bcl_1118534232.htm

Nevada Medicaid - Adult

Schedule of Benefits

Coverage, Limitations and Prior Authorization Requirements

PRIOR AUTHORIZATION TABLE:

01 = Prior authorization is required.

02 = Prior authorization is required. Covered services are for 1) adjacent/abutment tooth for partials or 2) for a pregnancy-related service (recipients age 21 years or older). NC = Not Covered

Code	Description	Limitations	Prior Auth Req	Prior Auth Req	Documentation/X-Ray Required
			Prior Auth Req	Prior Auth Req
			Adult Population	Pregnant Women
			Adult Population	Pregnant Women
	Diagnostic Services
D0120	Periodic oral evaluation	Adult Population: 1 (D0120) every 12 months - (VA)
D0120	Periodic oral evaluation	Pregnant Women: 1 (D0120) every 11 months
		Pregnant Women: 1 (D0120) every 11 months
D0140	Limited oral evaluation	3 (D0140) every 6 months
D0150	Comprehensive oral evaluation	1 (D0150) every 12 months	NC
D0160	Oral evaluation, problem focused	1 of (D0160, D0170) every 6 months
D0170	Re-evaluation, limited, problem focused	1 of (D0160, D0170) every 6 months
D0170	Re-evaluation, limited, problem focused
D0190	Screening of a patient	1 of (D0190, D0191) every 6 months
D0191	Assessment of a patient	1 of (D0190, D0191) every 6 months
D0191	Assessment of a patient
		1 (D0210) every 12 months. D0210 may not be billed on the same date of service as D0220
D0210	Intraoral, complete series of radiographic images	and/or D0230. Use code D0210 when providing 14 or more intraoral
		x-rays on the same date of service.
D0220	Intraoral, periapical, first radiographic image	1 (D0220) every 12 months. D0220 may not be billed on the same date of service as D0210. 4
D0220	Intraoral, periapical, first radiographic image	additional of (D0220, D0230) every 12 months - (VA)
		additional of (D0220, D0230) every 12 months - (VA)
		12 (D0230) every 12 months. D0230 may not be billed on the same date of service as D0210.
D0230	Intraoral, periapical, each add 'l radiographic image	No more than 13 units of any combination of D0220 and /or D0230 may be billed within 12
		months. 4 additional of (D0220, D0230) every 12 months - (VA)
D0240	Intraoral, occlusal radiographic image	2 (D0240) every 12 months
D0270	Bitewing, single radiographic image
D0272	Bitewings, two radiographic images	1 of (D0270-D0277) every 6 months
D0273	Bitewings, three radiographic images	1 of (D0270-D0277) every 6 months
D0273	Bitewings, three radiographic images	1 additional (D0274) every 12 months - (VA)
D0274	Bitewings, four radiographic images	1 additional (D0274) every 12 months - (VA)
D0274	Bitewings, four radiographic images
D0277	Vertical bitewings, 7 to 8 radiographic images
D0322	Tomographic survey	1 (D0322) every 6 months
D0330	Panoramic radiographic image	1 (D0330) every 36 months
D0340	2D cephalometric radiographic image, measurement and analysis	1 (D0340) every 36 months
D0350	2D oral/facial photographic image, intra-orally/extra-orally	1 (D0350) every 12 months
D0364	Cone beam CT capture & interpretation, limited view, less than one whole jaw
D0365	Cone beam CT capture & interpretation, view of one full arch, mandible	1 of (D0364-D0367, D0380-D0383) every 36 months			Narrative Required with Claim Submission
D0366	Cone beam CT capture & interpretation, view of one full arch, maxilla, cranium	1 of (D0364-D0367, D0380-D0383) every 36 months			Narrative Required with Claim Submission
D0366
D0367	Cone beam CT capture & interpretation, view of both jaws; cranium
D0370	Maxillofacial ultrasound capture and interpretation	1 of (D0370, D0386) every 36 months			Narrative Required with Claim Submission
D0380	Cone beam CT image capture with limited field of view, less than one whole jaw
D0381	Cone beam CT image capture with field of view of one full dental arch, mandible	1 of (D0364-D0367, D0380-D0383) every 36 months			Narrative Required with Claim Submission
D0382	Cone beam CT image capture with field of view of one full dental arch, maxilla	1 of (D0364-D0367, D0380-D0383) every 36 months			Narrative Required with Claim Submission
D0382
D0383	Cone beam CT image capture with field of view of both jaws
D0386	Maxillofacial ultrasound image capture	1 of (D0370, D0386) every 36 months			Narrative Required with Claim Submission
D0414	Laboratory process of microbial specimen, culture, sensitivity, prep, report	1 of (D0414-D0416) every 6 months
D0415	Collection of microorganisms for culture	1 of (D0414-D0416) every 6 months
D0416	Viral culture
D0460	Pulp vitality tests	1 (D0460) per patient, per day, same provider
D0502	Other oral pathology procedures, by report	1 (D0502) every 12 months
D0600	Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in	1 (D0600) every 6 months
D0600	structure of enamel, dentin, and cementum	1 (D0600) every 6 months
	Preventive Services
D1110	Prophylaxis, adult	Adult Population: 1 (D1110) every 12 months - (VA)		02
D1110	Prophylaxis, adult	Pregnant Women: 1 (D1110) every 6 months 2 additional (D1110) every 12 months - (VA)		02

