or teeth with a fixed partial denture will
not be approved under the Medicaid program when either no replacement or
replacement with a removable partial denture could be considered
appropriate based on Medicaid prosthetic guidelines.
For a member under the age of 21 or one whose pulpal anatomy precludes
crown preparation of abutments without pulp exposure, acid etched cast
bonded bridges (“Maryland Bridges”) may be approved only for the
replacement of a single missing maxillary anterior tooth, two adjacent
missing maxillary anterior teeth, or two adjacent missing mandibular incisors.
The same guidelines as previously listed apply. Abutments for resin bonded
fixed partial dentures (i.e. “Maryland Bridges”) should be billed using code
D6545 and pontics using code D6251.
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.
FIXED PARTIAL DENTURE PONTICS
D6210 Pontic - cast high noble metal (TOOTH) (PA REQUIRED) $400.00
D6211 Pontic - cast predominately base metal (TOOTH) (PA REQUIRED) $400.00
D6212 Pontic - cast noble metal (TOOTH) (PA REQUIRED) $400.00
D6214 Pontic - titanium and titanium alloys (TOOTH) (PA REQUIRED) $400.00
D6240 Pontic - porcelain fused to high noble metal (TOOTH) (PA $400.00
REQUIRED)
D6241 Pontic - porcelain fused to predominately base metal (TOOTH) $400.00
(PA REQUIRED)
D6242 Pontic - porcelain fused to noble metal (TOOTH) (PA REQUIRED) $400.00
D6243 Pontic - porcelain fused to titanium and titanium alloys $400.00
D6245 Pontic - porcelain/ceramic (TOOTH) (PA REQUIRED) $400.00

CODE DESCRIPTION
D6250 Pontic - resin with high noble metal (TOOTH) (PA REQUIRED) $400.00
D6251 Pontic - resin with predominately base metal (TOOTH) (PA $400.00
REQUIRED)
Limited to the pontic for resin bonded fixed partial dentures
(i.e. “Maryland Bridges”).
D6252 Pontic - resin with noble metal (TOOTH) (PA REQUIRED) $400.00
FIXED PARTIAL DENTURE RETAINERS-INLAYS/ONLAYS
D6545 Retainer - cast metal for resin bonded fixed prosthesis $145.00
(TOOTH)
(PA REQUIRED)
Limited to abutment for resin bonded fixed partial dentures
(i.e. “Maryland Bridges”).
FIXED PARTIAL DENTURE RETAINERS - CROWNS
D6720 Retainer crown - resin with high noble metal (TOOTH) (PA $500.00
REQUIRED)
D6721 Retainer crown - resin with predominately base metal (TOOTH) $500.00
(PA REQUIRED)
D6722 Retainer crown - resin with noble metal (TOOTH) (PA REQUIRED) $500.00
D6740 Retainer crown - porcelain/ceramic (TOOTH) (PA REQUIRED) $500.00
D6750 Retainer crown - porcelain fused to high noble metal (TOOTH) $500.00
(PA REQUIRED)
D6751 Retainer crown - porcelain fused to predominantly base metal $500.00
D6752 Retainer crown - porcelain fused to noble metal (TOOTH) $500.00
(PA REQUIRED)
D6753 Retainer crown – porcelain fused to titanium and titanium $500.00
alloys (TOOTH) (PA REQUIRED)
D6780 Retainer crown - ¾ cast high noble metal (TOOTH) (PA $400.00
REQUIRED)
D6781 Retainer crown - ¾ cast predominately base metal (TOOTH) $400.00
(PA REQUIRED)
D6782 Retainer crown - ¾ cast noble metal (TOOTH) (PA REQUIRED) $400.00
D6783 Retainer crown - ¾ porcelain/ceramic (TOOTH) (PA REQUIRED) $400.00
D6784 Retainer crown - ¾ titanium and titanium alloys (TOOTH) (PA $400.00
REQUIRED)
D6790 Retainer crown – full cast high noble metal (TOOTH) (PA $500.00
REQUIRED)
D6791 Retainer crown - full cast predominantly base metal (TOOTH) $500.00
(PA REQUIRED)
D6792 Retainer crown – full cast noble metal (TOOTH) (PA REQUIRED) $500.00
D6794 Retainer crown – titanium and titanium alloys (TOOTH) (PA $500.00
REQUIRED)
OTHER FIXED PARTIAL DENTURE SERVICES

D6930 Re-cement or re-bond fixed partial denture (QUAD) $45.00

CODE DESCRIPTION
D6980 Fixed partial denture repair necessitated by restorative (BR)
material failure (QUAD) (REPORT NEEDED)
For sectioning of a fixed partial denture, use procedure code D9120.
D6999 Unspecified, fixed prosthodontic procedure, by report (BR)
(REPORT NEEDED)

CODE DESCRIPTION
X. ORAL AND MAXILLOFACIAL SURGERY

D7000 - D7999
For details regarding the “ORAL AND MAXILLOFACIAL SURGERY” codes
that are associated with the implant and implant-related services benefit
ONLY (D7951, D7953), see section VIII. IMPLANTS.
All surgical procedures include the surgery and the follow-up care for
the period indicated after the procedure description (e.g. (POST
OPERATIVE CARE: 7 DAYS)). Necessary follow-up care beyond the listed
period should be billed using codes D7999, D9110 or D9430.
When multiple surgical procedures are performed on the same quadrant or
arch, the claim may be pended for professional review. When extensive
multiple surgical procedures are performed at the same operative session,
the total reimbursement requested will be evaluated on a case by case basis,
with possible reduction or denial of one or more of the billed procedures.
Removal of bilateral tori or bilateral impactions and multiple extractions
performed at the same operative session are examples of exceptions due to
the independence of the individual procedures.
When a provider performs surgical excision and removal of tumors, cysts
and neoplasms, the extent of the procedure claimed must be supported by
information in the member's record. This includes radiographic images,
clinical findings, and operative and histopathologic reports. To expedite
review and reimbursement, this material (except radiographs) should be
submitted on paper claims for procedures that have no established fee and
are priced "By Report."
If a change is needed or there exists a disagreement with a prior approval
review and you would like to challenge a determination rendered by the DOH
on an existing finalized prior approval, a request may be submitted with
supporting documentation and a detailed report using a “Prior Approval
Change Request Form”. This form may be submitted pre-operatively or post-
operatively. If the requested change is submitted post-operatively a copy of
the treatment notes should be included with the request.
The Prior Approval Change Request Form can be obtained by clicking
on the link below or by calling eMedNY at 1-800-343-9000.
eMedNY: Information: Paper Forms
EXTRACTIONS (INCLUDES LOCAL ANESTHESIA, SUTURING, IF

NEEDED, AND ROUTINE POSTOPERATIVE CARE)
D7111 Extraction, coronal remnants – primary tooth $35.00
D7140 Extraction, erupted tooth or exposed root (elevation and/or $50.00
forceps removal) (TOOTH) (POST OPERATIVE CARE: 3 DAYS)

