Commonwealth of Massachusetts
Executive Office of Health and Human Services Office of Medicaid
www.mass.gov/masshealth

MassHealth
Transmittal Letter DEN-92 June 2014

TO:     Dental Providers Participating in MassHealth
FROM:	Kristin L. Thorn, Medicaid Director	
RE:     Dental Manual (Revised Regulations and Service Codes)

This letter transmits revised regulations and an updated Subchapter 6 of the Dental Manual, as described in Dental Bulletin 43 (March 2014). Effective March 1, 2014, MassHealth pays for certain additional restorative services for members age 21 and older, subject to the descriptions and limitations in 130 CMR 420.425. Corresponding service codes in Subchapter 6 have also been updated to reflect this new coverage. Service codes affected by this update are effective March 1, 2014, and are listed below.
Current Dental Terminology (CDT) Codes Affected by Update D2140 – Amalgam restorations
D2150 – Amalgam restorations D2160 – Amalgam restorations D2161 – Amalgam restorations
D2332 – Resin-based composite restorations D2335 – Resin-based composite restorations D2391 – Resin-based composite restorations D2392 – Resin-based composite restorations D2393 – Resin-based composite restorations D2394 – Resin-based composite restorations

MassHealth Website

This transmittal letter and attached pages are available on the MassHealth website at
www.mass.gov/masshealth.

Questions

If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Services Center at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.

NEW MATERIAL
(The pages listed here contain new or revised language.) Dental Manual
Pages 4-9 through 4-14

Pages 6-1 through 6-6

MassHealth
Transmittal Letter DEN-92 June 2014
Page 2

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.) Dental Manual
Pages 4-9 through 4-12 — transmitted by Transmittal Letter DEN-85 Pages 6-1 through 6-7 — transmitted by Transmittal Letter DEN-90 Pages 4-13 and 4-14 — transmitted by Transmittal Letter DEN-91

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420.421: Covered and Noncovered Services: Introduction

(A)	Medically Necessary Services. The MassHealth agency pays for the following dental services when medically necessary:
(1)	the services with codes listed in Subchapter 6 of the Dental Manual, in accordance with the service descriptions and limitations described in 130 CMR 420.422 through 420.456; and
(2)	all services for EPSDT-eligible members, in accordance with 130 CMR 450.140 through
450.149, without regard for the service limitations described in 130 CMR 420.422 through 420.456, or the listing of a code in Subchapter 6. All such services are available to EPSDT-
eligible members, with prior authorization, even if the limitation specifically applies to other members under age 21.

(B)	Noncovered Services. The MassHealth agency does not pay for the following services for any member, except when medically necessary for members under age 21 with prior authorization.
(1)	cosmetic services;
(2)	certain dentures including unilateral partials, overdentures and their attachments, temporary dentures, CuSil-type dentures, other dentures of specialized designs or techniques, and preformed dentures with mounted teeth (teeth that have been set in acrylic before the initial impressions);
(3)	chair-side relines;
(4)	counseling or member-education services;
(5)	habit-breaking appliances;
(6)	implants of any type or description;
(7)	laminate veneers;
(8)	oral hygiene devices and appliances, dentifrices, and mouth rinses;
(9)	orthotic splints, including mandibular orthopedic repositioning appliances;
(10)	panoramic films for crowns, endodontics, periodontics, and interproximal caries;
(11)	root canals filled by silver point technique, or paste only;
(12)	tooth splinting for periodontal purposes; and
(13)	any other service not listed in Subchapter 6 of the Dental Manual.

