Download Advantica / Care1st Clinical and Billing Guidelines

Advantica / Care1st Clinical and Billing Guidelines:
AHCCCS & DDD Members Under 21
DDD Members Over 21 $1000 Dental Benefit
CDT
Code
Definition
Clinical & Billing Guidelines
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DDD Adult Members Aged 21 and Older
Effective 10/1/16 DDD Adult Members 21 and > have a $1,000 dental benefit.
1. Coverage is based on the contract year 10/1 - 9/30
2. Coverage is member specific and remains with the member if he or she transfers between health plans or between fee for service and managed care.
3. Unused benefits don’t roll over to the next year
4. Frequency limitations and services that require prior authorization still apply
5. Members can be billed for any covered services that exceed the $1000/yr. limit as long as they are notified by the provider ahead of time and agree to pay for
such services in writing.
a. The provider must supply the member a document describing the services and the cost of the services.
b. Prior to the service delivery the member must sign and date a document indicating he/she will be responsible for the cost of the services to the extent that it
exceeds the $1000 limit.
c. This includes Tribal members.
6. Dentures and general anesthesia are covered and count towards the $1000 limit
7. Once DDD Adult $1000 limit is reached, coverage is limited to benefits listed on "Advantica/Care1st Clinical and Billing Guidelines for AHCCCS & DDD Members >21"
Prior Authorization is always required for:
1. Treatment plans exceeding $1,000 in allowable charges; EXCLUDES DDD Adult Members 21 and Older
2. Treatment plans requiring hospitalization
3. All By-Report codes regardless of the Place of Service
4. All Non-Emergent Services provided by a Non-Par provider or facility except when Care1st is secondary
DIAGNOSTIC
• Prior Authorization is required for a General Dentists treating patients under age 5, except for exams, x-rays, prophy, and fluoride treatment.
Clinical Oral Evaluations
D0120
Periodic oral evaluation - established patient - To determine changes in
dental & medical health status since previous comprehensive or periodic
evaluation. Includes oral cancer evaluation and periodontal screening
where indicated. May require interpretation of information acquired
through additional diagnostic procedures (report separately).
D0140
Limited oral evaluation - problem focused - Limited to specific oral health Not appropriate when provided same day as preventive
problem or complaint. May require interpretation of information acquired services or D1550, D2920, D9430, D9440, D9110 or D5400through additional diagnostic procedures (report separately). Typically,
D5700.
patient presents with specific problem, dental emergency, trauma, acute
infection, etc.
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Not appropriate if Comprehensive Exam was performed less N/A
than 6 months before.
Not appropriate when provided same day as D0140, D0145,
D1550, D0160, D0180, D2920, D9430, D9440, D9110, D9930
or D5400-D5700.
N/A
N/A
N/A
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CDT
Code
Definition
Clinical & Billing Guidelines
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D0145
Oral evaluation for patient under 3 yrs old & counseling w/ primary
caregiver - Performed preferably within 6 months of eruption of first
primary tooth; includes recording oral & physical health history, evaluation
of caries susceptibility, development of preventive oral health regimen &
communication/counseling with child’s parent, legal guardian and/or
primary caregiver.
Comprehensive oral evaluation - new or established patient
Thorough evaluation & recording of extra oral & intraoral hard & soft
tissues. May require interpretation of information acquired through
additional diagnostic procedures (report separately). Includes evaluation
for oral cancer where indicated, evaluation & recording of patient’s dental
& medical history & general health assessment. May include evaluation &
recording of dental caries, missing or unerupted teeth, restorations,
existing prostheses, occlusal relationships, periodontal conditions
(including periodontal screening and/or charting) hard & soft tissue
anomalies, etc.
Under age 3.
N/A
N/A
D0150
D0160
D0171
*D0180
Detailed & extensive oral evaluation - problem focused, by report Extensive diagnostic & cognitive modalities based on findings of
comprehensive oral evaluation (Condition should be described &
documented). Examples may include dentofacial anomalies, complicated
perio-prosthetic conditions, complex temporomandibular dysfunction,
facial pain of unknown origin, conditions requiring multi-disciplinary
consultation, etc.
Re- evaluation- post-operative office visit
Comprehensive periodontal evaluation - new or established patient - For
patients showing signs or symptoms of periodontal disease. Includes
evaluation of periodontal conditions, probing & charting, evaluation &
recording of dental & medical history & general health assessment. May
include evaluation & recording of dental caries, missing or unerupted
teeth, restorations, occlusal relationships & oral cancer evaluation.
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
1 per dentist per lifetime, except by report.
N/A
1 per 6 months except when performed by Pediatric Dentist
within 6 months of a general dentist eval.
Not appropriate when provided same day as D9430, D9440,
D9110, D9930 or D5400-D5700.
By Report Only.
Clinically appropriate if performed by a Periodontist.
Narrative, if
applicable.
N/A
Narrative
N/A
Narrative
Narrative
N/A
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CDT
Definition
Code
Radiographs / Diagnostic Imaging (Including Interpretation)
Clinical & Billing Guidelines
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• Advantica follows guidelines issued by the American Dental Association and the American Academy of Pediatric Dentistry regarding frequency and necessity for
radiographs.
• Radiographs should be taken only for legitimate clinical reasons as described in the ADA guidelines.
• Radiographs should be of diagnostic quality, properly identified, mounted and dated.
• All radiographs should be part of the patient's clinical record and should be retained by the dentist.
• Any six (6) or more x-rays (including bitewings) that are taken on the same day or a Panoramic x-ray, D0272 and D0274, performed on the same day will be considered
a full mouth series x-ray D0210 which is limited to 1 per 36 months.
• When multiple x-rays are performed on the same date of service where the allowable amount exceeds the dollars allowed for a full mouth survey (D0210), the services
will be combined to the most comprehensive procedure code D0210 (full mouth series) for benefit determination purposes.
• Reimbursement for individual periapical radiographs will generally be confined to emergency situations and limited to one or two films per emergency visit. If more
than two films are taken, the provider must include a narrative with an explanation.
• If a claim is submitted for full mouth radiographs (ADA code D0210) or when a claim is submitted for bitewings and a panoramic film, additional payment will not be
made for other periapical films taken on the same date.
• When radiographs are medically contraindicated, chart documentation shall include a statement of the contraindication. Examples of contraindication are:
- The first trimester of pregnancy
- Recent exposure to therapeutic radiation of the head and neck area.
- Patient is uncooperative due to age or behavioral conditions that may necessitate general anesthesia
D0210
Intraoral - complete series (including bitewings)
Age 6 & over.
N/A
N/A
D0220
Intraoral - periapical first film
Maximum 2 per visit with bitewings; 4 per visit without
N/A
N/A
D0230
Intraoral - periapical each additional film
bitewings.
D0240
Intraoral - occlusal film
2 per 12 months, except by report
N/A
Narrative, if
For upper or lower anterior teeth.
applicable.
D0250
Extraoral - Extra-oral- 2D projection radiographic image
1 per 12 months, except by report.
N/A
Narrative, if
applicable.
D0251
Extra-oral posterior dental radiographic image
By report only.
N/A
Narrative, if
applicable.
D0270
Bitewing - single film
Age 2 & over
N/A
N/A
D0272
Bitewings - two films
D0273
D0274
*D0277
Bitewings - three films
Bitewings - four films
Vertical bitewings - 7 to 8 films
*D0290
*D0310
*D0320
*D0321
Posterior-anterior or lateral skull & facial bone survey film
Sialography
Temporomandibular joint arthrogram, including injection
Other temporomandibular joint films, by report
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
1 per 6 months, except by report.
Age 2 & over
Age 10 & over
N/A
N/A
Clinically appropriate if performed by a Periodontist, referral Narrative
required.
Clinically appropriate if performed by an Oral Surgeon.
Narrative
Narrative, if
applicable.
N/A
N/A
N/A
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CDT
Code
Definition
Clinical & Billing Guidelines
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D0330
Panoramic film
Oral Surgeons - 1 per 12 months, except by report.
Narrative
N/A
Clinically appropriate if performed by an Oral Surgeon.
Narrative
N/A
Other providers - 1 per 36 months, except by report.
Ages 5 & over.
