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NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA Revised: 4/1/2016 The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines. PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DIAGNOSTIC Clinical Oral Evaluations D0120-D0191 Pre-Diagnostic Services D0190-screening of a patient D0191-assessment of a patient Diagnostic Imaging Documentation in member record that includes all services performed for the code submitted Documentation in member record that includes all services performed for the code submitted. Documentation in the member record. Diagnostic, clear, readable images, dated with member name. Image capture with interpretationD0210-D0371 Criteria for codes D0364-D0368, D0380-D0386, D0391-D0395: Cone beam computed tomography (CBCT) is unproven and not medically necessary for routine dental applications. There is insufficient evidence that CBCT is beneficial for use in routine dental applications. CBCT should not replace traditional dental x-rays as a preliminary diagnostic tool, or for routine dental procedures such as restorations, but be used as an adjunct when the level of detail CBCT is needed to safely render treatment for complex clinical conditions (e.g. oral surgery, implant placement and endodontics). These procedures may have a higher risk of complications without the level of detail CBCT imaging provides. CBCT imaging used for these reasons should be read and interpreted by an appropriately trained professional. Image Capture onlyD0380-D0386 Interpretation and Report onlyD0391-D0395 In addition, radiation exposure associated with CBCT needs to be weighed against possible benefits, which have not been supported in the published literature. Limited definitive conclusions regarding the clinical role of CBCT can be reached due to the lack of well-designed studies that systematically evaluate diagnostic accuracy and the impact of CBCT on clinical decision making and 1 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE patient health outcomes. Additional studies are needed to verify that CBCT provides added diagnostic value beyond two-dimensional imaging such as panoramic radiography and conventional computed tomography and to determine whether CBCT improves treatment decision making and health outcomes. Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP.002.01) Tests and Examinations D0415-D0470 Provider narrative including clinical reason/diagnosis for test and type of test performed. D0601-D0603-caries risk assessment Oral Pathology Laboratory D0472-D0502 D0999-Unspecified diagnostic procedure by report PREVENTIVE Dental Prophylaxis D1110-D1120 Topical Fluoride Treatment D1206-D1208 Services performed must be documented in the member record. Age and medical necessity. An adult is generally defined as twelve years or older. For hypersensitivity and to prevent root caries and recurrent decay around existing restorations. Often for patients who have undergone head/neck radiation therapy. Other Preventive Services D1310-D1330 Sealants D1351-D1352 Documentation/narrative in member record that service was performed and materials supplied to member. Sealant: Tooth numbers. Provider responsible for three years for repair or Preventive Resin Restoration: replacement. No decay or restorations- the occlusal surface must be intact. Sealant cannot be done on the same tooth as a preventive resin. Space Maintenance Radiographs of the involved arch. 2 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE D1510-D1555 For primary dentition only. Should be submitted for primary tooth that has been extracted. All adjustments for 6 months are included. No benefit if permanent tooth is ready to erupt. If bilateral teeth are missing, benefit given for bilateral space maintainer, even if two unilateral space maintainers are requested. RESTORATIVE Direct Restorations: Amalgam Restorations D2140-D2161 Documentation Tooth number and surface. Caries removal documented in member record. Inclusive components: Local anesthesia; tooth prep; liners/bases; restorative material; polishing/sealing; adjustments; tooth etching. Criteria: Primary teeth should not be ready to exfoliate and requests are subject to review based on the age of the patient and the tooth number. Resin-Based Composite Restorations-Direct D2330-D2394 Gold Foil Restorations D2410-D2340 3 PROCEDURE Indirect Restorations: Inlay/Onlay Restorations D2510-D2664 (Inlay/onlays) Crowns-Single Restorations Only D2710-D2799 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Pre-operative x-rays. If endodontic therapy has been performed, a periapical radiographic image clearly showing the apex of the completed treatment is required; otherwise, bitewing x-rays may be sufficient at the discretion of the reviewer. A narrative or photograph may provide additional information, especially for replacement of existing crowns. “Cracked tooth syndrome” requires adequate documentation of extent of fracture, location and how it was diagnosed. Tooth must be symptomatic. Restorations for members under age 15 require statement of medical necessity. Inclusive Local anesthesia; tooth preparation; temporary crown; fitting; cementation; post-op adjustments, impressions; bases. 4 Criteria for codes D2510-D2664, D2710-D2799 Indications for Coverage Five-year longevity should be evident, periodontium must be healthy or have documentation the member has periodontal disease under control for a period of at least 6 months, and no evidence of endodontic pathology or potential endodontic issues on the radiographic image. Coverage includes local anesthetic, impressions, tooth preparation, temporary restoration, fitting, cementation, adjustment and any liners or bases. Crowns Crowns are indicated for the following: Extensive caries on three or more surfaces or 50% loss of clinical crown Large, >50% of the tooth, defective restoration that can be seen on the radiographic image Fracture of cusps Endodontically treated teeth, unless minimal access opening on anterior tooth Documentation that a direct restoration is not possible Crown/root ratio must be favorable Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image 50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and one or more cusps involved Anterior teeth: at least 50% involvement of incisal portion Bicuspids and molars: 3 or more surfaces and one or more cusps involved Symptomatic “cracked tooth syndrome” (not enamel “craze lines”) Full coverage restoration of a primary tooth without a permanent successor Crowns are not indicated for the following: If a lesser means of restoration is acceptable If root resorption is present Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration) For alteration of vertical dimension For purposes of preventing future fracture, or to eliminate enamel craze lines (Cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative. Tooth must be symptomatic). To treat non-pathologic wear/abrasion, or abfraction lesions in the absence of decay For molars exhibiting bone loss with a class III furcation involvement Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable PROCEDURE Other Restorative Services (D2910-D2999) DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Tooth number Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934 Prefabricated Crowns are indicated for the following: For the restoration of teeth with more than two surfaces affected with carious lesions, or where extensive one or two surface lesions are present. For one and two surface carious lesions in documented high caries risk children. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver has active caries; o White spot lesions or enamel defects; o Visible caries or previous restorations; o Poor oral hygiene; o Sub-optimal systemic fluoride intake; o Frequent exposure to cavity-producing foods and drinks; o Patients with special health care needs; o Low socioeconomic status; o Xerostomia; o More than one interproximal lesion; o Other factors identified by professional literature; Cervical decalcification, and/or developmental defects (hypoplasia, hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.). Interproximal caries extending beyond line angles. Following pulpotomy or pulpectomy. For restoring a primary tooth that is to be used as an abutment for a space maintainer. For the intermediate restoration of fractured teeth. Restoration and protection of teeth exhibiting extensive tooth surface loss due to attrition, abrasion or erosion. In patients with impaired oral hygiene in which the breakdown of intracoronal restorations is likely. When the tooth cannot be effectively isolated for amalgam or composite restorations. Porcelain/Ceramic Crown D2929 Stainless Steel Crown D2930, D2931, D2932, D2933, D2934 5 Prefabricated Crowns are not indicated for the following: A primary molar that is close to exfoliation, with more than half the roots resorbed. Excessive tooth crown loss resulting in the inability for mechanical retention. Loss of space due to tipping of neighboring teeth into carious defect interfering with the ability to attain proper fit. As a definitive restoration on a permanent tooth. For low and moderate caries risk patients, when a more conservative restoration is indicated. Solely for cosmetic purposes. As a prophylactic measure for teeth with no evidence of pathology. Refer to clinical policy: Prefabricated Crowns (DCP012.01) PROCEDURE Protective restoration D2940 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Recorded in member chart. Criteria Direct