(C)	Covered Services for All Members Aged 21 and Older. The MassHealth agency pays for the services listed in 130 CMR 420.422 through 420.456 for all members aged 21 and older in accordance with the service descriptions and limitations set forth therein:
(1)	diagnostic services as described in 130 CMR 420.422;
(2)	radiographs as described in 130 CMR 420.423;
(3)	preventive services as described in 130 CMR 420.424;
(4)	restorative services as described in 130 CMR 420.425;
(5)	exodontic services as described in 130 CMR 420.430, except for the following:
(a)	alveoplasty;
(b) vestibuloplasty;
(c) frenulectomy;
(d) excision of hyperplastic tissue;
(e)	excision of benign lesion; and
(f)	tooth reimplantation and stabilization;
(6)	anesthesia services as described in 130 CMR 420.452;
(7)	oral and maxillofacial surgery services as described in 130 CMR 420.453;
(8)	behavior management services as described in 130 CMR 420.456(C);
(1)	

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(9)	palliative treatment of dental pain or infection services as described in 130 CMR 420.456(D); and
(10)	house/facility call as described in 130 CMR 420.456(G).

(D)	Noncovered Services for All Members Aged 21 and Older. The MassHealth agency does not pay for the following services for all members aged 21 and older:
(1)	preventive services as described in 130 CMR 420.424(C);
(2)	prosthodontic services (fixed) as described in 130 CMR 420.429; and
(3)	other services as described in 130 CMR 420.456(A), (B), (E), and (F).

(E)	Additional Covered Services for DDS Clients Aged 21 and Older. The MassHealth agency pays for the following additional services for DDS clients aged 21 and older:
(1)	endodontic services as described in 130 CMR 420.426;
(2)	periodontic services as described in 130 CMR 420.427;
(3)	the following additional exodontic services as described in 130 CMR 420.430:
(a)	alveoplasty;
(b)	vestibuloplasty;
(c)	frenulectomy;
(d)	excision of hyperplastic tissue; and
(e)	excision of benign lesion;
(4)	prosthodontic services (removable) as described in 130 CMR 420.428; and
(5)	maxillofacial prosthetics as described in 130 CMR 420.455.

420.422: Service Descriptions and Limitations: Diagnostic Services

(A)	Comprehensive Oral Evaluation. The MassHealth agency pays for a comprehensive oral evaluation once per member per provider. A comprehensive oral evaluation is more thorough than a periodic oral evaluation, and includes a written review of the member's medical and dental history, the examination and charting of the member’s dentition and associated structures, periodontal charting if applicable, diagnosis, and the preparation of treatment plans and reporting forms.

(B)	Periodic Oral Evaluation. The MassHealth agency pays for a periodic oral evaluation twice per member per calendar year. A periodic oral evaluation includes an update of the member’s medical and dental history, the examination and charting of the member’s dentition and associated structures, periodontal charting if applicable, diagnosis, and the preparation of treatment plans and reporting forms. This service is not covered on the same date of service as an emergency treatment visit.

(C)	Limited Oral Evaluation. The MassHealth agency pays for a limited oral evaluation twice per member per calendar year. A limited oral evaluation may necessitate further diagnostic procedures (such as radiographs) to help the provider formulate a differential diagnosis about the member’s specific problem. A limited oral evaluation is not covered on the same date of service as an emergency treatment visit.

(D)	Detailed and Extensive Oral Evaluation. The MassHealth agency pays for a detailed and extensive, problem-focused evaluation twice per member per calendar year. A detailed and extensive oral evaluation entails extensive diagnostic and cognitive modalities based on the findings of a more comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation must be described and documented. A detailed and extensive oral evaluation is not covered on the same date of service as an emergency treatment visit.
(A)	

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420.423: Service Descriptions and Limitations: Radiographs

(A)	Introduction. The MassHealth agency pays for radiographs/diagnostic imaging taken as an integral part of diagnosis and treatment planning. The intent is to confine radiation exposure of members to the minimum necessary to achieve satisfactory diagnosis. The provider must document efforts to obtain any previous radiographs/diagnostic imaging before prescribing more. When radiographs and diagnostic imaging submitted to the MassHealth agency are not of good diagnostic quality, the provider may not claim payment for any retake of radiographs/diagnostic imaging requested by the MassHealth agency.

