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					                                     MaineCare
                                 Denture/Partial
                           Prior Authorization Process
                                                                                               Revised: 04/24/2009
Step #1 = Medical Necessity

   MaineCare will only approve dentures/partials when the “Primary Care Doctor” (not the dentist) fills out
   the Statement of Medical Necessity Forms completely, stating the medical necessity for dentures. If the
   patient qualifies under the qualifying criteria listed in these forms the doctor must attach supporting
   documentation.

      Reason such as removal of infection by extracting teeth or if they just do not have teeth is not a
       significant medical need. Just needing teeth to eat what they want is not enough, there has to be an
       underlying “Medical Condition” that will be improved or corrected with the placement of full or partial
       dentures.

Step #2 = Contacting a Dentist/Denturist

   MaineCare requires a Prior Authorization Form or Pretreatment Form from a dentist or denturist that
   will be making the dentures. Without this form we do not know who or exactly what service to prior
   authorize for the dentures IF approved.

      If you need help finding a dentist/denturist you can call Member Services at 1-800-977-6740 and ask if
       they can help you locate someone close to your home.

Stuff to know:
    To qualify for Full dentures a member MUST be edentulous (have NO teeth) this must be documented
        on form by the dentist or denturist x-rays may be required.

      Extractions do not require prior authorization if they have acute pain or infection but still there has to be
       a medical need for the dentures once the teeth are pulled.

 Step #3 = Getting Prior Authorization

       IF all of the information is not with the request or supporting documentation is not given on a qualifying
       criteria we may send you a letter asking YOU to have the provider get this information to us, you will
       have 30 days from the date of the letter to have what we need sent to us if it is not sent in, your dentures
       will be denied for lack of required documentation.

       Once MaineCare receives the complete request we will review to determine if it meets MaineCare
       criteria as medically necessary, when a decision is made a letter will be mailed to you and the dentist or
       denturist.




                                                  Questions?
                                              Call: 1-866-796-2463
                                                                       Department of Health and Human Services
                                                                                              MaineCare Services
                                                                                        Prior Authorization Unit
                                                                                         # 11 State House Station
                                                                                     Augusta, Maine 04333-0011
                                                                              Tel: (207) 624-6902; 1-866-796-2463
                                                                                               Fax: (207) 287-7643
                                                                                             TTY: 1-800-423-4331



Name: _____________________________________ID #: ________________________


Dear MaineCare Member,

For members age 21 and over, the next four pages need to be filled out by your medical doctor not by a dentist.
Please make sure these forms are read and filled out completely.

Your doctor must choose one of the qualifying criteria’s on page 2 and all supporting medical documentation
must be supplied where asked (such as chart notes, HgbA1c, etc.), showing how dentures or partials would
improve or correct an “underlying medical condition”.

To qualify for full dentures a member must be edentulous (have no teeth). The condition of being edentulous
can only be waived in cases where extenuating medical circumstances exist that substantiate the medical
necessity that immediate placement of dentures is clearly necessary for the member’s health due to a serious
medical condition (e.g. member is scheduled to have organ transplant surgery or chemotherapy in the near
future or the member has had extreme (>20%) weight loss over one (1) year or less and has an underlying
medical condition such as advanced HIV disease or uncontrolled Crohn’s disease).

Extractions do not require prior authorization when there is acute pain or infection.

If you have any questions please call the MaineCare Prior Authorization Unit at 1-800-796-2463 or 207-624-
6902.

Sincerely,


Prior Authorization Unit
                                                                                              Page 1 of 4


              Statement of Medical Necessity for Dentures
  Please do not fill out this form if the requested service is not for Dentures – other dental service
    requests should be sent in by dental provider on an ADA Dental claim formed marked as a
                                        Pre-Treatment Estimate.

Attention Doctor/Primary Care Provider ___________________________________________________;

As the physician or primary care provider fore the MaineCare (formerly Medicaid) member below, your
brief assistance is required.

As you may know, Dental Services for adults (over the age of 21) under MaineCare are limited (such as
dentures for adults) and those services can only be provided when they meet certain criteria (listed
below). To qualify for full dentures under A through D of Section 25.04-2, a member must be
edentulous. Requests for prior authorization will be considered for dentures only if one or more of
the following criteria is met:

Therefore, in order to provide the services described below to the MaineCare Member listed below, your
review and signature is required.

                             MaineCare Member Information

MaineCare Member’s Name ____________________________________________________________

MaineCare Identification number _______________________________________________________
(required)

                             Explanation of Medical Necessity

(Include underlying medical condition, such as weight loss, or member’s psychiatric condition or
behavior, and treatment history if related. Explain why the above services are cost effective)

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
                                                                                          Page 2 of 4



       Supporting MaineCare Benefits Manual Qualifying Criteria:
                        (One must be checked)

________   Members with dysphagia, aspiration or other choking-risk conditions will qualify for
           dentures or other appropriate medically necessary dental care if; (1) this condition is not
           amenable to, or is not suitable for corrective surgery or medical treatment; (2) a
           swallowing study or such therapy evaluation documenting the aspiration or choking
           risk is submitted; and (3) the treating physician, in consultation with the member’s
           dentist, states that their condition is most cost-effectively treated by dentures or other
           services. (example - recurrent esophageal stricture, not responsive to endoscopic dilations
           with episodes of obstruction).