D1206	Topical application of fluoride varnish	1 (D1206) every 6 months	NC	02
D1208	Topical application of fluoride, excluding varnish	1 (D1208) every 6 months	NC	02
D1575	Distal shoe space maintainer, fixed, unilateral	4 of (D1575) in a lifetime any provider, no more than 2 units every 12 months
	Restorative Services
D2140	Amalgam, one surface, primary or permanent		02	02
D2150	Amalgam, two surfaces, primary or permanent		02	02
D2160	Amalgam, three surfaces, primary or permanent		02	02
D2161	Amalgam, four or more surfaces, primary or permanent	1 of (D2140-D2335, D2391-D2394) per surface per tooth every 36 months	02	02
D2330	Resin-based composite, one surface, anterior		02	02
D2330	Resin-based composite, one surface, anterior		02	02
D2331	Resin-based composite, two surfaces, anterior		02	02
D2332	Resin-based composite, three surfaces, anterior		02	02
D2335	Resin-based composite, four or more surfaces, involving incisal angle		02	02
D2390	Resin-based composite crown, anterior	1 (D2390) per tooth every 36 months	02	02

NVMA-20180607

Making members shine, one smile at a time™

Nevada Medicaid - Adult

Schedule of Benefits

Coverage, Limitations and Prior Authorization Requirements

Code	Description	Limitations	Prior Auth Req	Prior Auth Req	Documentation/X-Ray Required
			Prior Auth Req	Prior Auth Req
			Adult Population	Pregnant Women
			Adult Population	Pregnant Women
	Restorative Services (continued)
D2391	Resin-based composite, one surface, posterior		02	02
D2392	Resin-based composite, two surfaces, posterior	1 of (D2140-D2335, D2391-D2394) per surface per tooth every 36 months	02	02
D2393	Resin-based composite, three surfaces, posterior		02	02
D2393	Resin-based composite, three surfaces, posterior		02	02
D2394	Resin-based composite, four or more surfaces, posterior		02	02
D2712	Crown, ¾ resin-based composite (indirect)		02	02
D2721	Crown, resin with predominantly base metal		02	02
D2740	Crown, porcelain/ceramic	1 of (D2712-D2791, D2960-D2962) per tooth in a lifetime	02	02
D2751	Crown, porcelain fused to predominantly base metal	1 of (D2712-D2791, D2960-D2962) per tooth in a lifetime	02	02
D2751	Crown, porcelain fused to predominantly base metal		02	02
D2781	Crown, ¾ cast predominantly base metal		02	02
D2791	Crown, full cast predominantly base metal		02	02
D2910	Re-cement or re-bond inlay, onlay, veneer, or partial coverage	1 of (D2910, D2920) per tooth every 12 months	01	01
D2920	Re-cement or re-bond crown	1 of (D2910, D2920) per tooth every 12 months
D2920	Re-cement or re-bond crown
D2921	Reattachment of tooth fragment, incisal edge or cusp
D2930	Prefabricated stainless steel crown, primary tooth	1 of (D2930, D2932, D2933) per tooth every 36 months	02	02
D2931	Prefabricated stainless steel crown, permanent tooth	1 (D2931) per tooth in a lifetime	02	02
D2932	Prefabricated resin crown	1 of (D2930, D2932, D2933) per tooth every 36 months	02	02
D2933	Prefabricated stainless steel crown with resin window	1 of (D2930, D2932, D2933) per tooth every 36 months	02	02
D2933	Prefabricated stainless steel crown with resin window		02	02
D2940	Protective restoration	2 (D2940) per tooth every 6 months
D2950	Core buildup, including any pins when required	1 (D2950) per tooth every 36 months	02	02
D2951	Pin retention, per tooth, in addition to restoration	2 (D2951) per tooth every 36 months	02	02
D2952	Post and core in addition to crown, indirectly fabricated	1 of (D2952, D2954) per tooth in a lifetime	02	02
D2953	Each additional indirectly fabricated post, same tooth	1 of (D2953, D2957) per tooth in a lifetime	02	02
D2954	Prefabricated post and core in addition to crown	1 of (D2952, D2954) per tooth in a lifetime	02	02
D2955	Post removal	1 (D2955) per tooth in a lifetime	02	02
D2957	Each additional prefabricated post, same tooth	1 of (D2953, D2957) per tooth in a lifetime	02	02
D2960	Labial veneer (resin laminate), chairside	1 of (D2712-D2791, D2960-D2962) per tooth in a lifetime	02	02
