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KMAP BULLETIN: Coverage of Denture and Partial Prosthetics for Ages 21 and Older

Date: 06/22/23

KMAP DENTAL BULLETIN 23145 (PDF)

Effective with dates of service on and after July 1, 2023, Medicaid will cover members ages 21 and older who meet medically necessary criteria for the following dental codes:
CodeRateCodeRate
D5110 $1106.14D5611$131.25
D5120$1107.92D5612$131.25
D5211$830.35D5621$133.65
D5212$843.91D5622$133.65
D5213$1177.06D5630$59.40
D5214$1176.75D5640$111.83
D5225$801.90D5650$138.87
D5226$801.90D5660$170.67
D5282$184.29D5670$103.95
D5283$184.29D5671$103.95
D5284$184.29D5730$242.35
D5286$184.29D5731 $243.05
D5410$89.10D5750$312.61
D5411$89.10D5751$314.29
D5421$59.40D5760$297.00
D5422$48.17D5761$297.00
D5511$132.05D5850$96.23
D5512$132.05D5851$96.23
D5520$113.28D6930$89.10

Prior Authorization (PA) is required.

Note: The rates noted in this bulletin are subject to future changes. Providers should check the Kansas Medical Assistance Program (KMAP) website for the most up-to-date rates.

Documentation needed for medical review of procedure:

  • Treatment plan
  • Appropriate radiographs showing clearly the adjacent and opposing teeth must be submitted for medical review: bitewings, periapicals or panorex.
  • Treatment rendered without necessary medical review will still require appropriate radiographs showing clearly the adjacent and opposing teeth be submitted with the claim for review for payment.

Criteria:

  • Prosthetic services are intended to restore oral form and function due to premature loss of permanent teeth that would result in significant occlusal dysfunction.
  • A denture is determined to be an initial placement if the patient has never worn prosthesis. This does not refer to just the time a patient has been receiving treatment from a certain provider. 
  • Partial dentures are covered for recipients with good periodontal health (AAP Type I or II), and a favorable prognosis where continuous deterioration is not expected.
  • Radiographs must show no untreated cavities or active periodontal disease in the abutment teeth, and abutments must be at least 50 percent supported in bone. 
  • As part of any removable prosthetic service, dentists are expected to instruct the patient in the proper care of the prosthesis
  • In general, if there is a pre-existing removable prosthesis (includes partial and full dentures), it must be at least five years old and unserviceable to qualify for replacement.
  • In general, a partial denture will be approved for benefits if it replaces one or more anterior teeth or replaces two or more posterior teeth unilaterally or replaces three or more posterior teeth bilaterally, excluding third molars, and it can be demonstrated that masticatory function has been severely impaired. The replacement teeth should be anatomically fullsized teeth.

Denture and partial prosthetics must be billed using the individual Medicaid provider number of the performing provider. The performing provider may be enrolled as either an individual or as a member of a non-Federally Qualified Health Center (FQHC) or Indian Health Service (IHS) physician group. The billing provider cannot be an FQHC or IHS National Provider Identifier (NPI) unless the FQHC or IHS and the physician group share the same NPI. When this occurs, the claim should be reimbursed under the physician group NPI. These services must be billed using Place of Service (POS) code 11 or 15. Adjustment, repair and reline procedures will be included in the encounter rate for PT/PS 08/080 and 31/351 and be paid Fee-for-Service (FFS) for the prosthetic.

Note: The effective date of the policy is July 1, 2023. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.