placement of a restorative material to protect tooth and/or tissue form. Used to relieve pain, promote healing, or prevent further deterioration. Covered as a separate procedure only if no other service other than radiographic images and exam were performed on the same tooth on the same day. Not to be used for endodontic access closure, or as a base or liner under a restoration Core buildup D2950 Documentation Bitewing unless tooth has had root canal therapy, then a periapical should be submitted. NOTE: (out of numerical order to keep code by crown procedures) Criteria Evidence of extensive caries or at least three surfaces of the tooth have severe breakdown. Must be necessary for retention of the crown. Not covered when procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation. Vertical height of clinical crown must be adequate to support a prosthetic crown. Evidence of radiographic decay around an existing restoration and removal of the filling is clinically indicated. Pin retention per tooth D2951 Post and Core D2952, D2953, D2954, D2957 Not benefited with post/core. One per lifetime per tooth Documentation in member record Post-op endodontic radiographic image required showing adequate root canal treatment. Criteria Only for retention or reinforcement when inadequate tooth structure remains for retention or to resist masticatory forces. An anterior tooth with minimal access opening may not require a post/core. There must be sufficient tooth structure to support a crown. No periodontal disease and at least 50% bony support. No benefit for post preparation. 6 PROCEDURE Labial Veneer D2960-2962 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Radiographic image and narrative of medical necessity. Intraoral photo helpful. Criteria May be benefited if the destruction is such that a crown is not recommended but a direct restoration will not suffice. Not covered when strictly cosmetic. Coping D2975 Documentation Bitewing or periapical if tooth has had root canal therapy Repairs necessitated by restorative material failure D2980-D2999 Documentation Narrative required, radiographic images if indicated ENDODONTICS Endodontic therapy D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348 Endodontic codes: D3110-D3240 D3310-D3333 D3346-D3348 D3351-D3357 Criteria Only if insufficient natural tooth structure remains to retain the crown or alignment is a problem. Documentation Pre and post-operative radiographic image and provider narrative if pathology is not evident on the film. Criteria for codes D3110-D3240, D3310-D3333, D3346-D3348, D3351-D3357 General documentation requirements Pre and post endodontic periapical radiographic images showing apex of tooth. For retreatment, surgical endodontics, cracked tooth syndrome and other procedures: pre- and post-op images, taken within one year and narrative if the reason for treatment is not evident on films. Criteria for codes D3110-D3240, D3310-D3333, D3346-D3348, D3351-D3357 Diagnosis Diagnostic tests used to determine a diagnosis of irreversible pulpitis or periapical pathology must be documented in the record. Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01) Indications for Coverage – Vital Pulp Therapy Direct Pulp Cap Direct pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis All caries has been removed Mechanical exposure of a clinically vital and asymptomatic pulp occurs Bleeding is controlled at the exposure site Exposure permits the capping material to make direct contact with the vital pulp tissue Exposure occurs when the tooth is under dental dam isolation Adequate seal of the coronal restoration can be maintained Patient has been fully informed that endodontic treatment may be indicated in the future Direct Pulp capping is not indicated for the following: A carious exposure in primary teeth 7 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Indirect Pulp Cap Indirect pulp capping is indicated for the following: Tooth has a vital pulp or been diagnosed with reversible pulpitis Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation No history of subjective pretreatment symptoms Pretreatment radiographs should not show periradicular pathosis Coverage Limitations and Exclusions for Direct and Indirect Pulp Cap Limited to once every 36 months Not to be billed on same day as any definitive restoration Not to be billed when a liner or a base is placed Not to be billed as a liner or base when the likelihood of pulpal exposure is absent Therapeutic Pulpotomy Therapeutic pulpotomy is indicated for the following: Exposed vital pulps or irreversible pulpitis of primary teeth Any bleeding was controlled within several minutes As an emergency procedure in permanent teeth until root canal treatment can be accomplished As an interim procedure for permanent teeth with immature root formation to allow continued root development In primary teeth, where there is a reasonable period of retention expected (approximately one year) Therapeutic pulpotomy is not indicated for the following: Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor As the first stage of complete root canal therapy Removal of pulp apical to the dentinocemental junction For primary teeth that are near exfoliation or less than 50% of the tooth root remains Coverage Limitations and Exclusions for Therapeutic Pulpotomy Not to be billed on same day as root canal therapy Partial Pulpectomy for Apexogenesis A partial pulpotomy for Apexogenesis is indicated for the following: In a young permanent tooth for a carious pulp exposure When the pulpal bleeding is controlled within several minutes A vital tooth, with a diagnosis of normal pulp or reversible pulpitis 8 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Coverage Limitations and Exclusions for Partial Pulpectomy for Apexogenesis Not to be billed on same day as any definitive restoration Not to be billed on same day as a surgical endodontic procedure Apexification/Recalcification Apexification/recalcification is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs. When closure or repair is complete, nonsurgical root canal treatment should be completed: Incomplete apical closure in a permanent tooth root External root resorption or when the possibility of external root resorption exists. Necrotic pulp, irreversible pulpitis or periapical lesion For prevention or arrest of resorption Perforations or root fractures that do not communicate with oral cavity Apexification/recalcification is not indicated for the following: Tooth with a completely closed apex If patient compliance or long term follow up may be questionable Pulpal Regeneration Pulpal regeneration is indicated for the following and involves two or more separate appointments: Permanent tooth with immature apex Necrotic pulp Pulp space not needed for post/core or final restoration When tooth is not restorable Pulpal regeneration is not indicated for the following: Primary teeth The pulp space would be needed for final restoration Indications for Coverage – Non Vital Pulp Therapy Pulpal Debridement (Pulpectomy) Pulpal Debridement (Pulpectomy) is indicated for the following: For a restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified For the relief of acute pain prior to complete root canal therapy For a primary tooth, where there is a reasonable period of retention expected (approximately one year) Pulpal Debridement (Pulpectomy) is not indicated for the following: 9 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Complete root canal therapy of an infected or necrotic tooth For primary teeth that are near exfoliation or less than 50% of the tooth root remains Coverage Limitations and Exclusions for Pulpal Debridement (Pulpectomy) Not to be billed on same day as any definitive restoration Not to be billed on same day as a surgical or non- surgical endodontic procedure Pulpal Therapy (resorbable filling) – Primary Teeth Pulpal Therapy for primary teeth is indicated for the following and includes all appointments need to complete treatment, as well as intra-operative radiographs: For a restorable primary tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified The prognosis for keeping the tooth is up to one year and the tooth root lies in at least 25% bone Pulpal Therapy is not indicated for the following: For primary teeth that are near exfoliation or less than 50% of the tooth root remains For permanent teeth Coverage Limitations and Exclusions for Pulpal Therapy – Primary Teeth Indicated to age 15 Endodontic Therapy Endodontic Therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs: For a restorable mature, completely developed permanent or primary tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure For teeth with radiographic periapical pathology For primary teeth without a permanent successor Trauma When needed for prosthetic rehabilitation Endodontic Therapy is not indicated for the following: Teeth with a poor long term prognosis Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease Teeth with incompletely formed root apices 10 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Coverage Limitations and Exclusions for Endodontic Therapy Not for third molars, unless necessary as bridge abutment with a good prognosis, or if tooth will be in functional occlusion Not covered solely for cosmetic/aesthetic reasons Treatment of root canal obstruction; non-surgical access Treatment of a root canal obstruction is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs: When there is an obstruction of the root canal system, (biological, iatrogenic ledges or