CODE DESCRIPTION
D7210 Extraction, erupted tooth requiring removal of bone and/or $85.00
sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated (TOOTH) (POST OPERATIVE CARE:
10 DAYS)
Includes related cutting of gingiva and bone, removal of tooth
structure, minor smoothing of socket bone and closure. Prior
approval is required if performed more than four (4) times within
twelve (12) months from the date of the first surgical extraction
(D7210).
D7220 Removal of impacted tooth - soft tissue (TOOTH) (PA REQUIRED) $100.00
D7230 Removal of impacted tooth - partially bony (TOOTH) (PA $180.00
D7240 Removal of impacted tooth - completely bony (TOOTH) $300.00
(PA REQUIRED) (POST OPERATIVE CARE: 10 DAYS)
D7241 Removal of impacted tooth - completely bony, with unusual (BR)
surgical complications (TOOTH) (REPORT NEEDED)
D7250 Removal of residual tooth roots (cutting procedure) (TOOTH) $58.00
Includes cutting of soft tissue and bone, removal of tooth structure, and closure
OTHER SURGICAL PROCEDURES
D7260 Oroantral fistula closure (QUAD 10 or 20) $200.00
D7261 Primary closure of sinus perforation (QUAD 10 or 20) $200.00
D7270 Tooth re-implantation and/or stabilization of accidentally $114.00
evulsed or displaced tooth (TOOTH) (POST OPERATIVE CARE: 30
DAYS)
Includes splitting and/or stabilization.
D7272 Tooth transplantation (includes re-implantation from one site $150.00
to another and splinting and/or stabilization) (TOOTH)
D7280 Exposure of an unerupted tooth (TOOTH) $290.00
An incision is made and the tissue is reflected and bone removed as
necessary to expose the crown of an impacted tooth not intended to
be extracted.
D7283 Placement of device to facilitate eruption of impacted tooth $50.00
(TOOTH) (POST OPERATIVE CARE: 14 DAYS)
Report the surgical exposure separately using D7280.
D7285 Biopsy of oral tissue - hard (bone, tooth) (REPORT NEEDED) $104.00
Claims must be submitted on paper with a copy of the operative
report, including the description and location of the lesion and
pathology report.

CODE DESCRIPTION
D7286 Biopsy of oral tissue – soft (REPORT NEEDED) $84.00
Claims must be submitted on paper with a copy of the operative
report, including the description and location of the lesion and
pathology report.
D7290 Surgical repositioning of teeth (TOOTH) (PA REQUIRED) $145.00
ALVEOPLASTY - PREPARATION OF RIDGE

D7310 Alveoloplasty in conjunction with extractions – four or more $70.00
teeth or tooth spaces, per quadrant (QUAD)
This procedure will be reimbursed when additional surgical
procedures above and beyond the removal of the teeth are required
to prepare the ridge for dentures. Not reimbursable in addition to
surgical extractions in the same quadrant. Claims should be
submitted on the same invoice as extractions to expedite review.
D7311 Alveoloplasty in conjunction with extractions – one to three $50.00
teeth or tooth spaces, per quadrant (QUAD)
This procedure will be reimbursed when additional surgical
procedures above and beyond the removal of the teeth are required
to prepare the ridge for dentures. Not reimbursable in addition to
surgical extractions in the same quadrant. Claims should be
submitted on the same invoice as extractions to expedite review.
D7320 Alveoloplasty not in conjunction with extractions – four or $115.00
more teeth or tooth spaces, per quadrant (QUAD)
The fee for each quadrant includes the recontouring of both osseous
and soft tissues in that quadrant. Will not be reimbursed in
conjunction with procedure code D7310 in the same quadrant.
D7321 Alveoloplasty not in conjunction with extractions – one to $75.00
three or tooth spaces, per quadrant (QUAD) (POST OPERATIVE
CARE: 14 DAYS)
The fee for each quadrant includes the recontouring of both osseous
and soft tissues in that quadrant. Will not be reimbursed in
conjunction with procedure code D7311 in the same quadrant.
VESTIBULOPLASTY
Vestibuloplasty may be approved when a denture could not otherwise be
worn.
D7340 Vestibuloplasty - ridge extension (secondary $300.00
epithelialization) (ARCH) (PA REQUIRED) (POST OPERATIVE CARE:
60 DAYS)

CODE DESCRIPTION
D7350 Vestibuloplasty - ridge extension (including soft tissue $400.00
grafts, muscle reattachment, revision of soft tissue
attachment and management of hypertrophied and
hyperplastic tissue) (ARCH)
(PA REQUIRED) (POST OPERATIVE CARE: 60 DAYS)
EXCISION OF SOFT TISSUE LESIONS (INCLUDES NON-

ODONTOGENIC CYSTS)
All claims for D7410, D7411, and D7412, should be submitted with a copy
of the operative report and all claims for D7413, D7414, and D7415 should
be submitted with a copy of the pathology and operative report(s). All
operative reports must include a description of the lesion and its location.
D7410 Excision of benign lesion up to 1.25 cm (REPORT NEEDED) $101.00
D7411 Excision of benign lesion greater than 1.25cm (REPORT (BR)
NEEDED) (POST OPERATIVE CARE: 60 DAYS)
D7412 Excision of benign lesion complicated (REPORT NEEDED) (BR)
D7413 Excision of malignant lesion up to 1.25cm (REPORT NEEDED) (BR)
D7414 Excision of malignant lesion greater than 1.25cm (REPORT (BR)
D7415 Excision of malignant lesion complicated (REPORT NEEDED) (BR)

EXCISION OF INTRA-OSSEOUS LESIONS

Claims must be submitted with a copy of the pathology and operative
report(s) and must include a description of the lesion and its location.
Reimbursement for routine or surgical extractions includes removal of tooth,
soft tissue associated with the root and curettage of the socket. Periapical
granulomas at the apex of decayed teeth will not be separately reimbursed
in addition to the tooth extraction.
D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm (BR)
(QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 30 DAYS)
D7441 Excision of malignant tumor -lesion greater than 1.25 cm (BR)
(QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)
D7450 Removal of benign odontogenic cyst or tumor-lesion $84.72
diameter up to 1.25 cm (QUAD) (REPORT NEEDED) (POST
D7451 Removal of benign odontogenic cyst or tumor-lesion greater (BR)
than 1.25 cm (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 60
DAYS)
D7460 Removal of benign nonodontogenic cyst or tumor - lesion $101.00
diameter up to 1.25 cm (QUAD) (REPORT NEEDED)