D2961	Labial veneer (resin laminate), laboratory	1 of (D2712-D2791, D2960-D2962) per tooth in a lifetime	02	02
D2962	Labial veneer (porcelain laminate), laboratory		02	02
D2980	Crown repair necessitated by restorative material failure	1 (D2980) per tooth in a lifetime	02	02
	Periodontal Services
D4210	Gingivectomy or gingivoplasty, four or more teeth per quadrant	1 of (D4210-D4212) per site/quadrant every 60 months	NC	02
D4211	Gingivectomy or gingivoplasty, one to three teeth per quadrant	1 of (D4210-D4212) per site/quadrant every 60 months	NC	02
D4212	Gingivectomy or gingivoplasty, restorative procedure, per tooth		NC	02
D4341	Periodontal scaling and root planing, four or more teeth per quadrant	1 of (D4341, D4342) per site/quadrant every 12 months	NC	02
D4342	Periodontal scaling and root planing, one to three teeth per quadrant	1 of (D4341, D4342) per site/quadrant every 12 months	NC	02
D4342			NC	02
D4346	Scaling in the presence of generalized moderate or sever gingival inflammation, full mouth after oral	1 (D4346) every 12 months	NC	02
	evaluation
D4355	Full mouth debridement to enable comprehensive evaluation and diagnosis, subsequent visit	1 (D4355) every 12 months			Narrative and X-rays Required with Claim Submission
D4910	Periodontal maintenance	1 (D4910) every 3 months	NC	02
	Removable Prosthodontic Services
D5110	Complete denture, maxillary
D5120	Complete denture, mandibular	1 of (D5110-D5140) per arch every 60 months, unless medically necessary			Narrative and X-rays Required with Claim Submission
D5130	Immediate denture, maxillary				Narrative and X-rays Required with Claim Submission
D5130	Immediate denture, maxillary
D5140	Immediate denture, mandibular
D5211	Maxillary partial denture, resin base
D5212	Mandibular partial denture, resin base	1 of (D5211-D5214) per arch every 60 months unless medically necessary			Narrative and X-rays Required with Claim Submission
D5213	Maxillary partial denture, cast metal, resin base				Narrative and X-rays Required with Claim Submission
D5213	Maxillary partial denture, cast metal, resin base
D5214	Mandibular partial denture, cast metal, resin base
D5221	Immediate maxillary partial denture, resin base	1 of (D5221-D5222) per arch in a lifetime	01	01
D5222	Immediate mandibular partial denture, resin base	1 of (D5221-D5222) per arch in a lifetime	01	01
D5222	Immediate mandibular partial denture, resin base		01	01
D5410	Adjust complete denture, maxillary
D5411	Adjust complete denture, mandibular	1 of (D5410-D5422) per arch every 6 months
D5421	Adjust partial denture, maxillary	1 of (D5410-D5422) per arch every 6 months
D5421	Adjust partial denture, maxillary
D5422	Adjust partial denture, mandibular
D5511	Repair broken complete denture base, mandibular	1 of (D5511, D5512) per arch every 60 months
D5512	Repair broken complete denture base, maxillary	1 of (D5511, D5512) per arch every 60 months
D5512	Repair broken complete denture base, maxillary
D5520	Replace missing or broken teeth, complete denture	1 (D5520) per arch every 60 months
D5611	Repair cast partial framework, mandibular	Contraindicated any provider, within 91 days
D5612	Repair cast partial framework, maxillary	Contraindicated any provider, within 91 days
D5612	Repair cast partial framework, maxillary
D5621	Repair cast framework, maxillary	Contraindicated any provider, within 91 days
D5622	Repair cast framework, mandibular	Contraindicated any provider, within 91 days
D5622	Repair cast framework, mandibular
D5630	Repair or replace broken clasp, per tooth	Contraindicated any provider, within 91 days
D5640	Replace broken teeth, per tooth	Contraindicated any provider, within 91 days
D5650	Add tooth to existing partial denture	Contraindicated any provider, within 91 days
D5660	Add clasp to existing partial denture, per tooth	Contraindicated any provider, within 91 days