post removal) and endodontic retreatment is needed Removal of obstruction is complex and/or requires significant time Treatment of a root canal obstruction is not indicated for the following: When there is no obstruction evident Coverage Limitations and Exclusions for Treatment of root canal obstruction Limited to once per tooth per lifetime Not billable if tooth has a history of incomplete endodontic therapy or internal root repair of perforation defects Incomplete endodontic therapy: inoperable, unrestorable or fractured tooth Incomplete endodontic therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs: During endodontic treatment of a tooth, it becomes apparent that the procedure cannot be successfully completed The tooth will not be able to be restored, or the tooth fractures, necessitating discontinuation of treatment Coverage Limitations and Exclusions for Incomplete endodontic therapy Limited to once per tooth per lifetime Internal root repair of perforation defects Internal root repair of perforation defects is indicated for the following and includes all appointments needed to complete treatment including intraoperative radiographs: There is a root perforation caused by pathology such as resorption or decay A communication between the pulp space and external root surface as a result of internal root resorption. Internal root repair of perforation defects is not indicated for the following: Teeth that are considered non-restorable 11 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Teeth with inadequate bone support or advanced untreated periodontal disease Coverage Limitations and Exclusions for Internal root repair of perforation defects Limited to once per tooth per lifetime Not billable for iatrogenic root perforation Retreatment of previous root canal therapy Retreatment of previous root canal therapy is indicated for the following and includes all appointments needed to complete treatment, including intraoperative radiographs: Canal fill appears to extend to a point shorter than 2millimeters from the apex, or extends significantly beyond the apex Fill appears to be incomplete Tooth is sensitive to pressure and percussion or other subjective symptoms The existing endodontics is poor Placement of a post has the potential to compromise the existing obturation or apical seal of the canal system The canal is accessible and allows for retreatment with a non-surgical procedure Coverage Limitations and Exclusions for Retreatment of previous root canal therapy Original treatment must be at least 8 weeks prior to the retreatment date Not benefited within 12 months of original treatment if by same dentist Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01) 12 PROCEDURE Surgical Endodontics D3410-D3950, D3999 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Pre and postoperative radiograph image. Provider narrative may be requested if pathology is not visible. Criteria for codes D3410-D3950, D3999 Apicoectomy Apicoectomy is indicated for the following: Failed retreatment of endodontic therapy When the apex of tooth cannot be accessed due to calcification or other anomaly Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked over extension of obturating materials interfering with healing Date of last root canal treatment if needed. Apicoectomy is not indicated for the following: Unusual bony or root configurations resulting in lack of surgical access The possible involvement of neurovascular structures Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease When non-surgical endodontic treatment has not been attempted or was not indicated Periradicular Surgery without Apicoectomy (includes surgery and periradicular curettage) Periradicular surgery without apicoectomy is indicated for the following: Failed retreatment of endodontic therapy When the apex of tooth cannot be accessed due to calcification or other anomaly When a biopsy of periradicular tissue is necessary Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist When individual patient considerations make prolonged non-surgical treatment not practical A marked overextension of obturating materials interfering with healing 13 Periradicular surgery without apicoectomy is not indicated for the following: Unusual bony or root configurations resulting in lack of surgical access The possible involvement of neurovascular structures Teeth that are considered non-restorable Teeth with inadequate bone support or advanced or untreated periodontal disease When non-surgical endodontic treatment has not been attempted or was not indicated PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE PERIODONTICS Surgical Periodontics – Resective Procedures D4210 D4211 D4212 D4230 D4231 D4240 D4241 D4245 D4249 D4261 D4274 Documentation/Other for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261 Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Documentation for code D4274 Pre-surgical radiograph images. Grafts: One soft tissue graft per two contiguous teeth. Bone graft and guided tissue regeneration: only one or the other allowed. Evidence of mobility, bruxism and/or hyperocclusion may contraindicate grafting Criteria for codes D4210-D4261, D4274 Gingivectomy/Gingivoplasty Gingivectomy/Gingivoplasty is indicated for the following: Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is fibrous and firm and there is an adequate zone of keratinized tissue; Elimination of gingival enlargements/overgrowth due to medications, medical conditions or tooth position; Elimination of suprabony periodontal abscesses; For exposure of soft tissue impacted teeth to aid in eruption; To reestablish gingival contour following an episode of acute necrotizing ulcerative gingivitis; To allow restorative access, including root surface caries. Gingivectomy/Gingivoplasty is not indicated for the following: When bone surgery is required for infrabony defects, or for the purpose of examining bone shape and morphology; Situations in which the bottom of the pocket is apical to the mucogingival junction; Areas where aesthetics are a concern (particularly in the anterior maxilla); In areas with a shallow palatal vault or prominent external oblique ridge; Severely edematous or inflamed tissue; Patients with poor plaque control or non-compliance with non-surgical procedures; Patients with an uncontrolled underlying medical condition; Solely for cosmetic/aesthetic purposes. Anatomical Crown Exposure Anatomical Crown exposure is indicated for the following: In an otherwise periodontally healthy area to facilitate the restoration of subgingival caries; In an otherwise periodontally healthy area to allow proper contour of restoration; In an otherwise periodontally healthy area to allow management of a fractured tooth in which the fracture extends subgingivally. Anatomical Crown exposure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition. Gingival Flap Procedure 14 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Gingival flap procedure is indicated for the following (includes root planing): The presence of moderate to deep probing depths; Loss of attachment; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful; The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods. Gingival flap procedure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies. Apically Positioned Flap Procedure Apically Positioned Flap Procedure is indicated for the following: The presence of moderate to deep probing depths; Loss of attachment; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful; The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods; To preserve keratinized tissue in conjunction with osseous surgery. Apically Positioned Flap Procedure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies. Clinical Crown Lengthening-Hard Tissue Clinical Crown Lengthening-Hard Tissue is indicated for the following: In an otherwise periodontally healthy area to allow a restorative procedure on a tooth with little to no crown exposure. Clinical Crown Lengthening-Hard Tissue is not indicated for the following: As treatment for periodontal disease; Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition. Osseous Surgery Osseous surgery is indicated for the following: 15 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Patients with a diagnosis of moderate to advanced periodontal disease; For cases of refractory periodontal disease; When less invasive therapy (i.e. non-surgical periodontal therapy, flap procedures) has failed to eliminate disease. Osseous surgery is not indicated for the following: Patients with a diagnosis of mild periodontal disease; For teeth with a hopeless prognosis (more than 80% bone loss and Class 3 or higher mobility); Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies. Distal or Proximal Wedge (when not performed in conjunction with surgical procedures in the same anatomical area) Distal or Proximal Wedge procedure is indicated for the following: The presence of moderate to deep probing depths (greater than 5mm) on a surface adjacent to an edentulous/terminal tooth area; The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful on a surface adjacent to an edentulous/terminal tooth area; The diagnosis of a cracked tooth, fractured root or external root resorption on a surface adjacent to an edentulous/terminal tooth area, when this cannot be accomplished by non-invasive methods. Distal or Proximal Wedge procedure is not indicated for the following: Solely for cosmetic/aesthetic purposes; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies; In areas in which there are teeth with proximal contact. Refer to clinical policy: Surgical Periodontics – Resective Procedures (DCP013.01) Surgical Periodontics – Regenerative Procedures D4263 D4264 D4265 D4266 Documentation Criteria for codes D4263-D4268, D4999 Full radiographic images (panoramic image) with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Bone Replacement Grafts Bone Replacement Grafts are indicated for the following: Infrabony/Intrabony vertical defects; Class II furcation involvements. 