CODE DESCRIPTION
D7461 Removal of benign nonodontogenic cyst or tumor - greater (BR)
than 1.25 cm (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 30
DAYS)
D7465 Destruction of lesion(s) by physical or chemical methods, by (BR)
report (REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)
EXCISION OF BONE TISSUE
D7471 Removal of lateral exostosis (maxilla or mandible) (QUAD) (BR)
(REPORT NEEDED) (POST OPERATIVE CARE: 21 DAYS)
D7472 Removal of torus palatinus (REPORT NEEDED) (POST OPERATIVE (BR)
CARE: 21 DAYS)
D7473 Removal of torus mandibularis (QUAD 30 or 40) (REPORT NEEDED) (BR)
D7485 Reduction of osseous tuberosity (QUAD 10 or 20) (BR)
D7490 Radical resection of maxilla or mandible (ARCH) (REPORT (BR)
SURGICAL INCISION
Reimbursement for incision and drainage procedures includes both the
insertion and the removal of all drains.
D7510 Incision and drainage of abscess – intraoral soft tissue $70.00
(QUAD) (POST OPERATIVE CARE: 10 DAYS) (REPORT NEEDED)
D7511 Incision and drainage of abscess – intraoral soft tissue – (BR)
complicated (includes drainage of multiple fascial spaces)
(QUAD) (REPORT NEEDED)
D7520 Incision and drainage of abscess – extraoral soft tissue $140.00
(QUAD) (POST OPERATIVE CARE: 21 DAYS)
D7521 Incision and drainage of abscess – extraoral soft tissue – (BR)
complicated (includes drainage of multiple fascial spaces)
(QUAD) (REPORT NEEDED)
D7530 Removal of foreign body from mucosa, skin, or (BR)
subcutaneous alveolar tissue (QUAD) (REPORT NEEDED)
D7540 Removal of reaction-producing foreign bodies – (BR)
musculoskeletal system (QUAD) (REPORT NEEDED) (POST
The report must include a description of the foreign body and its
location.
D7550 Partial ostectomy / sequestrectomy for removal of non-vital (BR)
bone (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS)
The report must include a description of the surgical site.
D7560 Maxillary sinusotomy for removal of tooth fragment or $435.00
foreign body (QUAD) (REPORT NEEDED) (POST OPERATIVE CARE:
60 DAYS)
Includes closure of oroantral communication when performed concurrently.

CODE DESCRIPTION
TREATMENT OF CLOSED FRACTURES

D7610 Maxilla - open reduction (teeth immobilized if present) $1,160.00
D7620 Maxilla - closed reduction (teeth immobilized if present) $435.00
D7630 Mandible - open reduction (teeth immobilized if present) $1,305.00
D7640 Mandible - closed reduction (teeth immobilized if present) $435.00
D7650 Malar and/or zygomatic arch - open reduction (REPORT $725.00
D7660 Malar and/or zygomatic arch - closed reduction (REPORT (BR)
D7670 Alveolus - closed reduction, may include stabilization of $203.00
teeth (REPORT NEEDED) (POST OPERATIVE CARE: 60 DAYS)
D7671 Alveolus - open reduction, may include stabilization of teeth (BR)
D7680 Facial bones – complicated reduction with fixation and (BR)
multiple surgical approaches (REPORT NEEDED)
TREATMENT OF OPEN FRACTURES

Reimbursement for codes D7710-D7740 includes splint fabrication when
necessary.
D7710 Maxilla – open reduction (REPORT NEEDED) (BR)
D7720 Maxilla - closed reduction (REPORT NEEDED) $580.00
D7730 Mandible - open reduction (REPORT NEEDED) (BR)
D7740 Mandible - closed reduction (REPORT NEEDED) $580.00
D7750 Malar and/or zygomatic arch - open reduction (REPORT (BR)
D7760 Malar and/or zygomatic arch - closed reduction (REPORT (BR)
D7770 Alveolus – open reduction stabilization of teeth (REPORT (BR)
D7771 Alveolus - closed reduction stabilization of teeth (REPORT (BR)
D7780 Facial bones – complicated reduction with fixation and (BR)
multiple approaches (REPORT NEEDED) (POST OPERATIVE CARE:
90 DAYS)

CODE DESCRIPTION
REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHER

TEMPOROMANDIBULAR JOINT DYSFUNCTIONS
Routine services for treatment of temporomandibular joint, myofacial pain
and related disorders are generally considered beyond the scope of the
program. Reimbursement for temporomandibular joint dysfunctions will be
permitted only in the specific conditions wherein a definitive diagnosis
corroborates necessary treatment. Appropriate documentation (e.g.,
operative report, procedure description) should accompany all claims as
attachments.
D7810 Open reduction of dislocation (REPORT NEEDED) $1450.00
D7820 Closed reduction of dislocation (REPORT NEEDED) $140.00
D7830 Manipulation under anesthesia (REPORT NEEDED) $174.00
D7840 Condylectomy (REPORT NEEDED) (POST OPERATIVE CARE: 90 $1740.00
DAYS)
D7850 Surgical discectomy; with/without implant $870.00
D7852 Disc repair (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS) $1,044.00
D7854 Synovectomy (REPORT NEEDED) (POST OPERATIVE CARE: 90 $812.00
DAYS)
D7856 Myotomy (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS) (BR)
D7858 Joint reconstruction (REPORT NEEDED) $2,900.00
D7860 Arthrotomy (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS) $870.00
D7865 Arthroplasty (REPORT NEEDED) (POST OPERATIVE CARE: 90 DAYS) $2,030.00
D7870 Arthrocentesis (REPORT NEEDED) (POST OPERATIVE CARE: 7 $116.00
DAYS)
D7872 Arthroscopy - diagnosis, with/without biopsy (REPORT $725.00
D7873 Arthroscopy: lavage and lysis of adhesions $725.00
D7874 Arthroscopy: disc repositioning and stabilization (REPORT $1,044.00
D7875 Arthroscopy: synovectomy (REPORT NEEDED) $1,044.00
D7876 Arthroscopy: discectomy (REPORT NEEDED) $1,044.00
D7877 Arthroscopy: debridement (REPORT NEEDED) $1,044.00
D7880 Occlusal orthotic appliance, by report (REPORT NEEDED) (BR)
Reimbursable only when performed in conjunction with a covered
surgical procedure. Not used for “night guards”, “occlusal guards”,
bruxism appliances, or other TMJ appliances.

CODE DESCRIPTION
D7899 Unspecified TMD therapy, by report (REPORT NEEDED) (BR)
REPAIR OF TRAUMATIC WOUNDS
Excludes closure of surgical incisions.
D7910 Suture of recent small wounds up to 5 cm (REPORT NEEDED) $100.00
COMPLICATED SUTURING (RECONSTRUCTION REQUIRING

DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR
METICULOUS CLOSURE)
Excludes closure of surgical incisions.
Utilized in situations requiring unusual and time-consuming techniques of
repair to obtain the maximum functional and cosmetic result. The extent of
the procedure claimed must be supported by information in the operative
report.
D7911 Complicated suture - up to 5 cm (REPORT NEEDED) $125.00
D7912 Complicated suture - greater than 5 cm, (REPORT NEEDED) (BR)
OTHER REPAIR PROCEDURES

D7920 Skin graft (identify defect covered, location and type of graft) (BR)
D7940 Osteoplasty - for orthognathic deformities (REPORT NEEDED) (BR)
Use to report genioplasty.
D7941 Osteotomy - mandibular rami (REPORT NEEDED) $1,450.00
D7943 Osteotomy - mandibular rami with bone graft; includes $2,175.00
obtaining the graft (REPORT NEEDED) (POST OPERATIVE CARE: 90
DAYS)
D7944 Osteotomy - segmented or subapical (REPORT NEEDED) $1160.00
D7945 Osteotomy - body of mandible (REPORT NEEDED) $1102.00
D7946 LeFort I (maxilla-total) (REPORT NEEDED) $2,175.00
D7947 LeFort I (maxilla-segmented) (REPORT NEEDED) $2,900.00
When reporting a surgically assisted palatal expansion without
downfracture, this code would entail a reduced service and should be
“by report” using procedure code D7999.
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface $2,900.00
hyperplasia or retrusion) - without bone graft (REPORT