NVMA-20180607

Making members shine, one smile at a time™

Nevada Medicaid - Adult

Schedule of Benefits

Coverage, Limitations and Prior Authorization Requirements

Code	Description	Limitations	Prior Auth Req	Prior Auth Req	Documentation/X-Ray Required
			Prior Auth Req	Prior Auth Req
			Adult Population	Pregnant Women
			Adult Population	Pregnant Women
	Removable Prosthodontic Services (continued)
D5670	Replace all teeth & acrylic on cast metal frame, maxillary	1 of (D5670, D5671) per arch every 60 months	01	01
D5671	Replace all teeth & acrylic on cast metal frame, mandibular	1 of (D5670, D5671) per arch every 60 months	01	01
D5671	Replace all teeth & acrylic on cast metal frame, mandibular		01	01
D5730	Reline complete maxillary denture, chairside
D5731	Reline complete mandibular denture, chairside
D5740	Reline maxillary partial denture, chairside	1 of (D5730-D5761) per arch every 6 months, no more than 3 per arch
D5741	Reline mandibular partial denture, chairside
D5750	Reline complete maxillary denture, laboratory	every 60 months
D5751	Reline complete mandibular denture, laboratory				Narrative Required with Claim Submission
D5760	Reline maxillary partial denture, laboratory				Narrative Required with Claim Submission
D5760	Reline maxillary partial denture, laboratory
D5761	Reline mandibular partial denture, laboratory
D5820	Interim partial denture, maxillary	1 of (D5820, D5821) per arch every 60 months			Narrative and X-rays Required with Claim Submission
D5821	Interim partial denture, mandibular	1 of (D5820, D5821) per arch every 60 months			Narrative and X-rays Required with Claim Submission
D5821	Interim partial denture, mandibular
D5850	Tissue conditioning, maxillary	1 of (D5850, D5851) per arch every 12 months
D5851	Tissue conditioning, mandibular	1 of (D5850, D5851) per arch every 12 months
D5851	Tissue conditioning, mandibular
D5862	Precision attachment, by report	1 (D5862) every 60 months	01	01
D5899	Unspecified removable prosthodontic procedure, by report	2 (D5899) every 60 months
	Maxillofacial Prosthetic Services
D5931	Obturator prosthesis, surgical	1 (D5931) in a lifetime	01	01
D5932	Obturator prosthesis, definitive	1 (D5932) in a lifetime	01	01
D5933	Obturator prosthesis, modification	1 (D5933) in a lifetime	01	01
D5936	Obturator prosthesis, interim	1 (D5936) in a lifetime	01	01
D5983	Radiation carrier	1 (D5983) every 12 months	01	01
D5984	Radiation shield	1 (D5984) every 12 months	01	01
D5985	Radiation cone locator	1 (D5985) every 12 months	01	01
D5988	Surgical splint	1 (D5988) in a lifetime	01	01
D5992	Adjust maxillofacial prosthetic appliance, by report	1 (D5992) every 12 months	01	01
D5993	Maintenance & cleaning, maxillofacial prosthesis, other than required adjustments, by report	1 (D5993) every 3 months	01	01
	Fixed Prosthodontic Services
D6930	Re-cement or re-bond fixed partial denture	Contraindicated any provider, within 91 days
	Oral and Maxillofacial Services
D7111	Extraction, coronal remnants, primary tooth
D7140	Extraction, erupted tooth or exposed root	1 of (D7111-D7250) per tooth in a lifetime. D7111, D7140, D7210, D7220, D7230, D7240,
D7210	Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth
D7210		D7241 and D7250 are contraindicated in conjunction with D9215 - same day, same recipient,
D7220	Removal of impacted tooth, soft tissue				Narrative and X-rays Required with Claim Submission
D7220	Removal of impacted tooth, soft tissue	any provider.
D7230	Removal of impacted tooth, partially bony	any provider.
D7230	Removal of impacted tooth, partially bony
