Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 140 - MEDICAL PAYMENT
Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES
Section 140.421 - Limitations on Dental Services

Universal Citation: 89 IL Admin Code ยง 140.421

Current through Register Vol. 48, No. 38, September 20, 2024

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.

Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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