*D0340
2D Cephalometric radiographic image, by report
*D0350
Oral/facial photographic images obtained intraorally or extraorally
Clinically appropriate if performed by an Oral Surgeon.
Narrative
N/A
*D0367
Cone beam CT capture and interpretation with filed of view of both jaws;
with or without cranium
Treatment simulation using 3D image volume
By report only.
Narrative
N/A
Clinically appropriate if performed by an Oral Surgeon.
Narrative
N/A
When needed for diagnostic purposes for difficult treatment Narrative
plans.
Clinically appropriate if performed by a Periodontist or Oral Narrative
Surgeon.
Narrative
N/A
*D0393
Tests & Examinations
*D0470
Diagnostic casts, by report
*D0502
Other oral pathology procedures, by report
*D0999
Unspecified diagnostic procedure, by report
N/A
N/A
PREVENTIVE
Dental Prophylaxis
D1110
Prophylaxis - adult (in permanent or transitional dentition) Scaling &
polishing; complete removal of coronal plaque, calculus & stains.
Objective: soft tissue can be maintained in good health by patient.
Age 14 & over.
Generally used for patients in permanent dentition.
N/A
N/A
*D1120
Prophylaxis - child (in primary or transitional dentition) Scaling &
polishing; complete removal of coronal plaque, calculus & stains.
Objective: soft tissue can be maintained in good health by patient.
Under age 14.
Prior Auth only required for patients under 12 months old.
Narrative, if
under 12
months old.
N/A
Topical Fluoride Treatment (Office Procedure)
D1206
Topical Fluoride Varnish; Therapeutic application for moderate to high
caries risk patients.
Except for children under age 3, clinically appropriate with a N/A
prophylaxis only.
N/A
D1208
Topical application of fluoride. Fluoride must be applied separately from
phrophylaxis paste.
Except for children under age 3, clinically appropriate with a N/A
prophylaxis only.
N/A
1 per 36 months, except by report.
Appropriate for ages 5 through 15 and for teeth
# 2, 3, 14, 15, 18, 19, 30 & 31.
If tooth requires restoration within 6 months after sealant
placement, restoration fee will be reduced by amount paid
for sealant.
Narrative, if
applicable.
Other Preventive Services
D1351
Sealant - per tooth - Designed for prevention of pit & fissure caries in
teeth that are free of decay and restorations for permanent 1st & 2nd
molars.
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
N/A
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CDT
Code
Definition
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D1352
Preventive resin restoration in moderate to high caries risk patient permanent tooth - Restoration of active cavitated lesion in pit or fissure
not extending into dentin. Includes sealant placement in radiating noncarious fissures or pits.
1 per 36 months, except by report
Appropriate for ages 5 through 15 and for teeth
#2, 3, 14, 15, 18, 19, 30 & 31.
If lesion extends into dentin, use code D2391.
N/A
Narrative, if
applicable.
D1353
Sealant Repair- per tooth
N/A
Narrative, if
applicable.
D1354
Interim caries arresting medicament application
1 per 36 months, except by report
Appropriate for ages 5 through 15 and for teeth
#2, 3, 14, 15, 18, 19, 30 and 31.
If lesion extends into dentin, use code D2391.
By report only.
N/A
Narrative
Space Maintainers (Passive Appliances)
• Space maintainers are a benefit with prior authorization for ages under 15 when there is adequate space to allow eruption of a succedaneous permanent tooth,
provided:
- the permanent tooth has not been extracted,
- is not congenitally missing, and
- its normal eruption space is adequate.
• Space maintainers are not a benefit for:
- maxillary or mandibular anterior region,
- first primary molars if the first permanent molars have erupted into occlusion, or
- missing permanent teeth.
*D1510 Space maintainer - fixed unilateral
1 per lifetime, except by report.
Recent x-ray
Under age 15.
Not appropriate for 1st primary molar if 1st permanent
*D1515 Space maintainer - fixed bilateral
molar has erupted into occlusion for patients over age 6.
*D1520 Space maintainer - removable unilateral
Not appropriate for primary teeth C-H nor M-R.
*D1525 Space maintainer - removable bilateral
D1550
Re-cementation of space maintainer
*D1555
Removal of fixed space maintainer - Not by dentist who originally placed
appliance
Unspecified preventive procedure, by report
*D1999
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
1 per lifetime, except by report.
Under age 15.
May not include an office visit charge.
1 per lifetime, except by report.
Narrative, if
applicable.
N/A
Narrative, if
applicable.
Recent x-ray &
Narrative
Narrative
Narrative, if
applicable.
N/A
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CDT
Code
Definition
Clinical & Billing Guidelines
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RESTORATIVE
• General Dentists treating patients under the age of 4 must obtain prior auth before performing all restorative services. When General Anesthesia is necessary,
restorative treatment must be completed by a Pediatric Dentist
• Note definitions of restorations in the current ADA, CDT book.
• All restored surfaces on a single tooth are considered connected when performed on the same date. Payment is made for a particular surface on a single tooth only
once in each course of treatment, regardless of the number or combinations of restorations placed.
• The total fee includes tooth and soft tissue preparation, cement bases, pulp capping, occlusal adjustment and local anesthesia.
• The dental office is responsible for any replacements necessary within the first 24 months for permanent teeth and 12 months for primary teeth. If a tooth requires
additional treatment due to decay within 24 months of original treatment, the original replacement fee is subtracted from the new fee. For example, if patient had a
DO composite placed 8 months prior to placement of a stainless steel crown, the fee for the crown is reduced by the amount the plan paid for the filling. This applies
to the same dentist and/or office.
• Restorations of primary lower incisors are not a benefit for age 5 & over.
• Resin based composite restorations refers to a broad category of materials that may be chemical cured composite, light cured composite, bonded composite, etc.
• Restorations for posterior teeth are used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Restorations placed with cavity
preparations that do not extend beyond the D-E junction should be billed as Sealants using code D1351.
Amalgam Restorations (Including Polishing)
D2140
D2150
D2160
D2161
Amalgam - one surface, primary or permanent
Amalgam - two surfaces, primary or permanent
Amalgam - three surfaces, primary or permanent
Amalgam - four or more surfaces, primary or permanent
1 per 12 months for primary, except by report.
1 per 24 months for permanent, except by report.
Not appropriate if performed within 12 months of D2950
(core build up).
N/A
Narrative, if
applicable.
1 per 12 months for primary, except by report.
1 per 24 months for permanent, except by report.
Not appropriate if performed within 12 months of D2950
(core build up).
N/A
Narrative, if
applicable.
1 per 12 months for primary, except by report
1 per 24 months for permanent, except by report
X-ray
N/A
Resin-based Composite Restoration - Direct
D2330
D2331
D2332
Resin-based composite - one surface, anterior
Resin-based composite - two surfaces, anterior
Resin-based composite - three surfaces, anterior
D2335
Resin-based composite - four or more surfaces or involving incisal angle,
anterior
*D2390
Resin-based composite crown, anterior
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
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CDT
Code
Definition
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D2391
Resin-based composite - one surface, posterior
N/A
D2392
D2393
Resin-based composite - two surfaces, posterior
Resin-based composite - three surfaces, posterior
Narrative, if
applicable.
D2394
Resin-based composite - four or more surfaces, posterior
1 per 12 months for primary, except by report.
1 per 24 months for permanent, except by report.
Not appropriate if performed within 12 months of D2950
(core build up).
Crowns - Single Restorations
Crowns are a benefit for permanent teeth if necessary based on the criteria below:
• The overall condition of mouth, patient attitude, oral health status, arch integrity, and prognosis of remaining teeth is considered. The tooth and remaining teeth must
generally not be involved with moderate or extensive periodontal disease. If patient exhibits poor oral hygiene and shows no improvement in hygiene over a period of
time, cast crowns are not a benefit.
• Cast metal laboratory processed crowns are not approved for patients under 18 or on teeth that have not been endodontically treated. For these patients, coverage
will be for stainless steel D2931 (posterior teeth) or resin based composite crowns D2390 (primary anterior teeth) when the criteria for coverage are met.
• Laboratory fabricated crowns are a benefit for age 18 & up if necessary for functional permanent endodontically treated teeth with the exception of 3rd molars.
