Crown PA Exception for Endodontic Therapy, CR 112997
In response to comments submitted during the public comment period for the recently adopted Section 25, Dental Services and Reimbursement Methodology rulemaking, the Department indicated that it would pursue system changes to waive prior authorization (PA) requirements for crowns in qualifying circumstances.
Effective October 19, 2022, MaineCare no longer requires a PA for crowns provided in conjunction with endodontic therapy when one of the qualifying diagnoses from the list below is included on the dental claim that is billed to MaineCare.
|
Qualifying Diagnosis Code |
Diagnosis Code Description |
|
K02.53 |
Dental caries on pit and fissure surface penetrating into pulp |
|
K02.63 |
Dental caries on smooth surface penetrating into pulp |
|
K04.0 |
Pulpitis |
|
K04.1 |
Necrosis of the pulp |
|
K04.5 |
Chronic apical periodontitis |
|
K04.6 |
Periapical abscess with sinus |
|
K04.7 |
Periapical abscess without sinus |
|
K04.8 |
Radicular cyst |
|
K04.90 |
Unspecified diseases of pulp and periapical tissues |
|
K04.99 |
Other diseases of pulp and periapical tissues |
Please note that a PA is still required when a crown is not delivered as part of endodontic therapy.
Questions should be directed to Henry Eckerson.
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