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Advantica / Care1st Clinical and Billing Guidelines: AHCCCS & DDD Members Under 21 DDD Members Over 21 $1000 Dental Benefit CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim 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 Page 1 of 27 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim 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 Page 2 of 27 10/01/2016mf CDT Definition Code Radiographs / Diagnostic Imaging (Including Interpretation) Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim • 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 Page 3 of 27 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim 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 Page 4 of 27 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim 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 Page 5 of 27 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim 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 Page 6 of 27 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim 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. Page 7 of 27 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim *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 Page 8 of 27 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim *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 Page 9 of 27 10/01/2016mf CDT Definition Code Pulpotomy Clinical & Billing Guidelines Submit w/ Prior Auth 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 Submit w/ Claim Page 10 of 27 10/01/2016mf CDT Definition Clinical & Billing Guidelines Code Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-up Care) Submit w/ Prior Auth Submit w/ Claim *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 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ Claim *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 10/01/2016mf 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 Submit w/ Prior Auth Submit w/ Claim Narrative, if applicable. Narrative, if applicable. Narrative, if applicable. Narrative, if applicable. Page 13 of 27 10/01/2016mf 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 Submit w/ Prior Auth Submit w/ Claim 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 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ 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 10/01/2016mf 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 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ 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 10/01/2016mf CDT Code Definition Clinical & Billing Guidelines Submit w/ Prior Auth Submit w/ 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 Page 20 of 27 10/01/2016mf 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 Page 21 of 27 10/01/2016mf 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 Page 22 of 27 10/01/2016mf 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. Page 23 of 27 10/01/2016mf 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 Page 24 of 27 10/01/2016mf 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 Page 25 of 27 10/01/2016mf 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. Page 26 of 27 10/01/2016mf 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 Page 27 of 27 10/01/2016mf