• All crowns including stainless steel crowns on permanent teeth and crowns on primary anterior teeth (C through H and M through R) must be preauthorized by
rendering dentist. A pre-operative x-ray must accompany the request. Additional x-rays may be required to evaluate integrity of the arch for some patients due to age.
If x-rays are not of diagnostic quality they will be returned and the prior authorization denied. If x-rays are unobtainable because of the age of child or behavior, the
claim can be retro-reviewed.
• Stainless steel crowns are covered when justified.
• Esthetic coated crowns or prefabricated resin crowns can be used on primary anterior teeth and prefabricated resin crowns on permanent teeth.
• The dentist is responsible for any replacements necessary within the first 12 months for primary teeth and within the first 24 months for permanent teeth following
stainless steel crown placement.
• Services or items furnished solely for cosmetic purposes are excluded from coverage.
• For age 18 & over, crowns will only be placed on endodontically treated teeth with opposing teeth.
*D2740
*D2750
Crown - porcelain/ceramic substrate
Crown - porcelain fused to high noble metal
*D2751
*D2752
*D2780
*D2782
*D2783
*D2790
*D2791
*D2792
*D2794
Crown - porcelain fused to predominately base metal
Crown - porcelain fused to noble metal
Crown- 3/4 cast high noble metal
Crown- 3/4 cast noble metal
Crown- 3/4 porcelain/ ceramic
Crown - full cast high noble metal
Crown - full cast predominately base metal
Crown - full cast noble metal
Crown - Titanium
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
1 per 7 years, except by report.
X-ray showing Narrative, if
Age 18 & over.
completed root applicable.
Covered only for endodontically treated teeth with opposing canal
teeth. Patient must have good oral hygiene. Tooth must not
be involved in periodontal disease.
1 per 7 years, except by report. Age 18 & over.
X-ray showing Narrative, if
Covered only for endodontically treated teeth with opposing completed root applicable.
teeth. Patient must have good oral hygiene. Tooth must not canal
be involved in periodontal disease.
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CDT
Code
Definition
Clinical & Billing Guidelines
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*D2799
Provisional crown- further treatment or completion of diagnosis
1 per 7 years, except by report. Age 18 & over.
X-ray showing Narrative, if
Covered only for endodontically treated teeth with opposing completed root applicable.
teeth. Patient must have good oral hygiene. Tooth must not canal
be involved in periodontal disease.
Other Restorative Services
D2910
D2915
D2920
Recement inlay, onlay, or partial coverage restoration
Recement cast or prefabricated post & core
Recement crown
*D2921
Reattachment of tooth fragment, incisal edge or cusp
*D2929
D2930
Prefabricated porcelain/ceramic crown-primary tooth
Prefabricated stainless steel crown - primary tooth
*D2931
Prefabricated stainless steel crown - permanent tooth
*D2932
Prefabricated resin crown - anterior, primary or permanent
*D2933
Prefabricated stainless steel crown with resin window
*D2934
Prefabricated esthetic coated stainless steel crown - primary tooth,
anterior only
Protective restoration - Temporary restoration placed to relieve pain. Not Not appropriate with a pulpotomy or on the same day as
to be used as base or liner under restoration.
permanent restoration.
Interim therapeutic restoration- primary dentition
Not appropriate with pulpotomy or on the same day as
permanent restoration.
D2940
D2941
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Age 18 & over
1 per 6 months, except by report.
Appropriate after crown has been in place for 6 months.
Not appropriate for primary anterior incisors.
1 per 24 months for permanent teeth, except by report
1 per 12 months, except by report.
1 per 12 months, except by report.
N/A
N/A
N/A
N/A
N/A
Narrative, if
applicable.
X-ray
Narrative, if
applicable.
N/A
Narrative, if
applicable.
Narrative, if
applicable.
X-ray
N/A
1 per 24 months, except by report.
X-ray
Age 6 & over.
Dentist is responsible for first 24 months for ages 6 through
20.
1 per 12 months for primary, except by report.
X-ray
1 per 24 months for permanent, except by report.
Dentist is responsible for first 12 months.
Appropriate for primary anterior teeth C-H and M-R only
and permanent anterior teeth.
Narrative, if
applicable.
N/A
N/A
N/A
Narrative
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Code
Definition
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*D2950
Core buildup, including any pins when required
1 per lifetime per provider, except by report.
X-ray showing Narrative, if
Not appropriate on primary teeth.
completed root applicable.
Must be endodontically treated and have interproximal
canal
decay or loss of tooth structure.
Multiple surface composite restorations cannot be billed in
addition to this procedure except by report.
Amalgam & composite fillings are not appropriate within 12
months for any teeth that have had a core build up.
*D2951
*D2952
*D2954
Pin retention - per tooth, in addition to restoration
Post & core in addition to crown, indirectly fabricated
Prefabricated post & core in addition to crown - Core is built around
*D2999
Unspecified restorative procedure, by report
Permanent teeth only.
Must be endodontically treated and have interproximal
decay or loss of tooth structure.
Dental Consultant will determine if clinically necessary
based on Prior Auth with X-ray.
X-ray showing N/A
completed root
canal
X-ray &
N/A
Narrative
VENEERS
• Veneers are not a covered benefit.
ENDODONTICS
• All referrals to an Endodontist must be submitted for prior approval and include a periapical x-ray and either a bitewing or panoramic film.
• On Endo referrals for molar teeth with interproximal breakdown, the referring dentist must place an age appropriate crown after the referred endodontic procedure is
complete. Cases without interproximal breakdown must be restored with the appropriate filling material.
• Endodontic treatment includes root canal on permanent teeth and pulpotomies on primary and permanent teeth. Root canal therapy is covered if tooth is non-vital or
pulp has been compromised by dental caries or trauma. In addition, the following criteria must be met:
> Dentist agrees to restore the tooth after the endodontic treatment is completed.
> The overall condition of the mouth, patient attitude, oral health status, arch integrity, and prognosis of remaining teeth must be considered. The tooth and
remaining teeth must generally not be involved with moderate or extensive periodontal disease. If patient exhibits poor oral hygiene and shows no improvement
in hygiene over a period of time, root canals are not a benefit.
> Root canal therapy for permanent anterior teeth is medically necessary and covered when:
- final restoration of the treated tooth allows acceptable longevity, and
- missing teeth do not jeopardize the integrity or masticatory function of the dental arch.
> Root canal therapy for permanent posterior teeth is covered when:
- post treatment restoration of treated tooth allows acceptable longevity,
- missing teeth do not jeopardize the integrity or masticatory function of the dental arch,
- tooth is opposed by a natural or artificial tooth, and
- tooth is necessary to maintain adequate masticatory function.
Pulp Capping
D3110
D3120
Pulp cap - direct
Pulp cap - indirect
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Included in fee allowed for the restoration.
N/A
N/A
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CDT
Definition
Code
Pulpotomy
Clinical & Billing Guidelines
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D3220
Therapeutic pulpotomy (excludes final restoration) - removal of pulp
coronal to the dentinocemental junction and application of medicament.
1 per lifetime, except by report.
N/A
Pulpotomy, pulpal debridement & root canal are not
appropriate on the same permanent tooth when performed
within a 12-month period by the same provider.
Pre & post
operative xrays.Narrative if
applicable.
*D3221
Pulpal debridement, primary & permanent teeth
1 per lifetime, except by report.
Pulpotomy, pulpal debridement & root canal are not
appropriate on the same permanent tooth when performed
within a 12-month period by the same provider.
Pre-op x-ray &
bitewing or
pano showing
integrity of the
arch
Pre & post
operative x-rays
if not submitted
with prior auth.
Narrative if
applicable.
*D3222
Partial pulpotomy for apexogenesis - permanent tooth with incomplete
root development
Ages 5 & over.
Pulpotomy, pulpal debridement & root canal are not
appropriate on the same permanent tooth when performed
within a 12-month period by the same provider.
Pre-op x-ray &
bitewing or
pano showing
integrity of the
arch
Pre & post
operative
x-rays, if not
submitted with
prior
auth.Narrative if
applicable.
Pre & post
operative
x-rays, if not
submitted with
prior
auth.Narrative if
applicable.