(B)	Intraoral Conventional or Direct Digital Radiographs.
(1)	Full-Mouth Radiographs. The MassHealth agency pays for full mouth radiographs only for members aged six years and older and only once per member every three calendar years per
provider office. Full mouth radiographs must consist either of a minimum of 10 periapical films and two posterior bitewing films, or two-to-four bitewing films and two periapical films taken with a panoramic film. However, panoramic films cannot be substituted for full mouth
radiographs if full mouth radiographs are required for a prior-authorization request, unless the member has complete bony impacted teeth and other surgical conditions listed under 130 CMR 420.423(C)(1). The MassHealth agency does not pay more for individual periapical films (with or
without bitewings) than it would for a full-mouth series.
(2)	Bitewing Radiographs. The MassHealth agency pays for up to four bitewing films as separate procedures based on the clinical guidelines set forth by the American Dental
Association. Providers must document variations from the ADA clinical guidelines in the member’s dental record. The MassHealth agency does not pay separately for bitewing films taken as part of a full-mouth series.
(3)	Periapical Films. Periapical films may be taken for specific areas where extraction is anticipated, or when infection, periapical change, or an anomaly is suspected, or when otherwise directed by the MassHealth agency. A maximum of four periapical films is allowed per member
per visit.

(C)	Panoramic Films. The MassHealth agency pays for panoramic films for surgical and nonsurgical conditions as described in 130 CMR 420.423(C)(1) and (2).The MassHealth agency does not pay for panoramic films for crowns, endodontics, periodontics, and interproximal caries.
(1)	Surgical Conditions. The MassHealth agency pays for panoramic films when used as a
diagnostic tool for surgical conditions, whether or not the film is taken prior to the procedure or on the same date as the surgical procedure. Surgical conditions include, but are not limited to
(a)	impactions;
(b)	teeth requiring extractions in more than one quadrant;
(c)	large cysts or tumors that are not fully visualized by intraoral films or clinical examination;
(d)	salivary-gland disease;
(e)	maxillary-sinus disease;
(f)	facial trauma;
(g)	trismus where an intraoral film placement is impossible; and
(h)	orthognatic surgery.
(a)	

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(2)	Nonsurgical Conditions.
(a)	Members Under Age 21. The MassHealth agency pays for only one panoramic film per member  per  three-year  period  for  nonsurgical  conditions,  to  monitor  the  growth  and
development of permanent dentition.
(b)	Members Aged 21 and Older. The MassHealth agency pays for only one panoramic  film per member per three-year period in lieu of a full-mouth series only for those members
who are unable to cooperate with the process for obtaining a full-mouth series. The provider must document in the member’s dental record the reasons why the member cannot  cooperate with the process for obtaining a full-mouth series.

(D)	Cephalometric Film. The MassHealth agency pays for cephalometric films in conjunction with surgical conditions. Surgical conditions include, but are not limited to status after facial trauma, mandibular fractures, dentoalveolar fractures, mandibular atrophy, and jaw dislocations. Payment for cephalometric film, or other radiographs, in conjunction with orthodontic diagnosis is included in the payment for orthodontic services. The MassHealth agency does not pay separately for additional radiographs when required for orthodontic diagnosis.

(E)	Oral/Facial Photographic Images.
(1)	The MassHealth agency pays for digital or photographic prints, not slides, only to support prior-authorization requests for orthodontic treatment.
(2)	Payment for digital or photographic prints is included in the payment for orthodontic services. The MassHealth agency does not pay for digital or photographic prints as a separate
procedure (see 130 CMR 420.413). Payment for orthodontic treatment includes payment for services provided as part of the pre-orthodontic workup, except if the MassHealth agency denies
the orthodontic treatment. In that case, the MassHealth agency pays for the pre-orthodontic workup.
(3)	The MassHealth agency may request digital or diagnostic photographic prints for other
services that require prior-authorization.

(F)	Diagnostic Casts. The MassHealth agency pays for diagnostic casts where medically necessary.

420.424: Service Descriptions and Limitations: Preventive Services

(A)	Prophylaxis. The MassHealth agency pays for prophylaxis twice per member per calendar year. The prophylaxis must include a scaling of natural teeth, removal of acquired stains, and polishing of the teeth. As part of the prophylaxis, the practitioner must review with the member oral-hygiene methods including toothbrush instruction and flossing methods.

