MedicaidPrior AuthHigh impact
Clarification of Dental Policy for Full Mouth Debridement and Oral Evaluations
Wisconsin Medicaid (ForwardHealth)·WI · Dentistry·Medical Policy
Effective date
Oct 5, 2026
We identified it
Oct 6, 2026
Summary
ForwardHealth clarified dental policy for full mouth debridement (D4355) effective October 5, 2026. Prior authorization is now required when D4355 is provided on the same date of service as specific oral evaluation codes (D0120, D0150, D0160). Coverage is allowed when D4355 is on a different date of service from prophylaxis or scaling codes, with a four-week restriction on other periodontal treatments following debridement.
Action Required
Already effective as of October 5, 2026: Billing and clinical teams must immediately verify current implementation of this policy. Specific actions required: (1) Billing team must update claim submission and prior authorization workflows to require prior authorization for CDT code D4355 when billed on the same date of service as D0120, D0150, or D0160 for BadgerCare Plus and Medicaid patients. (2) Billing team must ensure D4355 is allowed without prior authorization when provided on a different date of service from D1110, D1120, or D4346. (3) Clinical and billing staff must enforce the four-week restriction prohibiting authorization of D4341, D4342, or D4910 within four weeks after D4355 is performed. (4) All providers must retain complete documentation per Wisconsin Admin. Code § DHS 106.02(9) and be prepared to submit records upon DHS request; failure to produce documentation may result in claim denial, recoupment of paid claims, or program termination. (5) Contact managed care organizations (MCOs) to confirm their implementation of these requirements, as MCOs must provide at least the same benefits as fee-for-service arrangements.