Nf Peti Medical Necessity Certification Form

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NF PETI Medical Necessity Certification Form
Dental Services Criteria
Client name_______________________________________
Medicaid State ID Number ___________
Medical Necessity (Shall be completed by the attending physician)
Circle all appropriate items.
Dentures full or partial
1.
Edentulous, loss of teeth or planned removal of teeth.
2.
Denture wearer previously and currently not wearing due to:
A. Client did not have dentures when admitted.
B. Client’s dentures are broken/ lost. Nursing facility shall provide information regarding breakage/loss.
C. Dentures fit poorly.
D. Fit is poor and existing dentures cannot be adapted.
3.
Client desires and has the physical and cognitive ability to wear dentures.
4.
There is no history of or current contraindication to the client’s wearing dentures, (e.g.
poor healing, history of chronic mouth or gum infections, history of poor tolerance to
dentures).
Dental and Preventative Care
1.
Treatment is requested for:
A. Caries
B. Abscesses
C. Need for repair of teeth
D. Periodontal (gum) concerns
E. Other, be specific________________________________________________________
2.
Input received from primary care physician noting contraindications and/or the need for
prophylactic antibiotics.
Surgical procedures, crowns, fixed bridges or other dental procedures besides routine
dental hygiene.
1.
Surgery necessary to prepare mouth for dentures. Client shall meet criteria in Sections 3
and 4 above.
2.
Extractions.
3.
Other dental procedures requested through NF PETI shall contain adequate
documentation of medical necessity. Tooth numbers shall be provided with each request.
Facility Instructions
1.
Prescriptions for dentures (partial or full, fixed or removable) or dental care shall be
provided by a licensed dentist (Doctor of Dental Surgery, Doctor of Medical Dentistry).
2.
Purchase of new dentures, full or partial, to replace existing dentures shall include
documentation of the reason the existing dentures require replacement.
3.
For any procedure listed as a potential Adult Dental Medicaid benefit, a claim shall be
submitted to Medicaid and denied before that procedure can be submitted to NF PETI.
Revised August 2005

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