(B)	Fluoride.
(1)	Topical Fluoride Treatment.
(a)	Members Under Age 21. The MassHealth agency pays for topical fluoride treatment. Topical fluoride treatment consists of continuous topical application of an approved fluoride
agent such as gels, foams, and varnishes, for a period shown to be effective for the agent. The MassHealth agency pays for treatment that incorporates fluoride with the polishing compound as part of the prophylaxis. The MassHealth agency does not pay for treatment that
incorporates fluoride with the polishing compound as a separate procedure.
(b)	Members Aged 21 and Older. The MassHealth agency pays for topical fluoride only for members who have medical or dental conditions that significantly interrupt the flow of saliva.
(2)	Fluoride Supplements. The MassHealth agency pays for fluoride supplements only for members under age 21 and through the pharmacy program (see 130 CMR 406.000).
(1)	
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(C)	Sealants.
(1)	The MassHealth agency pays for sealants, which includes proper preparation of the enamel surface, etching, placement and finishing of the sealant, and reapplication if the process fails
within three years. The MassHealth agency does not pay to replace sealants lost or damaged during the three-year period when reapplied by the same provider. The MassHealth agency
does not pay for sealants applied to any tooth that has been restored or for sealants for primary (deciduous) molars.
(2)	The MassHealth agency pays only for sealants that meet all of the following requirements:
(a)	for permanent noncarious nonrestored molars;
(b)	for members who are under age 17; and
(c)	only once every three years per noncarious nonrestored molar.

(D)	Space Maintainers. The MassHealth agency pays for space maintainers and replacement space maintainers. Space maintainers are indicated when there is premature loss of teeth that may lead to loss of arch integrity. For primary cuspids, space maintainers prevent midline deviation and loss of arch length and circumference. Premature loss of primary molars also indicates the use of space  maintainers to prevent the migration of adjacent teeth. The loss of primary incisors usually does not require the use of a space maintainer. An initial diagnostically acceptable radiograph must be maintained in the member’s record, demonstrating that the tooth has not begun to erupt or that migration of the adjacent tooth has already occurred. The provider must maintain in the member’s record, diagnostic-quality radiographs that support the need for space maintainers whether initial or replacement. Payment for subsequent visits to adjust space maintainers is included in the original payment.

420.425: Service Descriptions and Limitations: Restorative Services

The MassHealth agency pays for restorative services in accordance with the service descriptions and limitations in 130 CMR 420.425(A) through (E). The MassHealth agency considers all of the following to be components of a completed restoration and includes them in the payment for this service: tooth and soft-tissue preparation, cement bases, etching and bonding agents, pulp capping, impression, local anesthesia, and polishing. The MassHealth agency does not pay for restorations replaced within one year of the date of completion of the original restoration when replaced by the same provider. The initial payment includes all restorations replaced due to defects or failure less than one year from the original placement.

(A)	Amalgam Restorations.
(1)	The MassHealth agency does not pay for restorations attempted on primary teeth when early exfoliation (more than two-thirds of the root structure resorbed) is expected.
(2)	The MassHealth agency pays for only one amalgam restoration per member per tooth surface per year. Occlusal surface restorations, including all occlusal pits and fissures, are payable as a one- surface restoration whether or not the transverse ridge on an upper molar is left intact.

(B)	Resin-Based Composite Restorations.
(1)	The MassHealth agency pays for the following:
(a)	all resin-based composite restorations for all surfaces of anterior and posterior teeth;
(b)	full-coverage composite crowns only for members under age 21, only for anterior primary teeth; and
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(c)	preventive resin restorations only for members under age 21, only on occlusal surfaces, and only as a single-surface posterior composite. Preventive resin restorations include instrumentation of the occlusal surfaces of grooves.
(2)	For anterior teeth, the MassHealth agency pays no more than the maximum allowable payment for four-or-more-surface resin-based composite restorations on the same tooth, except for reinforcing pins and commercial amalgam bonding systems.
(3)	The MassHealth agency pays for only one resin-based composite restoration per member per tooth surface per year.
(4)	The MassHealth agency does not pay more for a composite restoration on a posterior deciduous (primary) tooth than it would for an amalgam restoration.