16 PROCEDURE D4267 D4268 D4999 Codes D4265, D4266, D4267 and D4999 are each addressed in the Regenerative, Mucogingival and Resective Surgical Periodontics clinical policies. DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Bone Replacement Grafts are not indicated for the following: Class I furcation involvement; Class III or higher furcation involvement; Non-vertical defects; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies; Patients with poor oral hygiene; Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility). Biologic Materials to Aid in Soft and Osseous Tissue Regeneration Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated for the following: Intrabony/Infrabony vertical defects; Class II furcation involvements. Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are not indicated for the following: Class I and Class III or higher furcation involvement; Non-vertical defects; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies; Patients with poor oral hygiene; Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility). Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier (includes membrane removal) Guided Tissue Regeneration is indicated for the following: Intrabony/infrabony vertical defects; Class II furcation involvements. Guided Tissue Regeneration is not indicated for the following: Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility); Class I furcation involvement; Class III or higher furcation involvement; Horizontal bone loss; Non-vertical defects; Patients with an uncontrolled underlying medical condition; Patients who have been non-compliant with previous periodontal therapies; 17 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Patients with poor oral hygiene; Crater defects. Surgical Revision Procedure (per tooth) Surgical Revision Procedure is indicated to correct an abnormal healing response that interferes with the therapeutic goals of the original regenerative surgical procedure. Surgical Revision Procedure is not indicated solely for cosmetic/aesthetic purposes. Surgical Periodontics – Mucogingival Procedures D4270 D4273 D4275 D4276 D4277 D4278 D4283 D4285 Codes D4265, D4266, D4267 and D4999 are each addressed in the Regenerative, Mucogingival and Resective Surgical Periodontics clinical policies. Refer to clinical policy: Surgical Periodontics – Regenerative Procedures (DCP014.01) Criteria for codes D4265-D4267, D4270-D4273, D4275-D4278, D4283, D4285, D4999 Documentation/Other Pedicle soft tissue graft (D4270) is not benefited at the same time with other periodontal surgery. Soft tissue grafts are benefitted once per two contiguous teeth Documentation (see NOTE) Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. NOTE: No radiographs required for the following codes: D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285 18 Pedicle Soft Tissue Graft Procedure Pedicle Soft Tissue Graft Procedure is indicated for the following: Areas with less than 2 mm of attached gingiva; Unresolved sensitivity in areas of recession; Progressive recession or chronic inflammation; For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control; Ridge augmentation; To increase vestibular depth for the correct fit of prosthesis; To widen zone of attached gingiva for prosthetic abutment teeth; To increase vestibular depth to allow proper oral hygiene techniques; Gingival clefting. Pedicle Soft Tissue Graft Procedure is not indicated for the following: Roots covered with thin bony plates; Patients with an untreated medical condition. Autogenous Connective Tissue Graft Autogenous connective tissue graft is indicated for the following: Areas with less than 2 mm of attached gingiva; Unresolved sensitivity in areas of recession; Progressive recession or chronic inflammation; For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control; Ridge augmentation; To increase vestibular depth for the correct fit of prosthesis; To widen zone of attached gingiva for prosthetic abutment teeth; To increase vestibular depth to allow proper oral hygiene techniques; PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Gingival clefting. Autogenous connective tissue graft is not indicated for the following: Broad, shallow palatal donor site; Excessively glandular or fatty submucosal tissue in donor site; A donor site with roots covered with thin bony plates; Patients with an untreated medical condition. Non-Autogenous Connective Tissue Graft Non- autogenous connective tissue graft is indicated for the following: Areas with less than 2 mm of attached gingiva; Unresolved sensitivity in areas of recession; Progressive recession or chronic inflammation; For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control; Ridge augmentation; To increase vestibular depth for the correct fit of prosthesis; To widen zone of attached gingiva for prosthetic abutment teeth; To increase vestibular depth to allow proper oral hygiene techniques; Gingival clefting. Non- autogenous connective tissue graft is not indicated for the following: When indications for connective tissue grafting are not met; Patients with an untreated medical condition. Combined Connective and Double Pedicle Graft Combined Connective and Double Pedicle Graft is indicated for the following: Areas with less than 2 mm of attached gingiva; Unresolved sensitivity in areas of recession; Progressive recession or chronic inflammation; For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control; Ridge augmentation; To increase vestibular depth for the correct fit of prosthesis; To widen zone of attached gingiva for prosthetic abutment teeth; To increase vestibular depth to allow proper oral hygiene techniques; Gingival clefting. Combined Connective and Double Pedicle Graft is not indicated for the following: Roots covered with thin bony plates; Patients with an untreated medical condition. 19 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Free Soft Tissue Graft Procedure (including donor site surgery) Free Soft Tissue Graft Procedure is indicated for the following: Unresolved sensitivity in areas of recession; Progressive recession or chronic inflammation; For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control; To increase vestibular depth for the correct fit of prosthesis; To widen zone of attached gingiva for prosthetic abutment teeth; To increase vestibular depth to allow proper oral hygiene techniques; Gingival clefting. Free Soft Tissue Graft Procedure is not indicated for the following: Broad, shallow palatal donor site; Excessively glandular or fatty submucosal tissue in donor site; A donor site with roots covered with thin bony plates; Patients with an untreated medical condition. Biologic Materials to Aid in Soft and Osseous Tissue Regeneration Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated for the following: To enhance periodontal tissue regeneration and healing for mucogingival defects in conjunction with mucogingival surgeries with or without guided tissue regeneration. Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier (includes membrane removal) Guided Tissue Regeneration is indicated for the following: For sensitivity in areas of recession; Progressive recession or chronic inflammation; Areas of bone dehiscence and fenestration’ Single tooth, wide and deep localized recession; For areas associated with failed cervical restorations. Guided Tissue Regeneration is not indicated for the following: Multiple adjacent tooth sites of root coverage required; Solely for cosmetic/aesthetic purposes. Refer to clinical policy: Surgical Periodontics – Mucogingival Procedures (DCP015.01) 20 PROCEDURE Provisional Splinting D4320, D4321 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Criteria for codes D4320-D4321 Provisional Splinting using these codes is indicated for the following: Multiple teeth that have become mobile due to loss of alveolar bone loss and periodontium; During surgical and healing phases of regenerative periodontal therapy. Provisional Splinting using these codes is not indicated for the following: Tooth transplantation; Trauma resulting in the reimplantation of completely avulsed tooth/teeth; Trauma resulting in displacement or fracture of tooth/teeth. Coverage Limitations and Exclusions for Provisional Splinting Limited to once per 36 months per same tooth/teeth. Not to be billed on same day as any restoration, prostheses or implant for same tooth/teeth. Refer to coverage guideline: Provisional Splinting (DCG011.01) Non-Surgical Periodontal Therapy D4341, D4342, D4381, D4910 Documentation Criteria for codes D4341, D4342, D4381, D4910 Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Scaling and Root Planing Scaling and Root planing is indicated for any of the following: Localized or generalized mild chronic periodontal disease – characterized by 1-2 millimeters of clinical attachment loss (CAL). Localized or generalized moderate chronic periodontal diseasecharacterized by 3-4 millimeters clinical attachment loss (CAL). In molars, furcation involvement not to exceed Class 1. Localized or generalized