Pre & post
operative
x-rays, if not
submitted with
prior
auth.Narrative if
applicable.
Endodontic Therapy on Primary Teeth
*D3230
Pulpal therapy (resorbable filling) - anterior, primary tooth (excludes final
restoration) - on primary incisors & cuspids.
1 per 12 months per provider, except by report.
Under age 13.
X-ray
*D3240
Pulpal therapy (resorbable filling) - posterior, primary tooth (excludes final 1 per 12 months per provider except by report.
restoration) - on primary 1st & 2nd molars.
Under age 15.
X-ray
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
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Page 10 of 27
10/01/2016mf
CDT
Definition
Clinical & Billing Guidelines
Code
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-up Care)
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Prior Auth
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*D3310
Endodontic therapy, anterior (excludes final restoration) Includes
intraoperative films.
*D3320
Endodontic therapy, bicuspid (excludes final restoration) Includes
intraoperative films.
*D3330
Endodontic therapy, molar (excludes final restoration) Includes
intraoperative films.
1 per lifetime, except by report.
Patient must have good oral hygiene.
Tooth must not be involved with periodontal disease.
Dentist must agree to restore tooth once treatment is
completed.
Not appropriate for 3rd molars unless functioning in place of
missing molar.
Pre-op x-ray & a
bitewing or
pano showing
integrity of the
arch
Pre & post
operative x-rays
if not submitted
with prior auth.
Narrative, if
applicable.
*D3331
Non-surgical treatment of root canal obstruction
By report only.
X-ray &
Narrative
N/A
*D3332
Incomplete endodontic therapy; inoperable, unrestorable or fractured
tooth.
By report only.
X-ray &
Narrative
N/A
*D3333
Internal root repair of perforation defects
By report only.
X-ray &
Narrative
N/A
1 per lifetime, except by report.
Clinically appropriate if performed by an Endodontst or Oral
Surgeon.
Patient must have good oral hygiene.
Tooth must not be involved with periodontal disease.
Refer patient back to General DDS for restoration.
Pre-op x-ray & a
bitewing or
pano showing
integrity of the
arch
Pre & post
operative x-rays
if not submitted
with prior auth.
Narrative, if
applicable.
1 per lifetime, except by report.
Clinically appropriate if performed by an Endodontst or Oral
Surgeon.
Patient must have good oral hygiene.
Tooth must not be involved with periodontal disease.
Refer patient back to General DDS for restoration.
Pre-op x-ray & a
bitewing or
pano showing
integrity of the
arch
Pre & post
operative x-rays,
if not submitted
with prior auth.
Narrative, if
applicable.
1 per lifetime, except by report.
Clinically appropriate if performed by an Endodontist or Oral
Surgeon.
Patient must have good oral hygiene.
Tooth must not be involved with periodontal disease.
Refer patient back to General DDS for restoration.
Pre-op x-ray & a
bitewing or
pano showing
integrity of the
arch
Pre & post
operative x-rays,
if not submitted
with prior auth.
Narrative, if
applicable.
Endodontic Retreatment
*D3346
Retreatment of previous root canal therapy - anterior
*D3347
Retreatment of previous root canal therapy - bicuspid
*D3348
Retreatment of previous root canal therapy - molar
Apexification / Recalcification and Pulpal Regeneration Procedures
*D3351
Apexification/recalcification- initial visit
*D3352
Apexification/recalcification -interim medication replacement
*D3353
Apexification/recalcification- final visit
Apicoectomy / Periradicular Services
*D3410
Apicoectomy- anterior
*D3421
Apicoectomy- bicuspid (first root)
*D3425
Apicoectomy- molar (first root)
*D3426
Apicoectomy- (each additional root)
*D3430
Retrograde filling - per root
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Page 11 of 27
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CDT
Code
Definition
Clinical & Billing Guidelines
Submit w/
Prior Auth
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*D3450
Root amputation - per root
1 per tooth, except by report.
Patient must have good oral hygiene.
Tooth must not be involved with periodontal disease.
Dentist must agree to restore tooth once treatment is
completed.
Not appropriate for 3rd molars unless functioning in place of
missing molar.
Pre-op x-ray & a
bitewing or
pano showing
integrity of the
arch
Pre & post
operative
x-rays, if not
submitted with
prior auth.
Narrative, if
applicable.
1 per tooth, except by report.
Patient must have good oral hygiene.
Tooth must not be involved with periodontal disease.
Dentist must agree to restore tooth once treatment is
completed.
Not appropriate for 3rd molars unless functioning in place of
missing molar.
Pre-op x-ray & a
bitewing or
pano showing
integrity of the
arch
Pre & post
operative
x-rays, if not
submitted with
prior auth.
Narrative, if
applicable.
Narrative
Other Endodontic Procedures
*D3920
Hemisection (including any root removal);
Not including root canal therapy
D3999
Unspecified endodontic procedure, by report
N/A
PERIODONTICS
• All referrals to a Periodontist must be submitted for prior approval and include a periapical x-ray and either a bitewing or panoramic film.
• Periodontal services shall be limited to patients who have:
- good or improving oral hygiene (with the exception of D1110-adult prophy and D4355-full mouth debridement) and
- generalized periodontal pockets in excess of 4-5 mm.
• Periodontal services are approved on an ordered schedule initially encompassing only the direct, least invasive measures.
• Code D4355 requires prior authorization and should be used to enable comprehensive evaluation and diagnosis for age 14 & up.
• All requests for periodontal services must include:
- diagnostic periapical radiographs, or anterior periapicals x-rays and posterior bitewings;
- periodontal charting of pocket depths (except for D4355), bone loss, & mobility of all teeth & charting missing teeth & teeth to be extracted (except for D4355); and
- a brief description of the patient’s dental history and current oral hygiene.
Surgical Services (Including Usual Postoperative Care)
*D4210
Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth
1 per 36 months, except by report.
bounded space per quadrant - Excision of soft tissue wall of periodontal Limited to patients with:
pocket by external or internal bevel - to eliminate suprabony pockets after
Good or improving oral hygiene and
adequate initial preparation, to allow access for restorative dentistry in the Generalized pocket depths in excess of 4-5 mm.
presence of suprabony pockets, or to restore normal architecture when
gingival enlargements or asymmetrical or unaesthetic topography is
evident with normal bony configuration.
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
X-rays, perio
Narrative, if
charting,
applicable.
narrative of
dental history &
current oral
hygiene
Page 12 of 27
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CDT
Code
Definition
*D4211
Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth
1 per 36 months, except by report.
bounded space per quadrant - Excision of soft tissue wall of periodontal Limited to patients with:
pocket by external or internal bevel - to eliminate suprabony pockets after
Good or improving oral hygiene and
adequate initial preparation, to allow access for restorative dentistry in the Generalized pocket depths in excess of 4-5 mm.
presence of suprabony pockets, or to restore normal architecture when
gingival enlargements or asymmetrical or unaesthetic topography is
evident with normal bony configuration.
X-rays, perio
Narrative, if
charting,
applicable.
narrative of
dental history &
current oral
hygiene
*D4240
Gingival flap procedure, including root planing - four or more contiguous
teeth or tooth bounded spaces per quadrant
1 per 36 months, except by report.
Clinically appropriate if performed by a Periodontist.
Limited to patients with:
Good or improving oral hygiene,
Generalized pocket depths in excess of 4-5 mm.
*D4241
Gingival flap procedure, including root planing - one to three contiguous
teeth or tooth bounded spaces per quadrant
1 per 36 months, except by report.
Clinically appropriate if performed by a Periodontist.
Limited to patients with:
Good or improving oral hygiene, and
Generalized pocket depths in excess of 4-5 mm.
*D4249
Clinical crown lengthening - hard tissue
1 per lifetime, except by report.
*D4260
Osseous surgery, including flap entry & closure - four or more contiguous
teeth or tooth bounded spaces per quadrant
*D4261
Osseous surgery, including flap entry & closure - one to three contiguous
teeth or tooth bounded spaces per quadrant
1 per 36 months, except by report.
Clinically appropriate if performed by a Periodontist.
Limited to patients with:
Good or improving oral hygiene, and
Generalized pocket depths in excess of 4-5 mm.