(C)	Crowns, Posts and Cores and Fixed Partial Dentures (Bridgework).
(1)	Members Under Age 21. The MassHealth agency pays for the following:
(a)	crowns made from resin-based composite (indirect);
(b)	crowns porcelain fused to predominantly base metal, posts and cores on permanent incisors, cuspids, bicuspids, and first and second molars; and
(c)	prefabricated stainless-steel crowns for primary and permanent posterior teeth or prefabricated resin crowns for primary and permanent anterior teeth. Stainless-steel or
prefabricated resin crowns are limited to instances where the prognosis is favorable and must not be placed on primary teeth that are mobile or show advanced resorption of roots. The MassHealth agency pays for no more than four stainless-steel or prefabricated resin crowns
per member per date of service in an office setting.
(2)	DDS Clients Aged 21 and Older. The MassHealth agency pays for crown porcelain fused to predominantly base metal, and prefabricated posts and cores on anterior teeth only. The
MassHealth agency pays for porcelain fused to predominantly base metal and stainless steel crowns for posterior teeth only if extraction (the alternative treatment) would cause undue medical risk for a member with one or more medical conditions that include, but are not limited
to
(a)	hemophilia;
(b)	history of radiation therapy;
(c)	acquired or congenital immune disorder;
(d)	severe physical disabilities such as quadriplegia;
(e)	profound mental retardation; and
(f)	profound mental illness.

(D)	Reinforcing Pins. The MassHealth agency pays for reinforcing pins only when used in conjunction with a two-or-more-surface restoration on a permanent tooth. Commercial amalgam bonding systems are included in this category.

(E)	Crown Repair. The MassHealth agency pays for chairside crown repair and fixed partial denture repair. A description of the repair must be documented in the member’s dental record. The MassHealth agency pays for unspecified restoration procedures for crown repair by an outside laboratory only if the repair is extensive and cannot be done chairside.
(A)	

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601	Introduction

Dental providers who bill using Current Dental Terminology (CDT) codes must refer to the current version of the American Dental Association’s (ADA) code book for the service descriptions for codes listed in Subchapter 6 of the Dental Manual. Dentists who are specialists in oral surgery in accordance with 130 CMR 420.405(A)(7) must refer to the current version of the American Medical Association’s (AMA) Current Procedural Terminology (CPT) code book for the service descriptions for codes listed in Subchapter 6 of the Dental Manual.

MassHealth pays for dental services as described in MassHealth regulations at 130 CMR 420.000 and
450.000. A dental provider may request prior authorization for any medically necessary service payable  in accordance with the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provisions set forth in 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member under the age of 21. This applies even if the service is not listed in Subchapter 6 of the Dental Manual. For each dental service code, the description indicates any limitations, such as age and frequency, and if prior authorization is required for the member.

Dentists Who Are Specialists in Oral Surgery

A dentist who is a specialist in oral surgery in accordance with 130 CMR 420.405(A)(7) must submit all requests for prior authorization and claims containing Current Procedural Terminology (CPT) codes directly to MassHealth rather than to any third-party administrator or other MassHealth vendor, as described in 130 CMR 420.000.

When billing for multiple surgeries performed during the same operative session or on the same day, dental providers who are specialists in oral surgery in accordance with 130 CMR 420.405(A)(7), are reminded that Modifier 51 must be added to the second, third, and subsequent lines as appropriate. The primary procedure must be on line 1.

Modifiers

The following modifiers are for Provider Preventable Conditions (PPCs) that are National Coverage Determinations.

PA	Surgical or other invasive procedure on wrong body part PB	Surgical or other invasive procedure on wrong patient PC	Wrong surgery or other invasive procedure on patient

For more information on the use of these modifiers, see Appendix V of your provider manual.

Public Health Dental Hygienists

Public health dental hygienists may claim payment for Service Codes D0220, D0272, D0273, D0274, D1110, D1120, D1206, D1208, D1351, D4341, D4342, D9110, and D9410.

