<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.09.05.06" title_num="10" subtitle_num="09" chapter_num="05" heading="Preauthorization Requirements.">
  <paragraph num="A.">
    <text>Preauthorization is issued when:</text>
    <paragraph num="(1)">
      <text>Program procedures are met;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Program limitations are met;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The provider submits to the Department, adequate documentation demonstrating that the service to be preauthorized is medically necessary; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The participant is eligible for the service.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Preauthorization is required for the following:</text>
    <paragraph num="(1)">
      <text>Resin fused to metal crown;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Porcelain fused to metal crown;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Nonprecious metal crown (full cast);</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Apicoectomies and periradicular services;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Certain periodontal services;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Complete upper/lower denture;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Partial upper/lower denture (including clasps and teeth);</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Any elective clinical or surgical procedure not listed on the current dental fee schedule;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Surgery normally considered cosmetic but qualified by traumatic or pathological causation;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Laboratory rebasing of dentures;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Addition of teeth or clasps to an existing, functional complete or partial denture;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>General restorative treatment to be rendered in a hospital;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Special periodontal appliances;</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Apexification and recalcification procedures;</text>
    </paragraph>
    <paragraph num="(15)">
      <text>Hemisection, including any root removal, including endodontic therapy;</text>
    </paragraph>
    <paragraph num="(16)">
      <text>Overdenture complete;</text>
    </paragraph>
    <paragraph num="(17)">
      <text>Overdenture partial;</text>
    </paragraph>
    <paragraph num="(18)">
      <text>Condylectomy;</text>
    </paragraph>
    <paragraph num="(19)">
      <text>Meniscectomy;</text>
    </paragraph>
    <paragraph num="(20)">
      <text>Arthrotomy; and</text>
    </paragraph>
    <paragraph num="(21)">
      <text>All orthodontic procedures.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>At a minimum, the documentation required when requesting preauthorization for the following services is:</text>
    <paragraph num="(1)">
      <text>A complete radiographic survey of the mouth for:</text>
      <paragraph num="(a)">
        <text>Complete or partial dentures; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Except in the case of special needs children, where sedation would be required for a complete radiograph of the mouth, special periodontal appliances and periodontal therapies;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Individual periapical radiographs for:</text>
      <paragraph num="(a)">
        <text>Except in the case of special needs children, where sedation would be required for an individual periapical radiograph or bitewing, endodontic therapy (periapicals and bitewings shall be submitted when the request is for posterior teeth);</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Apicoectomy;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Except in the case of special needs children, where sedation would be required for an individual periapical radiograph, periradicular and apexification or recalcification services; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Full coverage permanent crown restorations (excludes stainless steel and provisional resin crowns); and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Full mouth radiographs and a periodontal chart, identifying the depths and locations of the pockets, when periodontal services are requested.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Except as described in §F of this regulation, preauthorization is valid for dental services when the services are approved and completed within 6 months after the date of the receipt of the preauthorization number from the Program.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Preauthorization normally required by the Program is waived when the services are covered and approved by Medicare. However, if the entire or any part of a claim is rejected by Medicare, and the claim is referred to the Program for payment, payment will be made for services covered by the Program only if authorization for those services has been obtained before billing. Non-Medicare claims require preauthorization according to §§A—D of this regulation.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Preauthorization for Orthodontic Treatment.</text>
    <paragraph num="(1)">
      <text>Preauthorization is required for traditional comprehensive orthodontic treatment and for self-ligating braces for the correction of medically necessary conditions, which cause dysfunction due to a handicapping malocclusion. At a minimum the following comprehensive pretreatment documentation shall be submitted:</text>
      <paragraph num="(a)">
        <text>Cephalometric head film with analysis;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Panoramic or full series of periapical radiographs;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>68 diagnostic quality extra-oral and intra-oral photographs;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Clinical summary with diagnosis;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>HLD score sheets from attending orthodontist; and</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Treatment plan.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Preauthorization for periodic orthodontic treatment is valid for:</text>
      <paragraph num="(a)">
        <text>24 months for traditional comprehensive orthodontic treatment; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>12 months for self-ligating braces.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>