Medicaid Minnesota policy
Dental Authorization Requirement Tables — Periodontics
Dental Authorization Requirement Tables — Periodontics is a public Medicaid Minnesota policy (effective Mar 12, 2026). It lists 19 CPT or HCPCS codes. Not a coverage decision; the payer's own document governs.
- Payer
- Medicaid Minnesota
- Effective
- Mar 12, 2026
- Line of business
- Medicaid
- States
- MN
- Source
- www.dhs.state.mn.us
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes.
| Code | Other Medicaid Minnesota policies |
|---|---|
| D4240 | Policies naming D4240 |
| D4241 | Policies naming D4241 |
| D4245 | Policies naming D4245 |
| D4249 | Policies naming D4249 |
| D4260 | Policies naming D4260 |
| D4261 | Policies naming D4261 |
| D4263 | Policies naming D4263 |
| D4264 | Policies naming D4264 |
| D4266 | Policies naming D4266 |
| D4267 | Policies naming D4267 |
| D4268 | Policies naming D4268 |
| D4270 | Policies naming D4270 |
| D4273 | Policies naming D4273 |
| D4274 | Policies naming D4274 |
| D4275 | Policies naming D4275 |
| D4276 | Policies naming D4276 |
| D4341 | Policies naming D4341 |
| D4342 | Policies naming D4342 |
| D4381 | Policies naming D4381 |