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602	Explanation of Abbreviations and Service Code Requirements

The following abbreviations are used in Subchapter 6 with certain services that may require special reporting, as described below.

(A)	Prior Authorization.
(1)	“PA” indicates that service-specific prior authorization is required (see 130 CMR 420.410). The provider must include in any request for prior authorization sufficiently detailed, clear information documenting the medical necessity of the service requested and, where specified, the information described in this Subchapter 6.

(2)	The MassHealth agency may require any additional information it deems necessary. If prior authorization is not required, the provider must maintain in the member’s dental record, all information necessary to disclose the medical necessity for the services provided. Pursuant to 130 CMR 420.410(B)(3), prior authorization may be requested for any exception to a limitation on a service otherwise covered for that member. (For example, MassHealth limits prophylaxis to two per member per calendar year, but pays for additional prophylaxis for a member within a calendar year if medically necessary.)

(B)	Individual Consideration. “IC” indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 420.412) and be sufficiently detailed to enable the MassHealth agency to assess the extent and nature of the services provided. The reports must include the following where applicable:

(1)	amount of time required to perform the service;
(2)	degree of skill required to perform the service;
(3)	severity and complexity of the member’s disease, disorder, or disability; and
(4)	any extenuating circumstances or complications. 603	Service Codes: Diagnostic Services
See 130 CMR 420.422 for service descriptions and limitations.

Service Code and Limitations	Covered Under Age 21?	Covered DDS
Clients Aged 21 and Older?	Covered Aged 21 and Older?	Prior-Authorization Requirements, Report Requirements, and Notations	
D0120	Twice per calendar year	Yes	Yes	Yes		
D0140	Twice per calendar year	Yes	Yes	Yes		
D0145	Twice per calendar year	Yes (IC)	No	No	See 602(B) above.	
D0150	Once per member per dentist	Yes	Yes	Yes		
D0160		Yes	Yes	Yes		

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604	Service Codes: Radiographs

See 130 CMR 420.423 for service descriptions and limitations.

Service Code and Limitations	Covered Under Age 21?	Covered DDS
Clients Aged 21 and Older?	Covered Aged 21 and Older?	Prior-Authorization Requirements, Report Requirements, and Notations	
D0210	(FMx) (including bitewings) (once every three calendar years)	Yes	Yes	Yes		
D0220		Yes	Yes	Yes		
D0230		Yes	Yes	Yes		
D0270		Yes	Yes	Yes		
D0272	Twice per calendar year	Yes	Yes	Yes		
D0273	Twice per calendar year	Yes (IC)	Yes (IC)	Yes (IC)	See 602(B) above.	
D0274	Twice per calendar year	Yes	Yes	Yes		
D0330		Yes	Yes	Yes		
D0340		Yes	Yes	Yes		

605	Service Codes: Preventive Services

See 130 CMR 420.424 for service descriptions and limitations.

Service Code and Limitations	Covered Under Age 21?	Covered DDS
Clients Aged 21 and Older?	Covered Aged 21 and Older?	Prior-Authorization Requirements, Report Requirements, and Notations	
D1110	Twice per calendar year – permanent dentition	Yes (Use this code for ages 14-
21.)	Yes	Yes		
D1120	Twice per calendar year – primary or mixed dentition	Yes (Use this code for
ages up to 14.)	No	No		

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605	Service Codes: Preventive Services (cont.)

Service Code and Limitations	Covered Under Age 21?	Covered DDS
Clients Aged 21 and Older?	Covered Aged 21 and Older?	Prior-Authorization Requirements, Report Requirements, and Notations	
D1206		Yes	No	No		
D1208		Yes	No*	No*	* Exception for members who have a medical or dental condition that significantly interrupts the flow of saliva  (PA). See 602(A)
above and 130 CMR 420.424(B)(1)(b).	
	Other Preventive Services	
D1351	Permanent first, second, and third noncarious, nonrestored molars	Yes	No	No		
	Space Maintenance (Passive Appliances)	
D1510		Yes	No	No		
D1515		Yes	No	No		
D1520		Yes	No	No		
D1525		Yes	No	No		
D1550		Yes	No	No		

606	Service Codes: Restorative Services

See 130 CMR 420.425 for service descriptions and limitations.