CODE DESCRIPTION
D7949 LeFort II or LeFort III with bone graft (REPORT NEEDED) $3,480.00
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible (BR)
or maxilla - autogenous or nonautogenous, by report
D7960 Frenulectomy – also known as frenectomy or frenotomy – $190.00
separate procedure not incidental to another procedure
(ARCH) (REPORT NEEDED) (POST OPERATIVE CARE: 14 DAYS)
Removal or release of mucosal and muscle elements of a buccal,
labial or lingual frenum that is associated with a pathological
condition, or interferes with proper oral development or treatment.
D7970 Excision of hyperplastic tissue- per arch (ARCH) (REPORT $150.00
D7971 Excision of pericoronal gingiva (TOOTH) (REPORT NEEDED) $60.00
All claims will be pended for professional review.
D7972 Surgical reduction of fibrous tuberosity (QUAD) (REPORT (BR)
D7980 Surgical sialolithotomy (POST OPERATIVE CARE: 14 DAYS) $290.00
D7981 Excision of salivary gland, by report (REPORT NEEDED) (BR)
D7982 Sialodochoplasty (REPORT NEEDED) (POST OPERATIVE CARE: 30 $826.00
DAYS)
D7983 Closure of salivary fistula (REPORT NEEDED) (BR)
D7990 Emergency tracheotomy $725.00
D7991 Coronoidectomy (REPORT NEEDED) (POST OPERATIVE CARE: 60 $551.00
DAYS)
D7997 Appliance removal (not by dentist who placed appliance), (BR)
includes removal of archbar (REPORT NEEDED)
Not for removal of orthodontic appliances. Includes both arches, if
necessary.
D7998 Intraoral placement of a fixation device not in conjunction (BR)
with a fracture (REPORT NEEDED)
Includes both arches, if necessary.
D7999 Unspecified oral surgical procedure, by report (REPORT (BR)
NEEDED)

CODE DESCRIPTION
XI. ORTHODONTICS D8000 - D8999

ELIGIBILITY
Eligibility is limited to members who:
1. are under 21 years of age;
2. meet financial standards for Medicaid eligibility; and,
3. exhibit a SEVERE PHYSICALLY HANDICAPPING MALOCCLUSION.
Orthodontic care for severe physically handicapping malocclusions is a once in a lifetime
benefit that will be reimbursed for an eligible member for a maximum of three years of
active orthodontic care, plus one year of retention care. Retreatment for relapsed cases
is not a covered service. Treatment must be approved and active therapy begun
(appliances placed and activated) prior to the member’s 21st birthday. Treatment of cleft
palate or approved orthognathic surgical cases may be approved after the age of 21 or
for additional treatment time.
With the exception of D8210, D8220 and D8999, orthodontic care is reimbursable
only when provided by an orthodontist or an Article 28 facility which have met the
qualifications of the DOH and are enrolled with the appropriate specialty code.

CODE DESCRIPTION
PRIOR APPROVAL
The following orthodontic procedures codes require prior approval: D8010,
D8020, D8030, D8040, D8050, D8060, D8070, D8080, D8090, D8670, and D8680.
The following documentation must be submitted along with the prior approval request:
 Pages 1 and 2 of the completed and signed “Handicapping Labio-Lingual (HLD)
Index Report”. The HLD Index Report is available on the internet at:
https://www.emedny.org/ProviderManuals/Dental/PDFS/HLD_Index_NY.pdf
 A panoramic and/or mounted full mouth series of intra-oral radiographic images;
 A cephalometric radiographic image with teeth in centric occlusion and
cephalometric analysis / tracing;
 Photographs of frontal and profile views;
 Intra-oral photographs depicting right and left occlusal relationships as well as an
anterior view;
 Maxillary and mandibular occlusal photographs;
 Photos of articulated models can be submitted optionally (Do NOT send stone
casts).
Subjective statements submitted by the provider or others must be substantiated by
objective documentation such as photographs, radiographic images, credible medical
documentation, etc. verifying the nature and extent of the severe physical handicapping
malocclusion. Requests where there is significant disparity between the subjective
documentation (e.g. HLD index report and narrative) and objective documentation
(e.g. photographs and/or radiographic images) will be returned for clarification
without review.
Requests for continuation of orthodontic treatment which was begun without prior
approval from the DOH or a NYS Medicaid Managed Care Plan will be evaluated using
the same criteria and guidelines to determine if a severe physically handicapping
malocclusion currently exists. A completed HLD index report based on the current
dentition, and all of the required documentation (listed above) must be submitted along
with the prior approval request. If continuation of treatment is denied, debanding and
retention might be approvable using procedure code D8690.
Orthognathic Surgical Cases with Comprehensive Orthodontic Treatment
 Members must be at least 15 years of age for case consideration;
 The surgical consult, complete treatment plan and approval for surgical
treatment (if necessary) must be included with the request for orthodontic
treatment;
 Prior approval and documentation requirements are the same as those for
comprehensive treatment;
 A statement signed by the parent/guardian and member that they understand
and accept the proposed treatment, both surgical and orthodontic, and
understand that approval for orthodontic treatment is contingent upon
completion of the surgical treatment.

CODE DESCRIPTION
LIMITED EXTENDED COVERAGE
Regardless of whether the dental benefit is administered through Managed Care

or through fee-for-service, when eligibility is lost after active orthodontic treatment has
been initiated, fee-for-service Medicaid will provide for up to:
• Two (2) quarterly payments; or,
• One (1) quarterly payment and retention; or,
• Retention alone.
The treating orthodontist may decide to complete active treatment (including retention
care), initiate retention care to preserve current status, or remove the appliances in
cases of minimal progress during active therapy. At least thirty (30) days of treatment
must have been provided following the loss of eligibility. When billing for the limited
extended coverage, submit a paper claim to eMedNY using procedure code D8999, the
last date of eligibility as the date of service and identify the stage of treatment when
eligibility was lost (e.g. 2nd quarter of second year; 1st quarter of third year, etc.). The
maximum benefit for limited extended coverage is only payable one (1) time during the
course of orthodontic treatment.
If approval for orthodontic treatment was issued through Medicaid Managed Care
(MMC) a copy of the authorization for treatment and remittance statement(s) must also
be included. Only those cases previously approved for comprehensive orthodontic
treatment (D8070, D8080, or D8090) in which appliances have been placed and
activated are eligible for the “Limited Extended Coverage” benefit. Claims for the
“Limited Extended Coverage” benefit MUST be submitted within 9 months of the loss of
eligibility. Claims submitted for payment beyond that time range will be subject to denial.
CONTINUATION OF ACTIVE ORTHODONTIC TREATMENT WHEN THE MEMBER’S
MEDICAID COVERAGE CHANGES
When a member undergoing active orthodontic treatment that was authorized by MMC
Plan (or their vendor) has coverage changed to fee-for-service Medicaid, a prior
approval for continued treatment is required from the fee-for-service program. In such
cases, providers must adhere to the original treatment time authorized by MMC Plans.
A prior approval request for continuation of orthodontic care (D8670) should be
submitted to eMedNY with the following documentation:
• A copy of the original Medicaid Managed Care Plan authorization or approval for
comprehensive orthodontic treatment;
• A copy of the remittance statement from the Medicaid Managed Care Plan;
• All pre-treatment records and recent progress photographs depicting the current
dentition; and,
• A brief narrative describing the services already rendered (e.g. Initial placement
of orthodontic appliances and two quarters of D8670 have been paid by
Healthplex).
Again, orthodontic coverage for procedure codes D8670 and D8680 is subject to the
member’s eligibility. If a member’s coverage is changed back to managed care a