D7240	Removal of impacted tooth, completely bony
		1 of (D7111-D7250) per tooth in a lifetime. D7111, D7140, D7210, D7220, D7230, D7240,
D7241	Removal impacted tooth, complete bony, complication	D7241 and D7250 are contraindicated in conjunction with D9215 - same day, same recipient,			Narrative and X-rays Required with Claim Submission
D7241	Removal impacted tooth, complete bony, complication	any provider. D7241 and D7261 are contraindicated against each other - within 90 days, same			Narrative and X-rays Required with Claim Submission

		recipient, any provider.
D7250	Removal of residual tooth roots (cutting procedure)	1 of (D7111-D7250) per tooth in a lifetime. D7111, D7140, D7210, D7220, D7230, D7240,			Narrative and X-rays Required with Claim Submission
D7250	Removal of residual tooth roots (cutting procedure)	D7241 and D7250 are contraindicated in conjunction with D9215 - same day, same recipient,			Narrative and X-rays Required with Claim Submission
		any provider.
D7251	Coronectomy, intentional partial tooth removal	2 (D7251) in a lifetime	01	01
D7280	Exposure of an unerupted tooth	1 (D7280) per tooth in a lifetime			Narrative and X-rays Required with Claim Submission
D7283	Placement, device to facilitate eruption, impaction				Narrative and X-rays Required with Claim Submission
D7287	Exfoliative cytological sample collection				Narrative Required with Claim Submission
D7288	Brush biopsy, transepithelial sample collection				Narrative Required with Claim Submission
D7291	Transseptal fiberotomy/supra crestal fiberotomy, by report				Narrative and X-rays Required with Claim Submission
D7292	Placement of temporary anchorage device [screw retained plate] requiring flap				Narrative and X-rays Required with Claim Submission
D7293	Placement of temporary anchorage device requiring flap; includes device removal				Narrative and X-rays Required with Claim Submission
D7294	Placement of temporary anchorage device without flap; includes device removal				Narrative and X-rays Required with Claim Submission
D7310	Alveoloplasty with extractions, four or more teeth per quadrant				Narrative and X-rays Required with Claim Submission
D7311	Alveoloplasty with extractions, one to three teeth per quadrant	1 of (D7310-D7321) per quadrant in a lifetime, contraindicated any provider within 3286 days			Narrative and X-rays Required with Claim Submission
D7320	Alveoloplasty, w/o extractions, four or more teeth per quadrant
D7320
D7321	Alveoloplasty, w/o extractions, one to three teeth per quadrant		01	01
D7412	Excision of benign lesion, complicated		01	01
D7440	Excision of malignant tumor, up to 1.25 cm				Narrative and X-rays Required with Claim Submission
D7441	Excision of malignant tumor, greater than 1.25 cm				Narrative and X-rays Required with Claim Submission
D7472	Removal of torus palatinus	2 of (D7472, D7243) in a lifetime			Narrative and X-rays Required with Claim Submission
D7473	Removal of torus mandibularis	2 of (D7472, D7243) in a lifetime			Narrative and X-rays Required with Claim Submission
D7473	Removal of torus mandibularis
D7490	Radical resection of maxilla or mandible		01	01
D7510	Incision & drainage of abscess, intraoral soft tissue	Incidental already part of another procedure			Narrative and X-rays Required with Claim Submission
D7511	Incision & drainage of abscess, intraoral soft tissue, complicated				Narrative and X-rays Required with Claim Submission
D7520	Incision & drainage of abscess, extraoral soft tissue	Incidental already part of another procedure			Narrative and X-rays Required with Claim Submission