X-rays, perio
charting,
narrative of
dental history &
current oral
hygiene
X-rays, perio
charting,
narrative of
dental history &
current oral
hygiene
X-rays, perio
charting,
narrative of
dental history &
current oral
hygiene
X-rays, perio
charting,
narrative of
dental history &
current oral
hygiene
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Clinical & Billing Guidelines
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Claim
Narrative, if
applicable.
Narrative, if
applicable.
Narrative, if
applicable.
Narrative, if
applicable.
Page 13 of 27
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CDT
Code
Definition
*D4263
*D4264
*D4265
*D4266
*D4267
Bone replacement graft - first site in quadrant
By report only.
Bone replacement graft - each additional site in quadrant
Biological material to aid in soft & osseous tissue regeneration
Guided tissue regeneration - resorbable barrier, per site/tooth
Guided tissue regeneration - non-resorbable barrier, per site (including
membrane removal)
Pedicle soft tissue graft
Autogenous tissue graft including donor site - 1st tooth
Distal or proximal wedge (when not performed with surgical procedures in
same anatomical area)
Non- autogenous tissue graft including donor site - 1st tooth
Combined connective tissue & double pedicle graft, per tooth
*D4270
*D4273
*D4274
*D4275
*D4276
Clinical & Billing Guidelines
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X-rays &
Narrative
N/A
X-ray &
Narrative
X-ray &
Narrative
X-rays, perio
charting,
narrative of
dental history &
current oral
hygiene
N/A
Non-Surgical Periodontal Services
*D4320
Provisional splinting - intracoronal
By report only.
*D4321
Provisional splinting - extracoronal
By report only.
*D4341
Periodontal scaling and root planing - four or more teeth per quadrant
Narrative, if
applicable.
*D4342
Periodontal scaling and root planing - one to three teeth per quadrant
*D4355
Full mouth debridement to enable comprehensive evaluation & diagnosis
1 per 36 months, except by report.
Limited to patients with:
Good or improving oral hygiene,
Generalized pocket depths in excess of 4-5 mm,
Scaling & root planing (D4341,D4342) must show
radiographic evidence of bone loss, otherwise
perform D1110-adult prophy for difficult prophy.
1 per 36 months, except by report.
Photograph (not
Not appropriate on same day or within 12 months following x-ray)
prophy (D1110 or D1120).
documenting
calculus & chart
notes
1 per 12 months, except by report.
Following active perio treatment.
Narrative of
previous perio
treatment
Narrative
Narrative, if
applicable.
N/A
N/A
Other Periodontal Services
*D4910
Periodontal maintenance
*D4920
Unscheduled dressing change (by someone other than treating dentist or
their staff)
Unspecified periodontal procedure, by report
*D4999
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
N/A
Narrative, if
applicable.
Narrative
Page 14 of 27
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CDT
Code
Definition
Clinical & Billing Guidelines
Submit w/
Prior Auth
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Claim
PROSTHODONTICS (Removable)
• A removable prosthesis is a benefit when using standard procedures that exclude precision attachments, implants, or other specialized techniques.
• A removable partial denture is a benefit only when necessary for the balance of a complete denture. Balance is generally considered to be the presence of sufficient
posterior teeth to afford satisfactory biomechanical support of a prosthetic appliance in all excursions of the mandible. Without such occlusion, a removable partial
denture may be authorized to provide that support.
• A removable partial may be covered if determined to be a medical necessity.
• Missing anterior teeth may be replaced with a treatment partial (flipper).
• Treatment partials (flippers) are available for the maxillary arch only.
• A removable prosthesis is a benefit once per lifetime, unless surgical or traumatic loss of oral-facial anatomic structure occurs. Treatment partials (flippers) may be
covered more frequently if the patient loses additional teeth due to trauma.
• A new prosthesis is not covered when it is evident that the existing prosthesis can be made serviceable by repair, reline, or replacement of teeth.
• Replacement for cosmetic purposes, such as discoloration of prosthetic teeth, are not covered.
• No replacement for lost or stolen prosthetics is provided.
• All placements of full dentures, partial dentures and treatment partials (flippers) must be prior authorized. Requests must include sufficient diagnostic X-rays or
other diagnostic materials to document missing and remaining teeth.
• Construction of new dentures or partial dentures is not a covered benefit if:
- it would be impossible or highly improbable for patient to adjust to a new prosthetic appliance. Dental history shows that previous attempts to contruct a
prosthetic appliance have been unsatisfactory for reasons that are not remediable (psychological).
- repair or reline of an existing denture is sufficient.
- prosthetic appliance, in patient’s opinion only, is loose or ill fitting but is recently enough constructed to indicate deficiencies limited to those inherent in dentures.
• Examination of a complete denture patient on a maintenance basis is not a covered benefit.
• Immediate dentures may be covered when:
- x-rays show extensive or rampant caries or severe periodontal conditions, or
- clinical exam shows excessive mobility and severe gingivitis.
• Dentures are not a covered benefit based solely on patient request just because a patient wants his/her teeth removed.
• Payment for prosthetic appliances includes adjustments and maintenance necessary for six (6) months following insertion of appliance.
• All restorative and oral hygiene procedures must be completed before impressions are taken for partial dentures.
• There is no benefit for fixed prosthetic bridgework.
Complete Dentures
*D5110
*D5120
*D5130
Complete denture - maxillary
Complete denture - mandibular
Immediate denture - maxillary - including limited follow-up care only; does
not include required future rebasing/relining or complete new denture
*D5140
Immediate denture - mandibular - including limited follow-up care only;
does not include required future rebasing/relining or complete new
denture
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
1 per lifetime, except by report.
Excludes precision alignments, implants or other specialized
techniques.
No coverage for lost or stolen appliances.
See above for further details.
X-rays or other Narrative, if
diagnostic
applicable.
materials to
show missing &
remaining teeth
Page 15 of 27
10/01/2016mf
CDT
Definition
Code
Partial Dentures
Clinical & Billing Guidelines
Submit w/
Prior Auth
*D5211
Maxillary partial denture - resin base - including conventional clasps, rests
& teeth, acrylic resin base denture with resin or wrought wire clasps
*D5212
Mandibular partial denture - resin base - including conventional clasps,
rests & teeth, acrylic resin base denture with resin or wrought wire clasps
1 per lifetime, except by report.
Excludes precision alignments, implants or other specialized
techniques.
No coverage for lost or stolen appliances.
See above for further details.
X-rays or other Narrative, if
diagnostic
applicable.
materials to
show missing &
remaining teeth
*D5213
*D5221
Maxillary partial denture - cast metal frame with resin denture base including conventional clasps, rests & teeth
Mandibular partial denture - cast metal frame with resin denture bases including conventional clasps, rests, & teeth
Immediate maxillary partial denture - resin based
By report only.
*D5222
Immediate mandibular partial denture - resin based
By report only.
*D5223
Immediate maxillary partial denture - cast metal framework
By report only.
*D5224
Immediate mandibular partial denture - cast metal framework
By report only.
*D5281
Removable unilateral partial denture - one piece cast metal - including
clasps and teeth
*D5214
Submit w/
Claim
Adjustments and Repairs to Complete Dentures
*D5410
*D5411
*D5421
*D5422
*D5510
*D5520
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
Repair broken complete denture base
Replace missing/broken teeth - complete denture (each tooth)
Excludes precision alignments, implants or other specialized
techniques.
No coverage for lost or stolen appliances.
See above for further details.
X-rays or other N/A
diagnostic
materials to
show missing &
remaining teeth
Excludes precision alignments, implants or other specialized
techniques.
No coverage for lost or stolen appliances.
See above for further details.
X-rays or other N/A
diagnostic
materials to
show missing &
remaining teeth
Repairs to Partial Dentures
*D5610
*D5620
*D5630
*D5640
*D5650
*D5660
Repair resin denture base
Repair cast framework
Repair or replace broken clasp - per tooth
Replace broken teeth - per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture - per tooth
Denture Rebase Procedures
*D5710
*D5711
*D5720
Rebase complete maxillary denture
Rebase complete mandibular denture
Rebase maxillary partial denture
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Excludes precision alignments, implants or other specialized X-rays or other
techniques.
diagnostic
No coverage for lost or stolen appliances.
materials to
N/A
Page 16 of 27
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CDT
Code
Definition
Clinical & Billing Guidelines
*D5721
Rebase mandibular partial denture
g
pp
See above for further details.