CODE DESCRIPTION
request for these orthodontic services will need to be submitted to the member’s
Managed Care Plan.
The total fee-for-service reimbursement amount for active treatment will not exceed the
maximum fees listed in the Dental Fee Schedule.
MEDICAID MEMBERS CANNOT BE BILLED

 By enrolling in the Medicaid program, a provider agrees to accept payment under
the Medicaid program as payment in full for services rendered.
 There is no separate billing for the replacement of broken appliances such as
bands, brackets or arch wires.
 Medicaid payment for orthodontic services represents payment in full for the
entire treatment protocol, regardless of the type of appliances used. Separately
billing the member for any portion of orthodontic treatment is prohibited.
 Orthodontists must offer Medicaid members the same treatment options offered
to the majority of patients in the provider’s practice with similar treatment needs
(e.g., orthodontists may not restrict Medicaid members to metal brackets if non-
Medicaid patients are routinely provided other types of devices (e.g. bonded
“clear” brackets, “Damon®” brackets, clear appliance therapy, bite plates or
removable appliances) and may not charge Medicaid members for the use of
these other techniques and/or devices.
 Reimbursement for orthodontic services includes the placement and removal of
all appliances and brackets. Should it become necessary to remove the bands
due to non-compliance or elective discontinuation of treatment by the provider,
parent, guardian or member the appliance(s) must be removed at no additional
charge to either the member, family or Medicaid.
DISCONTINUATION OF TREATMENT
In cases where treatment is discontinued, a “Release from Treatment” form must be
provided by the dental office which documents the date and the reason for discontinuing
care. The release form must be reviewed and signed by the parent/guardian and
member. The “Release from Treatment” form must indicate that all those involved
understand future orthodontic treatment will not be covered by Medicaid. A copy must
be sent to NYSDOH OHIP Bureau of Dental Review.
New York State Department of Health

Office of Health Insurance Programs
Bureau of Dental Review
431B Broadway
Menands, NY 12204-2836

CODE DESCRIPTION
Behavior Not Conducive to Favorable Treatment Outcomes
It is the expectation that the case selection process for orthodontic treatment take into
consideration the member’s ability over the course of treatment to:
 Tolerate orthodontic treatment;
 Comply with necessary instructions for home care (e.g. wear elastics, headgear,
removable appliance, etc.)
 Keep multiple appointments over several years;
 Maintain an oral hygiene regimen;
 Be cooperative and complete all needed preventive and treatment visits.
If it is determined that the member is exhibiting non-compliant behavior (e.g. multiple
missed orthodontic and general dental appointments, continued poor oral hygiene,
and/or failure to maintain the appliances and/or untreated dental disease) a letter must
be sent to the parent/guardian that documents the factors of concern and the corrective
actions needed and that failure to comply can result in discontinuation of treatment. A
copy must be sent to the DOH.
If orthodontic treatment is discontinued for cause, the parent/guardian and/or member
must sign a statement indicating they understand treatment is being discontinued prior
to completion; the reason(s) for discontinuation of treatment; and, that it will jeopardize
their ability to have further orthodontic treatment provided through the NYS Medicaid
Program. The treating orthodontist must make reasonable provisions to provide
necessary treatment during the transition of care to another provider or for debanding.
Dismissal of a member (patient) from a practice is a medico-legal issue; therefore, the
treating orthodontist should seek an appropriate legal counsel at their own discretion.
All approved courses of comprehensive orthodontic treatment must be concluded in a
manner acceptable to the DOH and the DOH must be notified. Appropriate means of
concluding treatment include:
 Successful completion of treatment and the issuance of a prior approval by the
DOH for debanding and/or retention;
 Notification that treatment is being discontinued for cause and that the
parent/guardian and/or member have been appropriately notified, or;
 Loss of eligibility and utilization of the “Limited Extended Coverage” benefit to
conclude treatment.
Treatment must continue to a point satisfactory to the DOH, regardless of the length of
time treatment is required and even if all Medicaid benefits have been exhausted,
without charge to the NYS Medicaid Program, the member or family. Failure to
conclude treatment in an acceptable manner can result in the recovery of the
entire cost of the complete course of treatment.

CODE DESCRIPTION
“BY REPORT” CODES THAT ARE ALSO “PA OPTIONAL”

For those procedures listed in this manual and/ or on the Dental Fee Schedule without
a published fee (D8210 and D8220) and are listed as both “(REPORT NEEDED, PA
OPTIONAL)”:
 Procedures can be reviewed for appropriateness and tentatively priced before

treatment is initiated by submitting a prior approval request.
- OR -
 Procedures can be priced after treatment without prior approval as a “By Report”
based on documentation submitted with the claim substantiating a qualifying
physically handicapping malocclusion.
ORTHODONTIC RECORDS TAKEN THAT ARE NOT REQUIRED BY DOH ARE NOT
REIMBURSABLE
Any records taken at the discretion of the provider cannot be charged to the NYS
Medicaid Program, the member or family.
The NYS Medicaid Program will reimburse for those services that are medically
necessary, are an integral part of the actual treatment, or that are required by the
Department. Orthodontic records taken solely for the provider’s records, such as
photographs (D0350), diagnostic casts/study models (D0470), and radiographic images
(including a FMS (D0210), panoramic (D0330) and cephalometric (D0340)) and are not
required by the Department will be considered part of the reimbursement for the
comprehensive orthodontic treatment and are not payable separately. The provider can
take these records as part of the treatment records, but they cannot charge the NYS
Medicaid Program, the member or family. Payment may be considered on an
exceptional basis if there is documentation of medical necessity.
LIMITED ORTHODONTIC TREATMENT
The submitted records must demonstrate a physically handicapping malocclusion
indicating the need for limited orthodontic treatment. Procedure codes D8030 and
D8040 cannot be substituted for procedure codes D8070, D8080, and D8090 if a
member does not qualify for comprehensive orthodontic treatment as per NYS Medicaid
criteria. Reimbursement will be determined based on supporting documentation
submitted.
D8010 Limited orthodontic treatment of the primary dentition
(PA REQUIRED)
D8020 Limited orthodontic treatment of the transitional dentition
(PA REQUIRED)
D8030 Limited orthodontic treatment of the adolescent dentition
(PA REQUIRED)
D8040 Limited orthodontic treatment of the adult dentition
(PA REQUIRED)