severe periodontal disease – characterized by more than 5 millimeters of CAL. Chronic refractory mild or moderate periodontal disease – characterized by patients who demonstrate additional attachment loss despite being longitudally monitored with periodontal maintenance. Periodontal abscess characterized by localized swelling and/or increased probing depth and loss of periodontal attachment. Scaling and root planing is not indicated for the following: In the absence of diagnosed periodontal disease. For the removal of heavy deposits of calculus and plaque. Gingivitis defined as inflammation of the gingival tissue without loss of attachment (bone and tissue). As a sole treatment for chronic periodontitis with advanced loss of support demonstrated by pockets greater than 6 millimeters with CAL greater than 4 millimeters, and radiographic bone loss. Mobility may or may not be 21 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE present. As a sole treatment for refractory chronic, aggressive or advanced periodontal diseases. Localized Delivery of Antimicrobial Agents Localized Delivery of Antimicrobial Agents is indicated as an adjunct to scaling and root planing in cases of refractory disease and/or residual probing depths greater than or equal to 5 millimeters with inflammation that are still present following conventional therapies. Localized Delivery of Antimicrobial Agents is unproven and not indicated in the absence of periodontal scaling and root planing (SRP) procedure. Periodontal Maintenance Periodontal Maintenance is indicated for the following: To maintain the results of non-surgical periodontal scaling and root planing therapy and prevent recurrent disease. As an extension of active periodontal therapy at selected intervals. Periodontal Maintenance is not indicated for the following: No history of scaling and root planing (SRP) or surgical procedures. Gingivitis- defined as inflammation of the gingival tissue without loss of attachment (bone and tissue). Gingival Irrigation Per Quadrant Gingival Irrigation per quadrant is unproven. There is limited evidence to support the efficacy of a single episode or multiple in office irrigation appointments. The available studies show the greatest problem with irrigation as an adjunctive therapy is that the antimicrobials are quickly eliminated. Refer to clinical policy: Non-Surgical Periodontal Therapy (DCP.004.01) Full mouth debridement D4355 Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. 22 Criteria for codes D4355 Indications for Coverage Full Mouth Debridement is a covered dental service and indicated when the following criteria have been met: Heavy calculus is present on teeth and usually visible on radiographs. Due to the amount of calculus, plaque and debris, a comprehensive examination and diagnosis is not possible. Coverage Limitations and Exclusions Limited to once every 36 months. Not to be billed on same day as any exam code or non-surgical periodontal therapy code. PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Not to be billed within 12 months of prophylaxis or periodontal maintenance. Not to be used as a therapeutic or preventive procedure such as scaling and root planing or prophylaxis. Refer to coverage guideline: Full Mouth Debridement (DCG.001.01) Unscheduled Dressing Change D4920 Gingival Irrigation- per quadrant D4921 REMOVABLE PROSTHETICS D5110-5899 General documentation requirements Full mouth radiographic images. Tooth numbers for missing teeth to be replaced, and other missing teeth. Date of extractions if indicated. Age of existing prosthesis. Immediate denture: X-rays showing at least one tooth present and severe periodontal disease or caries. Complete dentures D5110-D5140 Criteria Gross caries &/or advanced periodontal disease 23 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Partial dentures D5211-D5281 Criteria Distribution and condition of abutments Periodontal and endodontic status: disease/pathology must be treated before partial dentures will be approved. Crown/root ratio must be favorable Abutment teeth free of decay and have at least 50% bone support Replacement not allowed if current denture may be made serviceable Good five-year prognosis No replacement for loss, or damage. Adjustments, relines, rebases, repairs D5410-D5761 Criteria Relines, rebases inclusive in the first six months after placement. Exception: immediate denture-- one reline or rebase covered in first six months. Repairs and adjustments inclusive in first 12 months. Extensive repair of marginally functional dentures may not be covered. More than three repairs for same problem may not be benefited. Provider must pay for more frequent relines (one per 12 months is covered) if necessitated by a problem with the denture fabrication. 24 PROCEDURE Interim partial dentures D5820-D5821 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Criteria Distribution and condition of abutments Periodontal and endodontic status: disease/pathology must be treated before partial dentures will be approved. Crown/root ratio must be favorable Abutment teeth free of decay and have at least 50% bone support Replacement not allowed if current denture may be made serviceable Good five-year prognosis Radiographic images if indicated. No replacement for loss, or damage. Overdenture D5863, D5864, D5865, D5866 MAXILLOFACIAL PROSTHETICS Maxillofacial Prosthetics D5900-D5999 Documentation Criteria Interim complete denture considered final denture if in place > one year. Criteria Radiographic images if indicated. Follows full and partial denture criteria Documentation Narrative Radiographic images if indicated IMPLANTS D6010-D6013, D6040-D6050, D6104, D6199 Documentation Criteria for codes D6010-D6013, D6040-D6050, D6104, D6199 A dental implant is an artificial tooth root that is placed into the jaw to hold a replacement tooth or bridge. Adequate bone in the jaw is needed to support the implant, and recipients should have healthy gum tissues that are free of periodontal disease. For most plans, implants are not covered, but for those plans that do have coverage, the following identify guidelines for implant placement: The implant site must be osseointegrated prior to loading. Implant must have adequate crown/root ratio. Must not have more than two threads above the alveolar crest. Implant must not be closer than 1-1.5mm to adjacent roots. Same day implant placement at time of extraction considered acceptable. Single implant: periapical acceptable; request full mouth images or panoramic image if needed. More than one implant: full mouth images or panoramic image required. Bone graft at time of implant placement: periapical pre-op radiograph, request full mouth images or panoramic image if needed. 25 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE No direct loading of abutment and/or fixed prosthesis on date of implant placement. Periodontal health of existing dentition must be favorable. Long term prognosis must be favorable. Site is free of acute infection. Factors to consider in treatment planning for implants: Location of tooth/teeth; Bone quality/quantity; Periodontal status; Restorability; Patient cost; Patient age (implants not appropriate for patients under age 15); Patients undergoing strong chemotherapy; Myocardial infarction: within 6 months of an attack; Anticoagulant therapy; Severe neuropsychiatric disease, mental disability, and narcotic drug addicts ; Severe blood diseases; Systemic Risk Factors: o Smoking o Diabetes o Hypertension o Decreased estrogen levels in postmenopausal women o Use of IV bisphosphonates Refer to coverage guideline: Implant Placement (DCG.007.01) D6101-D6103 Documentation Review for medical necessity Pre-op periapical; request full mouth images or panoramic image if needed. Interim abutment D6051 Documentation/Criteria Post of radiograph to confirm interim abutment. Includes placement and removal. Healing cap is not an interim abutment. Loading of interim abutment on the same day as implant placement is acceptable for anterior teeth to allow for an esthetic temporary crown/bridge. FIXED PROSTHETICS 26 PROCEDURE D6205- D6999 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Criteria Radiographic images: full periapical set with bitewings. Panoramic with bitewings and PA of area (not preferable/panoramic needs to be high quality) of involved teeth, as well as contralateral and opposing sites. Inclusive components (where applicable) Tooth preparation, temps, bases, impressions, local anesthesia, all adjustment and occlusal correction. Pontic must be at least 2/3 the size of the tooth being replaced. Abutment considerations Repair: Reviewer may request narrative if needed. Replacement: Reviewer may request narrative if needed. Double abutments are usually not a benefit for most plans. If double abutments are indicated, alternate treatment should be considered. Should be at least 50% bony support with no ligament or apical pathology and with favorable crown/root ratio. Molars that have class III furcation problems or teeth that are significantly periodontally compromised are not covered unless teeth have been documented to have had periodontal evaluation by a specialist stating the teeth are stable and can withstand the stress of a bridge. Span of bridge and angulation of abutments should be considered in terms of suitable number of abutments. Excessive number of abutments relative to the number of teeth being replaced should be reviewed for dental necessity and possible alternate benefit. Dental services and treatments for restoring