Submit w/
Prior Auth
Submit w/
Claim
show missing &
remaining teeth
Denture Reline Procedures
*D5730
*D5731
*D5740
*D5741
*D5750
*D5751
*D5760
*D5761
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
Reline complete maxillary denture (laboratory)
Reline complete mandibular denture (laboratory)
Reline maxillary partial denture (laboratory)
Reline mandibular partial denture (laboratory)
Excludes precision alignments, implants or other specialized
techniques.
No coverage for lost or stolen appliances.
See above for further details.
X-rays or other N/A
diagnostic
materials to
show missing &
remaining teeth
1 per lifetime, except by report.
Excludes precision alignments, implants or other specialized
techniques.
No coverage for lost or stolen appliances.
See above for further details.
X-rays or other Narrative, if
diagnostic
applicable.
materials to
show missing &
remaining teeth
Interim Prosthesis
*D5820
*D5821
Interim partial denture (maxillary)
Interim partial denture (mandibular)
Other Removable Prosthetic Services
*D5850
*D5851
*D5899
Tissue conditioning, maxillary - Treatment reline using materials designed Excludes precision alignments, implants or other specialized
techniques.
to heal unhealthy ridges prior to more definitive final restoration.
No coverage for lost or stolen appliances.
Tissue conditioning, mandibular - Treatment reline using materials
See above for further details.
designed to heal unhealthy ridges prior to more definitive final restoration.
Unspecified removable prosthodontic procedure, by report
MAXILLOFACIAL PROSTHETICS
*D5911
*D5912
X-rays or other N/A
diagnostic
materials to
show missing &
remaining teeth
Facial moulage (sectional)
Facial moulage (complete)
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Excludes precision alignments, implants or other specialized
techniques.
No coverage for lost or stolen appliances.
See above for further details.
X-rays or other N/A
diagnostic
materials to
show missing &
remaining teeth
Page 17 of 27
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CDT
Code
Definition
Clinical & Billing Guidelines
Submit w/
Prior Auth
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Claim
*D5913
*D5914
*D5915
*D5916
*D5919
*D5922
*D5923
*D5924
*D5925
*D5926
*D5927
*D5928
*D5929
*D5931
*D5932
*D5933
*D5934
*D5935
Nasal prosthesis
Auricular prosthesis
Orbital prosthesis
Ocular prosthesis
Facial prosthesis
Nasal septal prosthesis
Ocular prosthesis, interim
Cranial prosthesis
Facial augmentation implant prosthesis
Nasal prosthesis, replacement
Auricular prosthesis, replacement
Orbital prosthesis, replacement
Facial prosthesis, replacement
Obturator prosthesis, surgical
Obturator prosthesis, definitive
Obturator prosthesis, modification
Mandibular resection prosthesis with guide flange
Mandibular resection prosthesis without guide flange
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
N/A
*D5936
*D5937
*D5951
*D5952
*D5953
*D5954
*D5955
*D5958
*D5959
*D5960
*D5982
*D5983
*D5984
*D5985
*D5986
*D5987
*D5988
*D5991
*D5992
Obturator prosthesis, interim
Trismus appliance (not for TMD treatment)
Feeding aid
Speech aid prosthesis, pediatric
Speech aid prosthesis, adult
Palatal augmentation prosthesis
Palatal lift prosthesis, definitive
Palatal lift prosthesis, interim
Palatal lift prosthesis, modification
Speech aid prosthesis, modification
Surgical stent
Radiation carrier
Radiation shield
Radiation cone locator
Fluoride gel carrier
Commissure splint
Surgical splint
Vesiculobullous disease medicament carrier
Adjust maxillofacial prosthetic appliance, by report
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
N/A
N/A
D5999
Unspecified maxillofacial prosthesis, by report
Clinically appropriate after 6 months from initial placement Narrative
only.
Clinically appropriate if performed by an Oral Surgeon.
N/A
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Narrative
Page 18 of 27
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CDT
Code
Definition
Clinical & Billing Guidelines
Submit w/
Prior Auth
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Claim
ORAL AND MAXILLOFACIAL SURGERY
• No prior authorization is needed for D7140 or D7111 with the exception of 3rd molars. 3rd molar extractions require prior authorization and can be
performed by a General Dentist or an Oral Surgeon.
• When tooth extraction is the reason for referral,a panoramic or periapical X-ray of good diagnostic quality showing entire crown & root structure of teeth to be
extracted must be submitted with referral/prior authorization.
• Diagnostic X-rays may be required for all surgical procedures except those involving only soft tissue lesions. In cases where radiographs are not necessary, submit
a short narrative to justify the need for the service.
• Extraction of asymptomatic and/or non-pathologic teeth is not a covered benefit. The following conditions may be considered symptomatic or pathologic in nature
when properly documented:
- Full bony impacted supernumerary teeth, such as mesiodens, or teeth that fail to erupt due to lack of alveolar ridge length.
- Unerupted teeth that are distorting the normal alignment of erupted teeth or causing crown or root resorption of other teeth.
- Pathology observed on x-ray that fails to elicit symptoms.
- Extraction of remaining teeth in preparation for a full denture that has been authorized.
- Teeth involved with an abscess, cyst, or other neoplasm.
- Teeth that are unrestorable due to caries or loss of crown and/or root structure.
• Extractions of asymptomatic deciduous teeth that appear about to exfoliate naturally on radiographic examination are not a benefit.
• Routine postoperative visits within 30 days following an extraction or surgical procedure are considered part of the surgical procedure.
• Hospitalization for oral surgical procedures may be considered only if medically necessary and procedure cannot be performed in dental office.
Extractions (Includes local anesthesia, suturing if needed, and routine postoperative care)
D7111
D7140
Extraction, coronal remnants - deciduous tooth Removal of soft tissue1 per lifetime, except by report.
retained coronal remnants.
Extraction, erupted tooth or exposed root - (elevation and/or forceps
removal) - Includes routine removal of tooth structure, minor smoothing of
socket bone, and closure, as necessary.
N/A
Narrative, if
applicable.
Surgical Extractions (Includes local anesthesia, suturing if needed, and routine postoperative care)
*D7210
Surgical removal of erupted tooth requiring removal of bone and/or
1 per lifetime, except by report.
X-ray &
sectioning of tooth, including elevation of mucoperiosteal flap if indicated. Must meet CDT description including removal of bone
Narrative
and/or sectioning of tooth.
Claims submitted for surgical extractions, D7210, where the
procedure code was changed due to unforeseen
circumstances while performing treatment, will require xrays and narrative for review.
*D7220
Removal of impacted tooth - soft tissue - Occlusal surface of tooth
covered by soft tissue; requires mucoperiosteal flap elevation.
*D7230
1 per lifetime, except by report.
Removal of asymptomatic teeth are not covered.
See above for conditions which are considered
Removal of an impacted tooth - partially bony - Part of crown covered by symptomatic.
bone; requires mucoperiosteal flap elevation & bone removal.
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
If treatment
plan changes on
date of service,
x-rays &
narrative must
be submitted.
Pano or
Narrative, if
periapical x-rays applicable.
showing crown
& root of teeth
to be extracted
and Narrative
Page 19 of 27
10/01/2016mf
CDT
Code
Definition
Clinical & Billing Guidelines
Submit w/
Prior Auth
*D7240
Removal of impacted tooth - completely bony - Most or all of crown
covered by bone; requires mucoperiosteal flap elevation & bone removal.
*D7241
Removal of impacted tooth - completely bony, with unusual surgical
complications - Most or all of crown covered by bone; unusually difficult
due to factors such as nerve dissection required, separate closure of
maxillary sinus required, or aberrant tooth position.
1 per lifetime, except by report.
Clinically appropriate if performed by an Oral Surgeon.
Removal of asymptomatic teeth are not covered.
See above for conditions which are considered
symptomatic.
Pano or
Narrative, if
periapical x-rays applicable.
showing crown
& root of teeth
to be extracted
and Narrative
*D7250
Narrative, if
applicable.