CODE DESCRIPTION
INTERCEPTIVE ORTHODONTIC TREATMENT
Interceptive orthodontics is an extension of preventive orthodontics that may include
localized tooth movement. Such treatment may occur in the primary or transitional
dentition and may include such procedures as the redirection of ectopically erupting
teeth, correction of dental crossbite or recovery of space loss where overall space is
inadequate. When initiated during the incipient stages of a developing problem,
interceptive orthodontics may reduce the severity of the malformation and mitigate its
cause. Complicating factors such as skeletal disharmonies, overall space deficiency, or
other conditions may require subsequent comprehensive therapy. HLD Index Report is
not required when submitting a prior approval request for interceptive orthodontic
treatment.
If comprehensive treatment is required following a course of interceptive treatment, a
period of 12 to 18 months should be allowed prior to requesting comprehensive
treatment to provide for stabilization of the result.
D8050 Interceptive orthodontic treatment of the primary dentition
(PA REQUIRED)
D8060 Interceptive orthodontic treatment of the transitional dentition
(PA REQUIRED)

CODE DESCRIPTION
COMPREHENSIVE ORTHODONTIC TREATEMENT

 With the exception of cleft palate and other surgical cases, only members with
late mixed dentition or permanent dentition will be considered for the initiation of
comprehensive orthodontic treatment.
 Reimbursement for codes D8070, D8080 or D8090 is limited to once in a lifetime
as initial payment for an approved course of orthodontic treatment. The
member’s dentition will determine the single code to be used and can only be
billed when all appliances have been placed and active treatment has been
initiated. The placement of the component parts (e.g. brackets, bands) does
not constitute commencement of active treatment.
 For quarterly payment, see procedure code D8670. Reimbursement for
comprehensive orthodontic treatment is ALL INCLUSIVE and covers ALL
orthodontic services, both fixed and removable that needs to be provided to
correct the orthodontic condition.
 A prior approval request for continuation of comprehensive orthodontic treatment
(2nd year, 3rd year and retention) must be submitted annually to the DOH along
with a progress report and photographs of the current conditions to assess the
progress of treatment and determine if additional treatment time (up to a
maximum of three (3) years) is warranted. For members age 21 and over, prior
approval requests for continuation of orthodontic care (2nd year, 3rd year and
retention) will be evaluated if the comprehensive orthodontic treatment was
approved by DOH / Medicaid Managed Care Plans and fixed orthodontic
appliances were placed and activated PRIOR to the member’s 21st birthday.
 Requests to RESTART comprehensive orthodontic treatment on a member for
which Medicaid FFS paid the original comprehensive code (D8070, D8080, or
D8090), but who now has Managed Care coverage, should be submitted to the
Manage Care plan or their vendor.
 As of 10/01/2012, orthodontic treatment is a covered benefit under Medicaid
Managed Care Plans. All prior approvals for orthodontic treatment that were
reviewed and approved on 10/1/12 and after, are subject to member’s eligibility
under the FFS (fee-for-service) Medicaid program. Providers must check the
member’s eligibility at every visit, as Medicaid eligibility status may change at
any time.
 As previously indicated on page 14 of this manual:
“If a member is enrolled in a managed care plan which covers the specific care
or services being provided, it is inappropriate to bill such services to the Medicaid
program on a fee-for-service basis whether or not prior approval has been
obtained."

CODE DESCRIPTION
D8070 Comprehensive orthodontic treatment of the transitional $986.00
dentition (PA REQUIRED)
D8080 Comprehensive orthodontic treatment of the adolescent $986.00
dentition (PA REQUIRED)
D8090 Comprehensive orthodontic treatment of the adult dentition $986.00
(PA REQUIRED)
MINOR TREATMENT TO CONTROL HARMFUL HABITS
The following procedures (D8210 and D8220) include appliances for habits such as
thumb sucking and tongue thrusting. They do not have a published fee and are listed
as both “(REPORT NEEDED, PA OPTIONAL)”. These procedure codes can be used by all
enrolled dentists regardless of specialty.
 Procedures can be reviewed for appropriateness and tentatively priced before
treatment is initiated by submitting a prior approval request.
- OR –
 Procedures can be priced after treatment without prior approval as a “By Report”
based on documentation submitted with the claim substantiating a qualifying
physically handicapping malocclusion.
D8210 Removable appliance therapy (REPORT NEEDED, PA OPTIONAL) (BR)
D8220 Fixed appliance therapy (REPORT NEEDED, PA OPTIONAL) (BR)
OTHER ORTHODONTIC SERVICES
D8660 Pre-orthodontic treatment examination to monitor growth and $29.00
development
Periodic observation of patient dentition, at intervals established by the dentist,
to determine when orthodontic treatment should begin. Diagnostic procedures
are documented separately.
 Orthodontist specialty designation required.
 May not be reimbursed in conjunction with other examination codes.
 Cannot be reimbursed after active orthodontic treatment has begun.
D8670 Periodic orthodontic treatment visit (as part of contract) $232.00
(PA REQUIRED)
The member must have been seen and actively treated at least once during the
quarter. Cannot be used for “observation”. This code requires prior approval
and can be billed quarterly for a maximum of twelve (12) payments and can only
be billed a maximum of four (4) times in a twelve-month period beginning 90 days
after the date of service on which orthodontic appliances have been placed and
active treatment begun and at the end of each subsequent quarter. Claims billed
more frequently will result in an automatic systems denial. In the event that
eligibility is lost during a quarter, at least one month of active treatment must have
elapsed to qualify for payment under the “limited extended coverage” benefit.

CODE DESCRIPTION
D8680 Orthodontic retention (removal of appliances, construction $174.00
and placement of retainer(s)) (PA REQUIRED)
Includes all follow-up visits needed for observation and adjustments.
Requests must be submitted and approval obtained PRIOR to the removal of
appliances. Any request denied or otherwise returned for insufficient results will
require the re-application of all appliances, if necessary, and continuation of care
without additional compensation. Payment will not be made for retention (D8680)
for a case that had been debanded without Medicaid prior authorization.
D8690 Orthodontic treatment (alternative billing to a contract fee) (BR)
(REPORT NEEDED)
Services provided by an orthodontist other than the original treating
orthodontist.
This is limited to transfer care and removal of appliances.
REPLACEMENT OF LOST OR BROKEN RETAINER

The following procedure codes (D8703 and D8704) will be reimbursed once per lifetime.
Must be within one year of D8680 having been paid by Medicaid. Appliances which do
not fit will not be replaced. The following documentation is required when submitting a
claim for a replacement retainer:
 Copy of a signed statement from patient / parent detailing the circumstances
of how the appliance was lost or broken;
 Copy of patient’s treatment / progress notes indicating the date of insertion;
and,
 Copy of dental laboratory bill, if available.
D8703 Replacement of lost or broken retainer – maxillary (REPORT $72.50
NEEDED)
D8704 Replacement of lost or broken retainer – mandibular (REPORT $72.50
NEEDED)
D8999 Unspecified orthodontic procedure, by report (BR)