NVMA-20180607

Making members shine, one smile at a time™

Nevada Medicaid - Adult

Schedule of Benefits

Coverage, Limitations and Prior Authorization Requirements

Code	Description	Limitations	Prior Auth Req	Prior Auth Req	Documentation/X-Ray Required
			Prior Auth Req	Prior Auth Req
			Adult Population	Pregnant Women
			Adult Population	Pregnant Women
	Oral and Maxillofacial Services (continued)
D7521	Incision & drainage of abscess, extraoral soft tissue, complicated				Narrative and X-rays Required with Claim Submission
D7530	Remove foreign body, mucosa, skin, tissue				Narrative Required with Claim Submission
D7540	Removal of reaction producing foreign bodies, musculoskeletal system				Narrative and X-rays Required with Claim Submission
D7550	Partial ostectomy/sequestrectomy for removal of non-vital bone				Narrative and X-rays Required with Claim Submission
D7560	Maxillary sinusotomy for removal of tooth fragment or foreign body				Narrative and X-rays Required with Claim Submission
D7610	Maxilla, open reduction (teeth immobilized, if present)				Narrative and X-rays Required with Claim Submission
D7620	Maxilla, closed reduction (teeth immobilized, if present)				Narrative and X-rays Required with Claim Submission
D7630	Mandible, open reduction (teeth immobilized, if present)				Narrative and X-rays Required with Claim Submission
D7640	Mandible, closed reduction (teeth immobilized, if present)				Narrative and X-rays Required with Claim Submission
D7650	Malar and/or zygomatic arch, open reduction	1 of (D7650, D7660, D7750, D7760) in a lifetime			Narrative and X-rays Required with Claim Submission
D7660	Malar and/or zygomatic arch, closed reduction	1 of (D7650, D7660, D7750, D7760) in a lifetime			Narrative and X-rays Required with Claim Submission
D7660	Malar and/or zygomatic arch, closed reduction
D7670	Alveolus, closed reduction, may include stabilization of teeth				Narrative and X-rays Required with Claim Submission
D7671	Alveolus, open reduction, may include stabilization of teeth				Narrative and X-rays Required with Claim Submission
D7680	Facial bones, complicated reduction with fixation, multiple surgical approaches				Narrative and X-rays Required with Claim Submission
D7710	Maxilla, open reduction				Narrative and X-rays Required with Claim Submission
D7720	Maxilla, closed reduction				Narrative and X-rays Required with Claim Submission
D7730	Mandible, open reduction				Narrative and X-rays Required with Claim Submission
D7740	Mandible, closed reduction				Narrative and X-rays Required with Claim Submission
D7750	Malar and/or zygomatic arch, open reduction	1 of (D7650, D7660, D7750, D7760) in a lifetime			Narrative and X-rays Required with Claim Submission
D7760	Malar and/or zygomatic arch, closed reduction	1 of (D7650, D7660, D7750, D7760) in a lifetime			Narrative and X-rays Required with Claim Submission
D7760	Malar and/or zygomatic arch, closed reduction
D7770	Alveolus, open reduction stabilization of teeth				Narrative and X-rays Required with Claim Submission
D7771	Alveolus, closed reduction stabilization of teeth				Narrative and X-rays Required with Claim Submission
D7780	Facial bones, complicated reduction with fixation and multiple approaches				Narrative and X-rays Required with Claim Submission
D7810	Open reduction of dislocation		01	01
D7820	Closed reduction of dislocation			NC	Narrative Required with Claim Submission