*D7260
*D7261
Oroantral fistula closure, by report
Primary closure of a sinus perforation, by report
1 per lifetime, except by report.
Not to be billed for exposed roots, in those cases bill using
code D7140.
1 per lifetime, except by report.
Clinically appropriate if performed by an Oral Surgeon.
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
*D7251
Surgical removal of residual tooth roots (cutting procedure)
Includes cutting of soft tissue & bone, removal of tooth structure, and
closure.
Coronectomy - intentional partial tooth removal
X-ray &
Narrative
X-ray &
Narrative
Narrative, if
applicable.
N/A
*D7270
X-ray &
Narrative
N/A
X-ray &
Narrative
N/A
*D7293
Tooth reimplantation and/or stabilization of accidentally evulsed or
Clinically appropriate if performed by an Oral Surgeon.
displaced tooth - Includes splinting/stabilization.
Surgical access of an unerupted tooth - Incision is made & the tissue is
reflected & bone removed as necessary to expose crown of impacted tooth
not intended to be extracted.
Mobilization of erupted or malpositioned tooth to aid eruption
Clinically appropriate if performed by an Oral Surgeon.
Placement of device to facilitate eruption of impacted tooth
Biopsy of oral tissue - hard (bone, tooth)
Biopsy of oral tissue - soft
Surgical placement: temporary anchorage device (screw retained plate)
requiring surgical flap
Surgical placement: temporary anchorage device requiring surgical flap
*D7294
Surgical placement: temporary anchorage device without surgical flap
X-ray &
Narrative
X-ray &
Narrative
N/A
Other Surgical Procedures
*D7280
*D7282
*D7283
*D7285
*D7286
*D7292
Submit w/
Claim
Alveoloplasty - Surgical Preparation of Ridge
*D7310
*D7311
Alveoloplasty in conjunction with extractions - four or more teeth or tooth Clinically appropriate if performed by an Oral Surgeon.
spaces, per quadrant
Alveoloplasty in conjunction with extractions - one to three teeth or tooth Clinically appropriate if performed by an Oral Surgeon.
spaces, per quadrant
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
N/A
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CDT
Code
Definition
Clinical & Billing Guidelines
Submit w/
Prior Auth
Submit w/
Claim
*D7320
Alveoloplasty not in conjunction with extractions - four or more teeth or
tooth spaces, per quadrant
N/A
*D7321
Alveoloplasty not in conjunction with extractions - one to three teeth or
tooth spaces, per quadrant
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
This procedure is a benefit if completed to correct surgical Narrative
or anatomical deformities or developmental or pathological
abnormalities.
This is not part of the normal extraction process and is not a
benefit if performed within 6 months following extraction of
teeth in same quadrant.
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
N/A
Surgical Excision of Soft Tissue Lesions
*D7410
*D7411
*D7412
*D7413
*D7414
*D7415
Excision of benign lesion up to 1.25 cm
Excision of benign lesion greater than 1.25 cm
Excision of benign lesion, complicated
Excision of malignant lesion up to 1.25 cm
Excision of malignant lesion greater than 1.25 cm
Excision of malignant lesion, complicated
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
Post operative xray
*D7440
*D7441
*D7450
Excision of malignant tumor - lesion diameter up to 1.25 cm
Clinically appropriate if performed by an Oral Surgeon.
Excision of malignant tumor - lesion diameter greater than 1.25 cm
Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25
cm
Removal of benign odontogenic cyst or tumor - lesion diameter greater
than 1.25 cm
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to Clinically appropriate if performed by an Oral Surgeon.
1.25 cm
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater
than 1.25 cm
Destruction of lesion(s) by physical or chemical method, by report
Clinically appropriate if performed by an Oral surgeon.
X-ray &
Narrative
Post operative xray
X-ray &
Narrative
Post operative xray
X-ray &
Narrative
N/A
X-ray &
Narrative
X-ray &
Narrative
N/A
Surgical Excision of Intra-Osseous Lesions
*D7451
*D7460
*D7461
*D7465
Excision of Bone Tissue
*D7471
Removal of lateral exostosis ( maxilla or mandible)
Clinically appropriate if performed by an Oral surgeon.
*D7472
*D7473
*D7485
*D7490
Removal of torus palatinus
Removal of mandibularis
Surgical reduction of osseous tuberosity
Radical resection of maxilla or mandible
Clinically appropriate if performed by an Oral Surgeon.
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
N/A
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CDT
Definition
Code
Surgical Incision
Clinical & Billing Guidelines
Submit w/
Prior Auth
Submit w/
Claim
D7510
D7511
Clinically appropriate if performed by an Oral Surgeon.
N/A
N/A
D7540
Incision and drainage of abscess - intraoral soft tissue
Incision and drainage of abscess - intraoral soft tissue - complicated
(includes drainage of multiple fascial spaces)
Incision and drainage of abscess - extraoral soft tissue
Incision and drainage of abscess - extraoral soft tissue - complicated
(includes drainage of multiple facial spaces)
Removal of foreign body from mucosa, skin, or subcutaneous alveolar
tissue
Removal of reaction producing foreign bodies, musculoskeletal system
*D7550
*D7560
Partial ostectomy/sequestrectomy for removal of non-vital bone
Maxillary sinusotomy for removal of tooth fragment or foreign body
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
N/A
Maxilla - open reduction (teeth immobilized, if present)
Maxilla - closed reduction (teeth immobilized, if present)
Mandible - open reduction (teeth immobilized, if present)
Mandible - closed reduction (teeth immobilized, if present)
Malar and/or zygomatic arch - open reduction
Malar and/or zygomatic arch - closed reduction
Alveolus - closed reduction, may include stabilization of teeth
Alveolus - open reduction, may include stabilization of teeth
Facial bones - complicated reduction with fixation and multiple surgical
approaches
Clinically appropriate if performed by an Oral Surgeon.
Only covered for reduction of trauma, including maxilla or
mandible reconstruction and/or treatment of TMJ
dysfunction related to acute traumatic incident or when
determined to be medically necessary.
X-ray &
Narrative
N/A
Maxilla - open reduction
Maxilla - closed reduction
Mandible - open reduction
Mandible - closed reduction
Malar and/or zygomatic arch - open reduction
Malar and or zygomatic arch - closed reduction
Alveolus - open reduction stabilization of teeth
Alveolus - closed reduction stabilization of teeth
Facial bones - complicated reduction with fixation and multiple surgical
approaches
Clinically appropriate if performed by an Oral Surgeon.
Only covered for reduction of trauma, including maxilla or
mandible reconstruction and/or treatment of TMJ
dysfunction related to acute traumatic incident or when
determined to be medically necessary.
X-ray &
Narrative
N/A
D7520
D7521
D7530
Treatment of Fractures - Simple
*D7610
*D7620
*D7630
*D7640
*D7650
*D7660
*D7670
*D7671
*D7680
Treatment of Fractures - Compound
*D7710
*D7720
*D7730
*D7740
*D7750
*D7760
*D7770
*D7771
*D7780
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
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CDT
Definition
Clinical & Billing Guidelines
Code
Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions
Submit w/
Prior Auth
Submit w/
Claim
*D7810
*D7820
*D7830
Open reduction of dislocation
Closed reduction of dislocation
Manipulation under anesthesia
Clinically appropriate if performed by an Oral Surgeon.
Only covered for reduction of trauma, including maxilla or
mandible reconstruction and/or treatment of TMJ
dysfunction related to acute traumatic incident or when
determined to be medically necessary.
X-ray &
Narrative
N/A
*D7840
*D7850
*D7852
*D7854
*D7856
*D7858
*D7860
*D7865
*D7870
*D7871
*D7872
*D7873
*D7874
*D7875
*D7876
*D7877
*D7880
Condylectomy
Surgical discectomy, with/without implant
Disc repair
Synovectomy
Myotomy
Joint reconstruction
Arthrotomy
Arthroplasty
Arthrocentesis
Non-arthroscopic lysis and lavage
Arthroscopy - diagnosis, with or without biopsy
Arthroscopy - surgical: lavage and lysis of adhesions
Arthroscopy - surgical: disc repositioning and stabilization
Arthroscopy - surgical: synovectomy
Arthroscopy - surgical: discectomy
Arthroscopy - surgical: debridement
Occlusal orthotic device, by report
Clinically appropriate if performed by an Oral Surgeon.