(REPORT NEEDED)

CODE DESCRIPTION
XII. ADJUNCTIVE GENERAL SERVICES D9000 -

D9999
UNCLASSIFIED TREATMENT
D9110 Palliative (emergency) treatment of dental pain - minor $25.00
procedure (REPORT NEEDED)
Not reimbursable in addition to other therapeutic services performed at the same
visit or in conjunction with initial or periodic oral examinations when the procedure
does not add significantly to the length of time and effort of the treatment provided
during that particular visit.
When billing, the provider must document the nature of the emergency, the
dental site and the specific treatment involved.
Not to be used for denture adjustments (Refer to procedure codes D5410 –
D5422).
D9120 Fixed partial denture sectioning (QUAD) (REPORT NEEDED) (BR)
ANESTHESIA
The cost of analgesic and anesthetic agents is included in the reimbursement for
the dental service. The administration of nitrous oxide is not separately reimbursable.
Reimbursement for general anesthesia, intravenous (parenteral) sedation and
anesthesia time is conditioned upon meeting the definitions listed below.
Anesthesia time begins when the doctor administering the anesthetic agent initiates the
appropriate anesthesia and non-invasive monitoring protocol and remains in continuous
attendance of the member. Anesthesia services are considered completed when the
member may be safely left under the observation of trained personnel and the doctor
may safely leave the room to attend to other patients or duties.
The level of anesthesia is determined by the anesthesia provider’s documentation of
the anesthetic’s effect upon the central nervous system and not dependent upon the
route of administration.
Anesthesia time should be commensurate with the treatment performed.
Anesthesia time is divided into 15 minute units for billing purposes; the number of such
units should be entered in the "Times Performed" field of the claim form using the
appropriate code (D9223, D9243).
D9222 Deep sedation/general anesthesia – first 15 minutes $76.00
Requires SED certificate in “General Anesthesia”
D9223 Deep sedation/general anesthesia – each subsequent 15 $76.00
minute increment
D9239 Intravenous moderate (conscious) sedation/analgesia – first $76.00
15 minutes
D9243 Intravenous moderate (conscious) sedation/analgesia – each $76.00
subsequent 15 minute increment

CODE DESCRIPTION
D9310 Consultation - diagnostic service provided by dentist or $30.00

physician other than requesting dentist or physician
The consulted provider must be enrolled in one of the dental specialty areas
recognized by the NYS Medicaid Program. The referring provider cannot be from
the same group as the consulting provider, although an exception can be made
if the referral is from a general dentist to a specialist for an evaluation requiring
the advanced skills and knowledge of that specialist.
If the consultant provider assumes the management of the member after the
consultation, subsequent services rendered by that provider will not be
reimbursed as consultation. Referral for diagnostic aids (including radiographic
images) does not constitute consultation but is reimbursable at the listed fees
for such services. Consultation will not be reimbursed if claimed by the same
provider within 180 days of an examination or an office visit for observation
(D9430). An exception can be made if a subsequent consultation is held for a
distinctly different condition, supported by documentation.
PROFESSIONAL VISITS
D9410 House/extended care facility call (REPORT NEEDED) $50.00
Per visit, regardless of number of members seen and represents the total extra
charge permitted, is not applicable to each member seen at such a visit. The
report must list all Medicaid covered patients seen at the facility on the date of
service.
Fee-for-service reimbursement will not be made for those individuals who
reside in facilities where dental services are included in the facility rate. In
those cases, reimbursement must be sought directly from the facility.
D9420 Hospital or ambulatory surgical center call (REPORT NEEDED) $75.00
Per visit, per member (to be added to fee for service). This service will be
recognized only for professional visits for pre-operative or operative care. Post-
operative visits are not reimbursable when related to procedures with assigned
follow-up days. Hospital calls are not reimbursable for hospital-based providers.
Payable only when provided in a FACILITY where professional services are
not included in the rate. Please submit documentation that services were
provided in a hospital, such as a copy of the hospital notes/record.

CODE DESCRIPTION
D9430 Office visit for observation (during regularly scheduled $20.00
hours) – no other services performed (REPORT NEEDED)
The provider must be enrolled in one of the dental specialty areas recognized by
the NYS Medicaid program. Used to monitor the status of a member following
an authorized phase of surgical treatment that are required beyond the post-
operative care period for that procedure. Not be used for orthodontic retention
follow-up visits. Reimbursement includes the prescribing of medications and is
limited to two instances per clinical episode.
May also be used for those individuals identified with a recipient exception code
of RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed Care Exemption”) where
definitive treatment cannot be performed due to the member’s behavior. This is
a “stand-alone” procedure and cannot be billed on the same date of service with
any other procedure code. Limited to four (4) instances per year per member.
Please include a report or narrative describing the circumstances involved.
D9440 Office visit - after regularly scheduled hours (REPORT NEEDED) $20.00
Cannot be billed in conjunction with an examination, observation or consultation.
Please include a report or narrative describing the circumstances involved.
DRUGS
D9610 Therapeutic parenteral drug, single administration (BR)
(REPORT NEEDED)
MISCELLANEOUS SERVICES
D9920 Behavior management $29.00
This is a per visit incentive to compensate for the greater knowledge, skill,
sophisticated equipment, extra time and personnel required to treat this
population. This fee will be paid in addition to the normal fees for specific dental
procedures. For purposes of the NYS Medicaid program, the developmentally
disabled population (OPWDD members) for which procedure code D9920 may
be billed is limited to those who receive ongoing services from community
programs operated or certified by the New York State Office for People with
Developmental Disabilities (OPWDD). These individuals are identified with a
recipient exception code of RE 81 (“TBI Eligible”) or RE 95 (“OPWDD/Managed
Care Exemption”). A “Medical Immobilization/Protective Stabilization (MIPS)”
form (Institutions only) also qualifies for use of this procedure code.
Not billable as a “stand-alone” procedure; another clinical service must be
provided on the same date.
Not billable in conjunction with D9430 or procedures performed under deep
sedation/general anesthesia.
Does not require a report.

CODE DESCRIPTION
For occlusal guards there must be a minimum interval of twelve (12) months between
all occlusal guards (D9944, D9945, and/or D9946) and the report must include
documentation of necessity, associated laboratory receipts and a copy of treatment
progress notes indicating the date of insertion.
D9944 Occlusal guard – hard appliance, full arch (REPORT NEEDED) $145.00
Removable dental appliance designed to minimize the effects of bruxism or other
occlusal factors. Not to be reported for any type of sleep apnea, snoring or TMD
appliances.
D9945 Occlusal guard – soft appliance, full arch (REPORT NEEDED) $145.00
occlusal factors. Not to be reported for any type of sleep apnea, snoring or TMD
appliances.
D9946 Occlusal guard – hard appliance, partial arch (REPORT $145.00
NEEDED)
occlusal factors. Provides only partial occlusal coverage such as anterior
deprogrammer. Not to be reported for any type of sleep apnea, snoring or
TMD appliances.
D9990 Certified translation or sign-language services – per visit* $22.00
(REPORT NEEDED)
*D9990 is a new code; it replaces T1013 beginning on 1/17/2019. For

dates of service prior to 1/17/2019 use T1013.
For patients with limited English proficiency defined as patients whose primary
language is not English and who cannot speak, read, write or understand the
English language at a level sufficient to permit such patients to interact effectively
with health care providers and their staff.
The need for medical language interpreter services must be documented in the
medical record and must be provided during a medical visit by a third party
interpreter, who is either employed by or contracts with the Medicaid provider.
These services may be provided either face-to-face or by telephone. The
interpreter must demonstrate competency and skills in medical interpretation
techniques, ethics and terminology. It is recommended, but not required, that such
individuals be recognized by the National Board of Certification for Medical
Interpreters (NBCMI).
Documentation of necessity must be submitted as an attachment to a paper claim.