D7840	Condylectomy			NC	Narrative and X-rays Required with Claim Submission
D7850	Surgical discectomy, with/without implant			NC	Narrative and X-rays Required with Claim Submission
D7852	Disc repair			NC	Narrative and X-rays Required with Claim Submission
D7854	Synovectomy			NC	Narrative and X-rays Required with Claim Submission
D7858	Joint reconstruction		01	NC
D7860	Arthrotomy			NC	Narrative and X-rays Required with Claim Submission
D7865	Arthroplasty			NC	Narrative and X-rays Required with Claim Submission
D7870	Arthrocentesis			NC	Narrative and X-rays Required with Claim Submission
D7872	Arthroscopy, diagnosis, with or without biopsy			NC	Narrative and X-rays Required with Claim Submission
D7873	Arthroscopy: lavage and lysis of adhesions			NC	Narrative and X-rays Required with Claim Submission
D7874	Arthroscopy: disc repositioning and stabilization			NC	Narrative and X-rays Required with Claim Submission
D7875	Arthroscopy: synovectomy			NC	Narrative and X-rays Required with Claim Submission
D7876	Arthroscopy: discectomy			NC	Narrative and X-rays Required with Claim Submission
D7877	Arthroscopy: debridement			NC	Narrative and X-rays Required with Claim Submission
D7880	Occlusal orthotic device, by report			NC	Narrative Required with Claim Submission
D7910	Suture of recent small wounds up to 5 cm				Narrative Required with Claim Submission
D7911	Complicated suture, up to 5 cm				Narrative Required with Claim Submission
D7912	Complicated suture, greater than 5 cm				Narrative Required with Claim Submission
D7940	Osteoplasty, for orthognathic deformities	1 (D7940) in a lifetime	01	01
D7941	Osteotomy, mandibular rami		01	01
D7943	Osteotomy, mandibular rami with bone graft; includes obtaining the graft	1 of (D7941-D7945) in a lifetime	01	01
D7944	Osteotomy, segmented or subapical	1 of (D7941-D7945) in a lifetime	01	01
D7944	Osteotomy, segmented or subapical		01	01
D7945	Osteotomy, body of mandible		01	01
D7946	LeFort I (maxilla, total)		01	01
D7947	LeFort I (maxilla, segmented)	1 of (D7946-D7949) in a lifetime	01	01
D7948	LeFort II or LeFort III, without bone graft	1 of (D7946-D7949) in a lifetime	01	01
D7948	LeFort II or LeFort III, without bone graft		01	01
D7949	LeFort II or LeFort III, with bone graft		01	01
D7951	Sinus augmentation with bone or bone substitutes via a lateral open approach				Narrative and X-rays Required with Claim Submission
D7953	Bone replacement graft for ridge preservation, per site		01	01
D7955	Repair of maxillofacial soft and/or hard tissue defect	1 (D7955) every 24 months	01	01
D7960	Frenulectomy (frenectomy or frenotomy), separate procedure	3 (D7960) in a lifetime			Narrative Required with Claim Submission
D7970	Excision of hyperplastic tissue, per arch				Narrative Required with Claim Submission
D7971	Excision of pericoronal gingiva				Narrative Required with Claim Submission
D7980	Surgical Sialolithotomy				Narrative Required with Claim Submission
D7981	Excision of salivary gland, by report				Narrative Required with Claim Submission
D7982	Sialodochoplasty				Narrative Required with Claim Submission
D7983	Closure of salivary fistula				Narrative Required with Claim Submission
D7990	Emergency tracheotomy				Narrative Required with Claim Submission
D7991	Coronoidectomy	1 (D7991) in a lifetime			Narrative Required with Claim Submission
D7996	Implant-mandible for augmentation purposes, by report		01	01