tooth structure loss from abnormal or excessive wear or attrition, abrasion, abfraction, bruxism, and /or erosion, except when due to normal masticatory function may not covered. Endodontic considerations Endodontic fill is dense, within 2mm of apex and not significantly beyond (as evidenced on post-op film). No new PAP on the radiographic image. Other clinical considerations Teeth are reviewed for crowns if bridge denied as indicated by plan. Diastema closure is not covered if this is the primary purpose for the restoration. Not generally covered to replace long-standing missing teeth in a stable occlusion. Example: teeth missing two (2) years or longer, not currently replaced, and where adjacent and opposing teeth are in full or partial occlusion 27 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE or contact. Cantilever: Not more than one pontic and sufficient abutments for support If dentition shows signs of excessive stress (wear facets), a cantilever may not be appropriate If three or more abutments are needed, consider alternate benefit Resin-bonded attachments are not appropriate Resin bonded retainer No large fillings or untreated periodontal condition. Consider span and number of pontics due to high failure rate as number of pontics increase. Can combine standard full coverage with bonded attachment. D6950 Precision attachment Only covered if abutment is tipped so as to prohibit seating of bridge D6980B Bridge repair Must involve a functional bridge with good long-term prognosis. Procedure necessitated by restorative material failure Full mouth reconstruction Full Mouth Reconstruction (FMR): FMR encompasses the re-establishment of the occlusal profile whereby all or most teeth are restored via laboratory fabricated crowns, onlays and/or fixed bridges. Treatment plans are generally extensive and delivered in phases over an extended period of time. FMR associated with a change in vertical dimension of occlusion, treatment of Temporomandibular Disorder, or cosmetic dentistry, is generally not covered. FMR may be covered to restore teeth damaged by significant decay, fracture or lack of structural integrity, as well as to replace large defective restorations—by application of the same criteria used for the consideration of indirect restorations. Periodontal splinting where teeth do not require crowns: 28 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Not covered by most plans. Remaining teeth and periodontal condition warrant splinting. Prognosis determined by review of progress notes, charting and x-rays. Not for sole purpose of maintaining or stabilizing occlusion. Replacement Narrative supporting open margins fractured solder joint, caries and existence of other missing teeth (for possible alternate benefit). Abutments must be periodontally stable with good five-year prognosis. Anterior bridge: not due to gingival recession or worn facings. Only if existing bridge cannot be made functional. Not covered for porcelain fracture if margins are intact and functional area not involved. Alternate benefit Consider for posterior if two or more missing teeth in arch; three or more teeth missing in one quadrant. Consider for anterior when member has bilaterally missing anterior teeth, advanced periodontal disease and missing teeth in the posterior on the same arch. Must be appropriate to the clinical situation (may not be appropriate for a patient who has undergone extensive perio therapy) Consider abutment teeth for full coverage If inadequate periodontal support for bridge If a tooth was recently extracted and can be added to an existing rpd A bridge on the opposite side has poor prognosis Other Congenitally Missing Teeth: Not covered if pre-existing condition exclusion in plan; otherwise considered the same as any other missing tooth. Covered if retained deciduous teeth have been functioning as permanent teeth and are then extracted. ORAL SURGERY D7111-D7999 Documentation Alternate benefit permitted if submitted code is not supported by documentation. Dated and labeled radiographic images including panoramic image or 29 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE periapicals usually taken within one year and appropriate to document the case. Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Narrative: If reason for extraction is not apparent For bicuspid with no apparent pathology, to determine if orthodontic extractions D7241, full bony impaction with complications D7260, oroantral closure D7270, reimplantation (copy of accident report helpful) D7340, 7350, vestibuloplasty D7953, bone graft for ridge preservation D7970, excision of hyperplastic tissue Cyst removal (D7450, 7451, 7460, 7461): Documentation of special services; size greater than 1.25mm and/or unrelated to tooth removal; operative notes and pathology report. Treatment notes if radiographic information not conclusive. Extractions D7111-D7250 Criteria Inappropriate removal of teeth to construct full dentures is excluded. Patient preference in the absence of clinical indications, is not sufficient Must be pathology involved (non-restorable caries, untreatable periodontal disease, untreatable endodontic disease) Exception to above may be made based on underlying medical condition Extraction of bicuspids may be ortho-related and fall under that benefit Bone graft with extraction is not a benefit unless a significant residual defect is present Inclusive components Sutures, local anesthesia, normal post-op care Third molar removal Classification is based on anatomic position of the tooth, not the technique 30 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE required for its removal. Classification is based on ADA CDT descriptor for the code submitted. See codes for specific guidelines. Extraction includes removal of soft tissue including but not limited to granulomatous, follicular or minor cystic tissue associated with the tooth. No bone graft is allowed unless a significant residual defect remains and is radiographically documented post op. ERUPTED THIRD MOLAR – one that is so positioned that the entire clinical crown in visible PARTIALLY ERUPTED THIRD MOLAR – one that is so positioned that only a portion of the clinical crown is visible UNERUPTED/IMPACTED THIRD MOLAR – one that has not penetrated through bone and/or soft tissue and entered the oral cavity. D7111 Coronal Remnants If near exfoliation (expected within 6 months) and presents with infection. Extraction of erupted tooth or exposed root D7140 Criteria Includes minor smoothing of socket and closure. Exposed Tooth: Bone loss >50% with active or recurrent disease involving vertical defects, furcations, 2+ mobility or other periodontal condition outside the scope of the plan Severe or rampant decay that does not lend itself to restoration with a good prognosis Non-restorable fracture Remaining teeth distributed in such a way to not be suitable abutments for partial denture Exposed Root: The tooth is severely decayed or fractured with no hope of restoration 31 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Surgical Extraction of Erupted Teeth and Retained Roots D7210, D7250 The tooth is a retained, exposed root The tooth is not encased in bone and removal does not require a flap procedure with bone removal Documentation Criteria for codes D7210, D7250 Dated and labeled radiographic images including panoramic image or periapicals usually taken within one year and appropriate to document the case. Surgical Extraction of an Erupted Tooth Surgical extraction of an erupted tooth is indicated for any of the following: No clinical crown is visible in the mouth; There is insufficient remaining clinical crown to allow a non-surgical extraction; The fracture of a tooth or roots during a non-surgical extraction procedure; Erupted teeth with unusual root morphology (dilacerations, cementosis); Erupted teeth with developmental abnormalities that would make nonsurgical extraction unsafe or cause harm; When fused to an adjacent tooth; In the presence of periapical lesions; For maxillary posterior teeth whose roots extend into the maxillary sinus; When severe crowding or ectopic position of the tooth is present; When tooth has been crowned or been treated endodontically; Other conditions as deemed necessary by a licensed dentist. Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Treatment notes if radiographic information not conclusive. Surgical extraction is not proven or indicated for the following: When a conservative non-surgical procedure is possible; When the Indications for Coverage criteria above are not met. Surgical Removal of Residual Tooth Roots 32 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Surgical removal of residual tooth roots is indicated for the following: When tooth roots, or fragments of tooth roots remain in the bone following a previous incomplete tooth extraction; Extreme tooth decay resulting in the destruction of the dentition to the extent that only root tips remain. Refer to coverage guideline: Surgical Extraction of Erupted Teeth and Retained Roots (DCG.005.01) 33 PROCEDURE Surgical Extraction of Impacted Teeth D7220 D7230 D7240 D7241 D7251 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Criteria for codes D7220, D7230, D7240-D7241, D7251 Dated and labeled radiographic images including panoramic image or periapicals usually taken within one year and appropriate to document the case. The prophylactic extraction of impacted third molars that are asymptomatic and disease free remains highly controversial. In the absence of strong clinical evidence to support or refute prophylactic extractions of asymptomatic and disease free third molars, the following coverage rationale has been adopted. Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Narrative: If reason for extraction is not apparent For bicuspid with no apparent pathology, to determine if orthodontic extractions D7241, full bony impaction with complications Cyst removal (D7450, 7451, 7460, 7461): Documentation of special services; size greater than 1.25mm and/or unrelated to tooth removal; operative notes and pathology report. Treatment notes if radiographic information not conclusive. Surgical extraction of soft tissue impacted teeth Surgical extraction of soft tissue impacted teeth is indicated for the following: Extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted; For a tooth/teeth in the line of a jaw fracture or complicating fracture management; As part of comprehensive treatment in orthognathic surgery; Moderate to severe or acute pain, or recurrent episodes that do not respond to conservative treatment (i.e. pain medication or antibiotics); Non restorable caries; Management of, or limiting the progression of periodontal disease; In the case of acute/chronic infection (abscess, cellulitis, pericoronitis); Pulpal exposure; Non restorable pulpal or periapical lesion; Internal resorption; As a prophylactic procedure for an underlying medical or surgical condition (e.g. organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer ); Tumor resection; Ectopic position; For purposes of prosthetic rehabilitation (partial dentures and complete dentures). Surgical extraction of soft tissue impacted teeth is not indicated for the following: For prophylactic reasons other than an underlying medical condition; When a more conservative procedure can be performed; For pain or discomfort related to normal tooth eruption. 34 Surgical extraction of partially bony impacted teeth Surgical extraction of partially bony impacted teeth is indicated for the following: Extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted; Tooth/teeth in the line of a jaw fracture or complicating fracture management; As part of comprehensive treatment in orthognathic surgery; Moderate to severe or acute pain, or recurrent episodes that do not respond to conservative treatment (i.e. pain medication or antibiotics); Non restorable caries; Management of, or limiting the progression of periodontal disease; PROCEDURE Oroantral fistula closure D7260 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Benefitted if the condition cannot be treated by approximating the soft tissue and suturing and requires excision of fistulous tract with closure by advancement flap. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Primary closure of sinus perforation D7261 Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Subsequent to surgical removal of tooth, exposure of sinus requiring repair in absence of fistulous tract. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Tooth reimplantation D7270 Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Recent history of facial trauma. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Performed within 3 hours of accident. Avulsion of tooth. Includes splinting/stabilization. 35 PROCEDURE Surgical exposure of unerupted tooth D7280 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Tooth developing normally and in good position. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Dense, fibrotic tissue appears to prevent eruption. Adequate space to erupt. Part of orthodontic treatment plan. Mobilization of erupted or malpositioned tooth to aid eruption D7282 Supernumeraries and third molars not benefited. Tooth developing normally and in good position. Adequate space to erupt.. Hx. Of 7280 Documentation Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Placement of device to aid eruption of impacted tooth D7283 Documentation Tooth developing normally and in good position. Adequate space to erupt.. Hx. Of 7280 Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Surgical placement of temporary anchorage device D7279, D7293, D7294 Documentation Tooth developing normally and in good position. Adequate space to erupt.. Hx. Of 7280 Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. 36 PROCEDURE Alveoloplasty with extractions D7310, D7311 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Bone requires osteoplasty as preparation for prosthesis beyond that expected during healing. For full quad: at least four contiguous extractions. Alveoloplasty without extractions D7320, D7321 Treatment notes if radiographic information not conclusive or radiographs are not applicable. Can be done up to 6 months post extraction of >4 teeth if indicated. Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Teeth removed sometime in the past. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Vestibuloplasty D7340, D7350 Narrative that current prosthesis is causing irritation, sore spots or inflammatory lesions due to thin or irregular alveolar crest. Needed to remove spicules or exostoses that result in chronic irritation or pathology. Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Sometimes performed for periodontal purposes when an abnormally shallow vestibule threatens the attached gingiva. May be performed to prepare an area for a denture. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Excision of benign lesions D7411, D7412 Removal of benign odontogenic cyst or tumor D7450, D7451 Should be reviewed if on the same date as a soft tissue graft or periodontal surgery. Narrative of procedure Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Cyst is not attached to or removed with tooth. Size, color or consistency indicates need for pathology examination. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Removal of benign non- Documentation Criteria 37 PROCEDURE odontogenic cyst or tumor D7460, D7461 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Presence of hard, attached or freely movable raised or erythematous lesion. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Removal of exostoses or tori D7471, D7472, D7473 Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Impinges on speech or freeway space of tongue. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Frequent sore spots from denture. Prevents adequate extension of denture. Prevents fabrication of denture. Factor in periodontal disease. Not with osseous surgery or alveoloplasty. Incision and drainage D7510, D7520 Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Not usually benefited when at same time as extraction. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Collection and application of autologous blood concentrate product D7921 Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Treatment notes if radiographic information not conclusive or radiographs are not applicable. 38 Must be history of extraction on same day PROCEDURE Sinus augmentation via lateral open approach D7951 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Usually for purposes of placement of an implant. Narrative and radiographic images to document the clinical need. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Sinus augmentation via a vertical approach D7952 Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. Medically necessary Treatment notes if radiographic information not conclusive or radiographs are not applicable. Bone graft for ridge preservation D7953 Frenectomy or frenotomy D7960 Documentation Criteria Dated and labeled radiographic images including panoramic or periapicals usually taken within one year and appropriate to document the case as applicable. The healing process normally repairs the defect following an extraction. In cases such as a large defect after lesion removal, the graft may be allowed. Treatment notes if radiographic information not conclusive or radiographs are not applicable. Implant note: if an implant is a covered procedure, this does not automatically imply approval of a bone graft. Radiographic images and narrative should be reviewed. SEE IMPLANT CRITERIA Documentation If implant is placed at time of bone graft then use code D6104 Criteria/Documentation Narrative if applicable Narrative may be requested from reviewer Frenuloplasty D7963 Apparent cause of diastema. Causing recession. Tissue hinders home care. Pre-prosthetic. 39 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Tongue movement limited. Excision of hyperplastic tissue D7970 Documentation Denture lacerates or irritates frenum and cannot be resolved by denture adjustment. Criteria (see also D4210) Narrative if applicable Severe or gross overgrowth of tissue associated with ill-fitting denture. Tissue not responsive to non-invasive therapy (conditioning, liners). Pre-prosthetic purposes. Hinders fit of existing prosthesis. Tissue hinders home care. Excision of periocoronal gingival D7971 Surgical reduction of fibrous tuberosity D7972 ORTHODONTICS Medically Necessary Orthodontic Treatment D8050-D8090, D8220, D8660D8680, D8690-D8691, D8999 Narrative and radiographic images to document the clinical need Must be in an area of missing teeth where a full or partial denture or pontic will rest. Medically necessary Narrative and radiographic images to document the clinical need Medically Necessary Criteria for codes D8050-D8090, D8220, D8660-D8680, D8690-D8691, D8999 All of the following documentation must be received: Panoramic imaging; Cephalometric imaging; 5-7 intraoral photographs; Other forms as required by the state. Indications for Coverage Orthodontic treatment is a covered dental service and medically necessary when the following criteria have been met: All services must be approved by the plan; and The member is under the age 19 (through age 18, unless the benefit plan document indicates a different age); and Services are related to one of the following conditions: o Cleft lip and/or cleft palate; o Crouzon’s Syndrome; o Treacher-Collins Syndrome; o Pierre-Robin Syndrome o Hemi-facial atrophy; o Hemi-facial hypertrophy o Severe craniofacial deformities that result in a physically handicapping malocclusion; OR o Other clinical criteria based on state specific language. 