CODE DESCRIPTION
TELEHEALTH / TELEDENTISTRY
Telehealth is defined as “the use of electronic information and communication

technologies to deliver health care to patients at a distance, which shall include the
assessment, diagnosis, consultation, treatment, education, care management and/or
self-management of a patient (Medicaid member)”.
Originating Site is defined as “a site at which a patient is located at the time health care
services are delivered to him or her by means of telehealth.”
Distant Site is defined as “a site at which a telehealth provider is located while delivering
health care services by means of telehealth.”
 Originating and Distant sites must be located within the fifty United States or
United States’ territories and may include:
o Facilities licensed under Article 28 of the Public Health Law (PHL):
hospitals, nursing homes and diagnostic and treatment centers;
o Facilities licensed under Article 40 of the PHL: hospice programs;
o Facilities as defined in subdivision 6 of Section 1.03 of the Mental Hygiene
Law (MHL): clinics certified under Articles 16, 31 and 32;
o Certified and non-certified day and residential programs funded or operated
by the Office of People with Developmental Disabilities (OPWDD);
o Private physician or dentist offices located within the State of New York;
o Adult care facilities licensed under Title 2 of Article 7 of the Social Security
Law (SSL);
o Public, private and charter elementary and secondary schools located
within the State of New York;
o School-age child care programs located within the State of New York;
o Child daycare centers located within the State of New York; and,
o The member's place of residence in New York State, or other temporary
location in or out of state.
 Services provided by means of telehealth must be in compliance with the Health
Insurance Portability and Accountability Act (HIPAA) and all other relevant laws
and regulations governing confidentiality, privacy, and consent (including, but not
limited to 45 CFR Parts 160 and 164 [HIPAA Security Rules]; 42 CFR Part 2; PHL
Article 27-F; and MHL Section 33.13).
 Dentists providing services via telehealth must be licensed and currently
registered in accordance with NYS Education Law or other applicable law and
enrolled in NYS Medicaid.
 Telehealth services must be delivered by dentists acting within their scope of
practice.
 Reimbursement will be made in accordance with existing Medicaid policy related
to supervision and billing rules and requirements.

CODE DESCRIPTION
 When services are provided by an Article 28 facility, the telehealth dentist must be
credentialed and privileged at both the originating and distant sites in accordance
with Section 2805-u of PHL. The law can be viewed at the following link:
http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO (Select LAWS; select PBH;
select Article 28; select 2805u)
 Telephone conversations, e-mail or text messages, and facsimile transmissions
between a dentist and a Medicaid member or between two dentists are not
considered telehealth services and are not covered by Medicaid when provided
as standalone services.
 Remote consultations between practitioners, without a Medicaid member present,
including for the purposes of teaching or skill building, are not considered
telehealth and are not reimbursable.
 The acquisition, installation and maintenance of telecommunication devices or
systems is not reimbursable.
 Providers should bill using the claim format appropriate to their category of service.
 Place of Service (POS) code: Use 02 on professional claims to specify the location
teledentistry associated services were provided.
(continued next page)

CODE DESCRIPTION
D9995 Teledentistry – synchronous; real time encounter $0.00
 Procedure code D9995 may be used by the provider at the
distant site;
 Must be reported on claim line #1;
 Report all services rendered on subsequent lines;
 There is no reimbursement for procedure code D9995.
D9996 Teledentistry – asynchronous; information stored and $0.00
forwarded
Store-and-Forward Technology - involves the asynchronous,
electronic transmission of a member's health information in the
form of patient-specific pre-recorded videos and/or digital images
from a provider at an originating site to a telehealth provider at a
distant site.
 Store-and-forward technology aids in diagnoses when live
video or face-to-face contact is not readily available or not
necessary.
 Pre-recorded videos and/or static digital images (e.g.,
pictures), excluding radiology, must be specific to the
member's condition as well as be adequate for rendering or
confirming a diagnosis or a plan of treatment.
 Procedure code D9996 may be used by the provider at the
distant site;
 Report all services rendered on subsequent lines;
 There is no reimbursement for procedure code D9996.
 Accompanying payable services will be reimbursed at 75%
of the requested fee, not exceeding 75% of the current
Medicaid fee.
Q3014 Telehealth originating site facility fee $27.76
 Procedure code Q3014 may be used by the provider at the
originating site;
 Report all services rendered on subsequent lines.
D9999 Unspecified adjunctive procedure, by report (REPORT NEEDED) (BR)

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NEW YORK STATE

POLICY AND PROCEDURE CODE

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VII. MAXILLOFACIAL PROSTHETICS D5900 - D5999 ............................................... 49

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Section I - Requirements for Participation in Medicaid

A specialist is one who:

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iv. Dental, Enteral Conscious (Moderate) Sedation for patients 13 years

Application of Free Choice

Credential Verification Reviews

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• physical attributes of the place of business

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Section II - Dental Services

Children’s Dental Services

A child is defined as anyone under age 21 years.

Scope of Hospitalization Services

Child/Teen Health Program

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Child Health Plus Program

Dental Mobile Van

Requirements and Expectations of Dental Clinics

 Dental clinics licensed under Article 28 reimbursed on a rate basis or through

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Public health programs in schools, Head-Start Centers, dental schools, clinics

Services Not Within the Scope of the Medicaid Program

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 Gingivectomy or gingivoplasty, except for the sole correction of severe hyperplasia

Services Which Do Not Meet Existing Standards of Professional

These services include but are not limited to:

Other Non-Reimbursable Services

 Treatment of deciduous teeth when exfoliation is reasonably imminent.

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 Extraction of deciduous teeth without clinical necessity.

NYS Rules of the Board of Regents: Part 29

The patient’s Dental Record is to include:

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Locum Tenens Arrangements

Record of either arrangement must be maintained in writing to substantiate locum

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NYS Medicaid Exclusion List

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Section III - Basis of Payment for Services Provided

Payment for Services Not Listed on the Dental Fee Schedule

Payment for Services Exceeding the Published Frequency Limitations

Payment for Orthodontic Care

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Dental Services Included in a Facility Rate

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Third-party insurers (including Medicare) provide reimbursement for various dental

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Unspecified Procedure Codes

Prior Approval / Prior Authorization Requirements

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