Only covered for reduction of trauma, including maxilla or
mandible reconstruction and/or treatment of TMJ
dysfunction related to acute traumatic incident or when
determined to be medically necessary.
X-ray &
Narrative
N/A
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
N/A
Clinically appropriate if performed by an Oral Surgeon.
X-ray &
Narrative
N/A
X-ray &
Narrative
N/A
Repair of Traumatic Wounds (Excludes closure of surgical incisions)
*D7910
Suture of recent small wounds up to 5 cm
Complicated Suturing (Reconstruction Requiring Delicate Handling of Tissues and Widening Undermining for Meticulous Closure)
*D7911
*D7912
Complicated suture - up to 5 cm
Complicated suture - greater than 5 cm
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Clinically appropriate if performed by an Oral Surgeon.
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CDT
Definition
Code
Other Repair Procedures
Clinical & Billing Guidelines
*D7920
*D7940
*D7941
*D7943
Skin graft (identify defect covered, location and type of graft)
Clinically appropriate if performed by an Oral Surgeon.
Osteoplasty - for orthognathic deformities
Osteotomy - mandibular rami
Osteotomy - mandibular rami with bone graft; includes obtaining the graft
*D7944
*D7945
*D7946
*D7947
*D7948
Osteotomy - segmented or subapical
Osteotomy - body of mandible
LeFort I (maxilla - total)
LeFort I (maxilla - segmented)
LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or
retrusion) - without bone graft
Lefort II or LeFort III - with bone graft
Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla autogenous or nonautogenous, by report
Sinus augmentation with bone or bone substitutes
Bone replacement graft for ridge preservation - per site
Repair of maxillofacial soft and/or hard tissue defect
Frenulectomy (frenectomy or frenotomy) - separate procedure not
Clinically appropriate if performed by an Oral Surgeon or
incidental to another
Periodontist and one of these conditions exists:
- labial frenum interferes w/mobility of center of lip,
- hypertrophy of frenum interferes with proper
fitting and retention of a prosthetic appliance,
- attachment of frenum causes periodontal disease,
- hypertrophy of maxillary frenum extends to
palatal papilla and produces a diastama.
Mandibular (lingual) frenectomy requires documentation
that frenum interferes with speech.
Patient must have maxillary lateral incisors erupted with at
least 2/3 of root development - AND - be in orthodontic
appliances - OR - have maxillary permanent canines erupted.
Maxillary frenectomy is not a benefit for children with
primary dentition.
*D7949
*D7950
*D7951
*D7953
*D7955
*D7960
*D7963
Frenuloplasty - Excision of frenum with accompanying excision or
repositioning of aberrant muscle and z-plasty or other local flap closure
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Clinically appropriate if performed by an Oral Surgeon or
Periodontist.
Submit w/
Prior Auth
Submit w/
Claim
X-ray &
Narrative
N/A
For maxillary
N/A
frenectomy in
children, include
a periapical
x-ray &
photograph of
central incisor
region and
Narrative
X-ray &
Narrative
N/A
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CDT
Code
Definition
*D7970
*D7971
*D7972
*D7980
*D7981
*D7982
*D7983
*D7990
*D7991
*D7995
*D7996
*D7998
Excision of hyperplastic tissue - per arch
Clinically appropriate if performed by an Oral Surgeon.
Excision of pericoronal gingiva
Surgical reduction of fibrous tuberosity
Sialolithotomy
Excision of salivary gland, by report
Sialodochoplasty
Closure of salivary fistula
Emergency tracheotomy
Coronoidectomy
Synthetic graft - mandible or facial bones, by report
Implant - mandible for augmentation purposes (excluding alveolar ridge),
by report
Appliance removal (not by dentist who placed appliance), includes removal
of archbar
Intraoral placement of a fixation device not in conjunction with a fracture
*D7999
*D8999
Unspecified oral surgery procedure, by report
Unspecified orthodontic procedure, by report
*D7997
Clinical & Billing Guidelines
Medically necessary only; ex. Cleft palate
Submit w/
Prior Auth
Submit w/
Claim
X-ray &
Narrative
N/A
X-ray &
Narrative
N/A
ADJUNCTIVE GENERAL PROCEDURES
• Advantica follows the guidelines issued by the American Dental Association, The American Academy of Pediatrics and the American Academy of Pediatric Dentists
Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.
• Nitrous Oxide and Oral Conscious Sedation are Clinically appropriate with operative or surgical services.
* Nitrous Oxide cannot be billed with Oral Conscious Sedation, Deep Sedation/ General Anesthesia or IV Sedation
• If patient is to be hospitalized for dentistry, the practitioner must prior authorize hospital admission with health plan. Advantica reserves the right to request a letter
from patient’s primary care physician before granting approval for general anesthesia.
• All procedures for oral conscious sedation or general anesthesia must be prior authorized with narrative documenting why general anesthesia or oral conscious
sedation is needed.
• Patients requiring general anesthesia or IV sedation must be treated by a pediatric dentist.
• The general rule is to allow 1 unit of oral conscious sedation for every 5 teeth being treated.
• Deep sedation/general anesthesia or IV sedation for third molar extractions is not covered, except for medical related problems.
• An Arizona State Board permit is required for anesthesia codes.
General Anesthesia claims must be accompanied by an anesthesia report detailing they type and duration of the anesthesia as well as the start and finish time by the provider
completing the dental treatment.
Unclassified Treatment
D9110
*D9120
Palliative (emergency) treatment of dental pain - minor procedure Not appropriate on the same day with any other procedure N/A
Typically reported on a “per visit” basis for emergency treatment of dental except diagnostic services.
pain.
Fixed partial denture sectioning
N/A
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
N/A
N/A
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CDT
Definition
Code
Anesthesia
D9210
Clinical & Billing Guidelines
Local anesthesia not in conjunction with operative or surgical procedures
Submit w/
Prior Auth
Submit w/
Claim
N/A
N/A
**D9223 Deep sedation/ general anesthesia - each 15 minute increment
Current Arizona State Board permit required.
Narrative of
medical
condition that
warrants use of
GA or OCS
Anesthesia
report including
operative start
and finish times
D9230
Inhalation of nitrous oxide/analgesia, anxiolysis
**D9243 Intravenous conscious sedation/ analgesia- each 15 minutes
Current Arizona State Board permit required.
Narrative of
medical
condition that
warrants use of
GA or OCS
Anesthesia
report including
operative start
and finish times
**D9248 Non-intravenous (conscious) sedation
D9248 Not to be billed in conjunction with D9230
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Professional Consultation
D9310
Consultation - diagnostic service provided by dentist or physician other
than requesting dentist or physician
Professional Visits
D9410
D9420
D9430
D9440
House/extended care facility call
Hospital or ambulatory surgical center call
Office visit for observation (during regularly scheduled hours) - no other
services performed
Office visit - after regularly scheduled hours
Not appropriate on the same day as treatment.
Drugs
*D9610
*D9612
Therapeutic parenteral drugs, single administration
Therapeutic parenteral drugs, two or more administrations, different
medications
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
By report only.
Therapeutic drug injections are not appropriate when:
- self-administered & dispensed by the dentist for
the beneficiary’s use.
- administered as an analgesic or sedative in
conjunction with conscious sedation, relative
analgesia, or nitrous oxide.
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CDT
Definition
Code
Miscellaneous Services
*D9930
*D9940
Treatment of complications (post surgical) - unusual circumstances, by
report
Occlusal guard, by report
*D9951
Occlusal adjustment - limited
*D9999
Unspecified adjunctive procedure, by report
* Prior Authorization is Required for AHCCCS and DDD Members <21
** Prior Authorization is Required for AHCCCS Members <21 and ALL DDD Members
Clinical & Billing Guidelines
Submit w/
Prior Auth
Submit w/
Claim
Narrative
N/A
Photograph (not N/A
x-rays) to
document
occlusal wear
AND Narrative
of symptoms
Bill per visit; not per tooth. When used for discing, clinically Narrative
N/A
appropriate for primary anteriors only.
Narrative
N/A
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