New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 566 - DENTAL SERVICES
Section He-W 566.06 - Non-Covered Services

(a) A dental procedure, which is attempted but cannot be completed;

(b) Behavior management or the administration of psychotropic medication to modify the recipient's behavior in the dental office;

(c) Experimental, investigational, or cosmetic dental procedures;

(d) Dental and orthodontic treatment or surgery for the purpose of preserving or improving appearance, except when required for the prompt repair of accidental injury;

(e) Services that have not been proven to be safe or effective, as documented in dental peer review literature;

(f) Fixed prostheses of more than one unit;

(g) Implants and procedures associated with implants such as bone grafting;

(h) Dental services rendered in locations other than the dental office, such as in outpatient hospital settings or ambulatory surgical centers, when such services could be performed in a dentist's office and there is no medical need for the use of an acute care, outpatient hospital, or ambulatory facility;

(i) Orthodontic treatment for recipients who have failed to comply with a prescribed treatment plan that has been approved through prior authorization by the department, including non-compliance with appointments, hygiene, or care of appliances, with such failure documented by the provider;

(j) Periodic examinations for recipients age 21 or over;

(k) Services that are not dental in nature;

(l) Services that are more costly than other services but are expected to provide the recipient with the same functional outcome;

(m) Replacement or repair of dental appliances required as a result of recipient neglect, wrongful disposition, intentional misuse or abuse;

(n) Extractions of asymptomatic teeth and third molars, unless prior authorized in accordance with He-W 566.07;

(o) Periodontal treatment consisting of subgingival placement of biological materials or chemotherapeutic agents;

(p) Periodontal surgery, unless prior authorized in accordance with He-W 566.07;

(q) The portion of the orthodontic treatment plan carried out after the recipient reaches 21 years of age;

(r) Any treatment, such as extractions, radiographs, examinations, and other services, that are ancillary to an orthodontic treatment plan that has not been prior authorized for medicaid coverage;

(s) Dental records, including casts and radiographs, when such records do not meet the criteria set forth in He-W 566.05(a)-(b) above or He-W 546.05; and

(t) Endodontics, including root canal therapy, that has not been deemed complete in accordance with He-W 566.04(a)(18) and He-W 566.10(e).