________   Members who have an underlying medical condition, e.g. uncontrolled diabetes melitus
           with documentation as outlined below, or medical condition causing documented
           inappropriate weight loss of greater than 10% of body weight over one (1) year or
           less that will be corrected or improved by the provision of medically necessary dental
           services, including full and partial dentures, will qualify for dentures or other
           appropriate medically necessary dental care so long as such services are cost effective
           compared to other MaineCare covered services. A trial period of other cost effective means
           may be required before dentures are approved for treatment of an underlying medical
           condition. Gastro-esophageal reflux disease (GERD), being overweight or morbidly obese,
           or being at risk for coronary artery disease are examples of diagnoses that do not, alone,
           substantiate the medical necessity for dentures, as these conditions have not been shown to
           be more effectively treated with dentures than other means. Therefore, a trial period of
           other cost effective means may be required before dentures are approved for treatment of
           an underlying medical condition. Documentation that is required to substantiate that
           uncontrolled diabetes may be appropriately treated adjunctively with the use of
           dentures must include all of the following: (1) HgbA1c of > 8% on at least two (2)
           occasions at least six (6) months apart; (2) Documentation of at least two dietary
           counseling sessions with a dietician regarding an edentulous diet; and (3)
           Participation in an ADEF (Ambulatory Diabetes Education and Follow-up) program
           within one (1) year prior to, or between the two HgbA1c measurements.

________   Members whose behavior secondary to dental pain or the psychological complications of
           being edentulous are causing severe medical or psychiatric complications, (e.g. debilitating
           psychiatric illness or physical harm), as documented by a licensed psychologist or
           psychiatrist, would qualify for necessary dental services under this Subsection.

________   Members with dentures who require replacement dentures and whose dentures are
           medically necessary to correct or ameliorate an underlying medical condition, and for
           whom the Department determines that the provision of those dentures will be cost effective
           in comparison to the provision of other covered medical services for the treatment of that
           condition.
                                                                                                  Page 3 of 4

                 Physician or Primary Care Provider Authorization

       I have reviewed the adult dental services being requested, the justification for the services, the
       qualifying MaineCare criteria and I do authorize the above services as medically necessary.


(print name)                                                                 (date)


(signature)




       I do NOT authorize the above request as medically necessary.


(print name)                                                                 (date)


(signature)




Please fax or mail (do not do both) the required information to:

Division of HealthCare Management
Prior Authorization Unit
11 State House Station
Augusta, Maine 04333-0011
Fax # (207) 287-7643
                                                                                                                           Page 4 of 4
                         Prior Authorization Request for Dentures
Member: ______________________________________________ Member ID#_________________________________

Per the Maine Medical Assistance Manual, Chapter II, Section 25.04, the following information is needed from the member’s
physician to determine medical necessity before a decision can be made regarding dentures.

Please explain, in detail, what the member’s underlying medical condition that is directly related to lack of teeth or teeth in
poor condition. _________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Please describe the treatment history for said condition. _________________________________________________________
______________________________________________________________________________________________________

Please attach clinical documentation of medical necessity.

Is this member Diabetic?       ____ Yes ____ No         Type _________
   Please include copies of 2 current hemoglobin A1C’s six months apart, or more recent blood sugar readings that demonstrate declining
   control.

Please, attach copies of office or hospital notes that document poor control or need for improvement of blood sugars.

Has the member had any recent significant weight loss? _____ Yes           _____ No
           Amount of weight change. _____ What kind of time frame did the change occur over? ________
   Please provide chart notes documenting weight loss.

What is the member’s current weight compared to his/her ideal body weight? Current _________ vs. Ideal _________

Other comments regarding this member’s weight and physical health. _______________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

How could providing dentures correct or ameliorate his/her related medical condition? Please send copies of any documented
clinical studies showing dentures, as an intervention will directly improve the member’s medical condition.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

If the underlying condition is psychiatric, please explain in detail. (This information must come from a licensed psychologist or
psychiatrist)

Diagnosis: _______________________________________________________________________________________

         Describe the member’s behavior: _____________________________________________________________________
         ________________________________________________________________________________________________

         Is the member’s behavior secondary to dental pain? ______Yes ______No
         Explain behavior and type of dental pain. _______________________________________________________________
         ________________________________________________________________________________________________

         Is the behavior putting the member at risk for significant medical complications? ____Yes ____No
         Please explain: ____________________________________________________________________________________

Other pertinent information is included: _______________________________________________________________________

Name of Medical Practice: _________________________________________________________________________________

Complete Mailing Address:_________________________________________________________________________________

____________________________________                      _____________________________                    ________________________
Physician’s Signature                                     Please Print Name                                Phone Number