Service Code and Limitations	Covered Under Age 21?	Covered DDS
Clients Aged 21 and Older?	Covered Aged 21 and Older?	Prior-Authorization Requirements, Report Requirements, and Notations	
	Amalgam Restorations (Including Polishing)	
D2140		Yes	Yes	Yes		
D2150		Yes	Yes	Yes		
D2160		Yes	Yes	Yes		
D2161		Yes	Yes	Yes		
	Resin-Based Composite Restorations	
D2330		Yes	Yes	Yes		
D2331		Yes	Yes	Yes		
D2332		Yes	Yes	Yes		
D2335		Yes	Yes	Yes		

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606	Service Codes: Restorative Services (cont.)

Service Code and Limitations	Covered Under Age 21?	Covered DDS
Clients Aged 21 and Older?	Covered Aged 21 and Older?	Prior-Authorization Requirements, Report Requirements, and Notations	
D2390		Yes	No	No		
D2391		Yes	Yes	Yes		
D2392		Yes	Yes	Yes		
D2393		Yes	Yes	Yes		
D2394		Yes	Yes	Yes		
	Crowns – Single Restoration Only	
D2710	Indirect	Yes	No	No		
D2740		Yes	No	No		
D2750		Yes	No	No		
D2751		Yes	Yes (PA)	No	Include periapical film of the tooth. See 602(A) above and
130 CMR 420.425(C)(2).	
D2752		Yes	No	No		
D2790		Yes	No	No		
	Other Restorative Services	
D2910		Yes	Yes	No		
D2920		Yes	Yes	No		
D2930		Yes	No	No		
D2931		Yes	No*	No	* Exception for members with undue medical risk. See
130 CMR 420.425(C)(2).	
D2932	Primary anterior teeth only	Yes	No	No		
D2934		Yes	No	No		
D2951		Yes	Yes	No		
D2954		Yes	Yes (PA)	No	Include periapical film of the tooth. See
602(A) above and
130 CMR 420.425(C)(1)(c)	
D2980	Chairside	Yes	Yes	No		
D2999	Outside laboratory	Yes (PA) (IC)	Yes (PA)
(IC)	No	Include documentation to substantiate why the repair could not be done chairside. See 602(A) and
(B) above and
130 CMR 420.425(E).	

Commonwealth of Massachusetts MassHealth
Provider Manual Series

Dental Manual	
Subchapter Number and Title

6. Service Codes	
Page

6-6	
	
Transmittal Letter

DEN-92	
Date

03/01/14	

607	Service Codes: Endodontic Services

See 130 CMR 420.426 for service descriptions and limitations.

Service Code and Limitations	Covered Under Age 21?	Covered DDS
Clients Aged 21 and Older?	Covered Aged 21 and Older?	Prior-Authorization Requirements, Report Requirements, and Notations	
	Pulpotomy	
D3220		Yes	No	No		
	Root Canal Therapy (Including Pre- and Post-Treatment Radiographs and Follow- up Care)	
D3310	Excluding final restoration	Yes	Yes	No		
D3320	Excluding final restoration	Yes	No*	No	* Exception for members with undue medical risk. See
130 CMR 420.426(B)(3).
PA required.	
D3330	Excluding final restoration	Yes	No*	No	* Exception for members with undue medical risk. See
130 CMR 420.426(B)(3).
PA required.	
D3346		Yes	Yes	No		
D3347		Yes	No*	No	* Exception for members with undue medical risk or with one or more medical conditions listed in
130 CMR 420.425(C)(2).
See
130 CMR 420.426(C)(2).
PA required.	
	Endodontic Retreatment	
D3348		Yes	No*	No	* Exception for members with undue medical risk or with one or more medical conditions listed in
130 CMR 420.425(C)(2).
See
130 CMR 420.426(C)(2).
PA required.