NVMA-20180607

Making members shine, one smile at a time™

Nevada Medicaid - Adult

Schedule of Benefits

Coverage, Limitations and Prior Authorization Requirements

Code	Description	Limitations	Prior Auth Req	Prior Auth Req	Documentation/X-Ray Required
			Prior Auth Req	Prior Auth Req
			Adult Population	Pregnant Women
			Adult Population	Pregnant Women
	Oral and Maxillofacial Services (continued)
D7998	Intraoral placement of a fixation device not in conjunction with a fracture				Narrative Required with Claim Submission
	Adjunctive General Services
D9110	Palliative (emergency) treatment, minor procedure	1 (D9110) per day same provider, 2 every 6 months
D9120	Fixed partial denture sectioning	1 (D9120) every 60 months
D9210	Local anesthesia not in conjunction, operative or surgical procedures				Narrative Required with Claim Submission
D9212	Trigeminal division block anesthesia				Narrative Required with Claim Submission
D9215	Local anesthesia in conjunction with operative or surgical procedures				Narrative Required with Claim Submission
D9222	Deep sedation/general anesthesia, first 15 minute increment	5 of (D9222, D9223) per day, not to be completed on same date of service with D9239,
D9222	Deep sedation/general anesthesia, first 15 minute increment	D9243. Anesthesia must show actual beginning and ending times. Anesthesia time begins
					Narrative and X-rays Required with Claim Submission
		when the provider start to physically prepare the recipient for induction of anesthesia in the

D9223	Deep sedation/general anesthesia, each subsequent 15 minute increment	operating area and ends when the provider is no longer in constant attendance ( i.e., when
D9223		the recipient can be safe placed under postoperative supervision)


D9230	Inhalation of nitrous oxide/analgesia, anxiolysis				Narrative Required with Claim Submission
D9239	Intravenous moderate (conscious) sedation/analgesia, first 15 minute increment	5 of (D9239, D9243) per day, not to be completed on same date of service with D9222,
D9239		D9223. Anesthesia must show actual beginning and ending times. Anesthesia time begins
					Narrative and X-rays Required with Claim Submission
		when the provider start to physically prepare the recipient for induction of anesthesia in the

D9243	Intravenous moderate (conscious) sedation/analgesia, each subsequent 15 minute increment	operating area and ends when the provider is no longer in constant attendance ( i.e., when
D9243		the recipient can be safe placed under postoperative supervision)


D9248	Non-intravenous (conscious) sedation, includes non-IV minimal and moderate sedation				Narrative and X-rays Required with Claim Submission
D9310	Consultation, other than requesting dentist
D9311	Consultation with a medical health care professional	1 (D9311) every 6 months			Narrative and X-rays Required with Claim Submission
D9410	House/extended care facility call
D9420	Hospital or ambulatory surgical center call
D9610	Therapeutic parenteral drug, single administration	1 (D9610) every 12 months			Narrative Required with Claim Submission
D9612	Therapeutic parenteral drugs, two or more administrations, different meds.	1 (D9612) every 12 months			Narrative Required with Claim Submission
D9630	Drugs or medicaments dispensed in the office for home use				Narrative Required with Claim Submission
D9930	Treatment of complications, post surgical, unusual, by report	1 (D9930) every 12 months			Narrative Required with Claim Submission
D9991	Dental case management, addressing appointment compliance barriers
D9992	Dental case management, care coordination	1 of (D9991-D9994) every 6 months			Narrative Required with Claim Submission
D9993	Dental case management, motivational interviewing	1 of (D9991-D9994) every 6 months			Narrative Required with Claim Submission
D9993	Dental case management, motivational interviewing
D9994	Dental case management, patient education to improve oral health literacy

NVMA-20180607

Making members shine, one smile at a time™