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);

B)        Treatment necessary to correct the following conditions, effective January 1, 2025:

i)          Cleft palate or other craniofacial anomalies;

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);

v)         Overjet of 9mm or greater or;

vi)        Impacted teeth where eruption is impeded but extraction is not indicated.

C)        Effective January 1, 2025, if a prior authorization request for orthodontic treatment is denied, the provider who submitted the request shall be provided with the HLD scoring tool and the HLD score that prompted denial of the request.

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.

(Source:  Amended at 49 Ill. Reg. 3537, effective March 10, 2025)