40 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE All of the following documentation must be received: Panoramic imaging; Cephalometric imaging; 5-7 intraoral photographs; Other forms as required by the state. Coverage Limitations and Exclusions Orthodontic services that do not meet the criteria listed above. Orthodontic services that are specifically excluded. Orthodontic services for crowded dentitions (crooked teeth), excessive spacing between teeth, temporomandibular joint (TMJ) conditions and/or horizontal/vertical discrepancies (overjet/overbite). Refer to coverage guideline: Medically Necessary Orthodontic Treatment (DCG.003.01) ANESTHESIA SERVICES General Anesthesia and Conscious Sedation D9210-D9212, D9215, D9219, D9223, D9230, D9243, D9248 Documentation & Time Recommendations & Nitrous/Extraction Recommendations Criteria for codes D9210-D9212, D9215, D9219, D9223, D9230, D9243, D9248 Provider notes including: duration, type of anesthetic, dosage. Sedation for dentistry is proven to help decrease anxiety, diminish fear and increase tolerance for dental procedures. It is necessary for the safe and comprehensive dental treatment of patients that meet selection criteria. Local anesthesia is not covered in conjunction with operative or surgical procedures. Nerve blocks are not addressed in this coverage guideline; please refer to appropriate medical policy. If restorative/surgical procedures and age do not meet criteria: Narrative documenting medical necessity, including description of underlying medical problem; description of behavior problem and age of patient. Anesthesia time is defined as the period between the beginning of the administration of the agent and the time that the anesthetist is no longer in personal attendance. Local Anesthesia is considered an inclusive component of any dental procedure unless used for pain relief or if pain relief is required to make an accurate diagnosis. General Time Guidelines for IV sedation & General Anesthesia: Regional and trigeminal block anesthesia is not a covered service. 3-4 Teeth D7230, D7240 1.5 hours 1-2 Teeth D7230, D7240 45 min 3-4 Teeth D7210, D7220 1 hour 1-2 Teeth D7210, D7220 45 min Full Mouth Extractions or + Teeth D7111, D7140 1.5 hours 3-6 Teeth D7111, D7140 45 min. 1-3 Teeth D7111, D7140 30 min. Nitrous Oxide: Extraction Coverage Recommendations: 41 Nitrous Oxide Coverage Limitations/Exclusions o Limited to once per day o Excluded when reported on same date of service as IV sedation, nonIV sedation or General Anesthesia o Patient convenience Nitrous Oxide is proven effective for sedation in adults and children for the following: o Ineffective local anesthesia o Anxiety o Special needs patients PROCEDURE DOCUMENTATION o o o o CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE More than one soft tissue impacted tooth D7220 One or more partial or full bony D7230, D7240 More than six simple extractions D7140 Multiple surgical extractions D7210 o Lengthy procedures for special needs patients and children o Behaviorally challenged or uncooperative patients Nitrous Oxide is contraindicated for patients with but not limited to the following: o Severe underlying medical conditions ( e.g., severe chronic obstructive pulmonary diseases, congestive heart failure, sickle cell anemia, acute otitis media, recent tympanic membrane graft, acute severe head injury) o Severe emotional disturbances o Drug related dependencies o Pregnancy – first trimester o Treatment with bleomycin sulfate (injection used in cancer patients) o Methlenetetrahydropfolate reductase deficiency o Vitamin B12 deficiency Intravenous (IV) Sedation Coverage Limitations/Exclusions o Limited to once per day IV sedation is proven and effective for the following: o Anxiety/Fear o Pain Control o Oral Surgery o Medically compromised patients or those with special needs IV sedation is contraindicated for patients with but not limited to the following: o Allergy to IV medications o Certain prescribe pharmaceuticals o In any patient where IV sedation has been considered unsafe Non-IV Sedation Coverage Limitations/Exclusions o Not allowed on same day as general anesthesia Non-IV sedation is proven and effective for the following: o Anxiety o Uncooperative or unmanageable patient Non-IV sedation is contraindicated for patients with but not limited to the following: o Patient or dentist convenience Nerve Blocks are not covered for dental services; please refer to appropriate medical policy for specifics regarding coverage for nerve blocks. General anesthesia 42 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE General anesthesia is proven and effective. The decision to administer should be made on an individual patient basis and should be limited to: o Clinical procedures of extensiveness or complexity or situations that require more than a local anesthetic o At least 2 attempts using office technique and the failure documented o Uncooperative or Unmanageable Patient o Physical, Cognitive or Developmental Disabilities o Significant underlying medical condition o Allergy or sensitivity to local anesthesia o Lengthy restoration procedures for pediatric patients o A child who has resisted all other conventional management procedures General anesthesia is contraindicated for patients with but not limited to the following: o Patients with predisposing medical and/or physical conditions that potentially make general anesthesia unsafe o Cooperative patients with minimal dental needs o Choice of an alternative option for treatment o Language or cultural barriers o Parental objection Refer to coverage guideline: General Anesthesia Conscious Sedation Services (DCG.016.01) ADJUNCTIVE SERVICES Palliative treatment D9110 Criteria Not payable with other services such as extraction, incision/drainage, sedative on same date-of-service, with the exception of x-rays and exam (usually D0140). For immediate relief of pain and not a definitive procedure Bridge sectioning D9120 Consultation D9310 Radiographic image required. Code for both preparing teeth for extraction and for retaining part of fixed prosthesis. Criteria A diagnostic service not by the practitioner providing the specific or on-going treatment. The condition may be out of the scope of practice, requiring second opinion. Professional Visits D9410-D9450 Documentation Narrative from member record. 43 PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Therapeutic parenteral drugs D9610, D9612 Criteria Inclusive when administered through the IV during IV sedation. Other drugs D9630 Covered when administered as a separate IV or intramuscular injection. D9610 Single administration of antibiotics, steroids, anti-inflammatory drugs, or other therapeutic medications. NOT to be used to report administration of sedative, anesthetic or reversal agents. D9612 Multiple administrations of drugs listed for D9610. Only used when two or more drugs are used and no to be reported in addition to code D9610. D9630 Dispensing of oral antibiotics/home fluoride, oral analgesics, not limited to these drugs. Does not include writing of a prescription. Application of Desensitizing Medicament D9910 Desensitizing Resin D9911 Documentation Criteria Narrative with explanation of symptoms. Documentation Typically used for root sensitivity per tooth. Not covered for bases/liners. Criteria Narrative with explanation of symptoms. Adhesive application for root sensitivity per tooth. Not covered for bases/liners/adhesives under restorations. Criteria Behavior management D9920 Appropriate in cases where substantial time and effort is expended in allaying the patient’s fear and apprehension. Narrative required. Criteria Treatment of complication D9930 Occlusal guard D9940 Narrative and/or radiographic images required. Examples: dry socket, extensive hemorrhage. Not for temporomandibular joint treatment. Documentation/Criteria Provider narrative which includes a history of bruxism, grinding, &/or clenching resulting in excessive wear. Should include occlusal analysis and symptoms. Athletic guard D9941 Documentation Narrative 44 Indications: bruxism, grinding, clenching, excessive wear &/or myofascial pain due to bruxing, grinding, clenching, PROCEDURE Repair/Reline of Occlusal Guard D9942 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Documentation Narrative Occlusal analysis D9950 Criteria Not for TMJ treatment. Criteria Occlusal adjustment D9951, D9952 Enamel Microabrasion D9970 Not for TMJ treatment, completed prosthetic appliance or with endodontic therapy. Criteria Documentation Narrative, intraoral photos helpful. Odontoplasty D9971 Bleaching and unspecified report D9972-D9999 Discolored surface enamel from altered mineralization/decalcification. Per visit basis. Criteria Documentation Narrative, intraoral photos helpful. Documentation 1-2 teeth –includes removal of enamel projections. Narrative, intraoral photos, images. 45