Ill. Admin. Code tit. 89 § 140.421

Current through Register Vol. 48, No. 45, November 8, 2024
Section 140.421 - Limitations on Dental Services

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

a) The Department shall impose prior approval requirements to determine the medical necessity of dental services listed in this Section. Prior approval is required for:
1) Crowns;
2) Partial Pulpotomy;
3) Periodontal services, except full mouth debridement for diagnostic purposes;
4) Apexification and recalcification;
5) Apicoectomy;
6) Dentures, partial dentures and denture relines;
7) Maxillofacial prosthetics;
8) Prosthodontics;
9) Removal of impacted teeth;
10) Surgical removal of residual roots;
11) Surgical exposure to aid eruption;
12) Alveoloplasty;
13) Incision and drainage of abscess;
14) Removal of cysts or tumors;
15) Frenulectomy;
16) Orthodontics. Effective January 1, 2017, medically necessary orthodontic treatment is approved only for patients under the age of 21 and is defined as:
A) treatment necessary to correct a condition that scores 28 points or more on the Handicapping Labio-Lingual Deviation Index (HLD); or
B) treatment necessary to correct the following conditions:
i) Cleft palate;
ii) Deep impinging bite with signs of tissue damage, not just touching palate;
iii) Anterior crossbite with gingival recession;
iv) Severe traumatic deviation (i.e., accidents, tumors, etc.; attach description); and
v) Effective January 1, 2019, impacted maxillary central incisor;
17) General anesthesia, conscious sedation or deep sedation;
18) Therapeutic drug injection;
19) Other drugs and medicaments;
20) Unspecified miscellaneous adjunctive general services or procedures;
21) Dental services not listed in Table D.
b) The dentist may request post-approval when a dental procedure requiring prior approval is provided on an emergency basis. Approval of the procedures shall be given if the dental procedure is medically necessary.

Ill. Admin. Code tit. 89, § 140.421

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

Amended at 38 Ill. Reg. 23623, effective 12/2/2014
Amended at 41 Ill. Reg. 999, effective 1/19/2017
Amended at 42 Ill. Reg. 22352, effective 11/28/2018
Amended at 43 Ill. Reg. 1014, effective 12/31/2018