Download national standardized dental claim utilization review criteria

NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA
Revised: 6/1/2016
The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior
authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances
that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical
Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies
and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a
full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental
Clinical Policies & Coverage Guidelines.
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
DIAGNOSTIC
Clinical Oral Evaluations
D0120–D0191
Documentation in member record that includes all services performed
for the code submitted
Pre-Diagnostic Services
D0190 screening of a patient
D0191 assessment of a patient
Documentation in member record that includes all services performed
for the code submitted.
Diagnostic Imaging
Documentation in the member record. Diagnostic, clear, readable
images, dated with member name.
Image capture with interpretation
D0210–D0371
Image Capture only
D0380–D0386
Interpretation and Report only
D0391–D0395
Criteria for codes D0364–D0368, D0380–D0386, D0391–D0395:
Cone beam computed tomography (CBCT) is unproven and not medically
necessary for routine dental applications.
There is insufficient evidence that CBCT is beneficial for use in routine dental
applications. CBCT should not replace traditional dental x-rays as a preliminary
diagnostic tool, or for routine dental procedures such as restorations, but be
used as an adjunct when the level of detail CBCT is needed to safely render
treatment for complex clinical conditions (e.g. oral surgery, implant placement
and endodontics). These procedures may have a higher risk of complications
without the level of detail CBCT imaging provides. CBCT imaging used for these
reasons should be read and interpreted by an appropriately trained
professional.
In addition, radiation exposure associated with CBCT needs to be weighed
against possible benefits, which have not been supported in the published
literature. Limited definitive conclusions regarding the clinical role of CBCT can
be reached due to the lack of well-designed studies that systematically evaluate
diagnostic accuracy and the impact of CBCT on clinical decision making and
patient health outcomes. Additional studies are needed to verify that CBCT
provides added diagnostic value beyond two-dimensional imaging such as
panoramic radiography and conventional computed tomography and to
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PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
determine whether CBCT improves treatment decision making and health
outcomes.
Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography
(DCP.002.01)
Tests and Examinations
D0415–D0470
Provider narrative including clinical reason/diagnosis for test and type of
test performed.
caries risk assessment
D0601–D0603
Oral Pathology Laboratory
D0472–D0502
Unspecified diagnostic procedure
by report D0999
PREVENTIVE
Dental Prophylaxis
D1110–D1120
Services performed must be documented in the member record.
Topical Fluoride Treatment
D1206, D1208
Documentation
Age and medical necessity. An adult is generally defined as twelve years
or older.
Criteria for codes D1206, D1208
Topical Application of Fluoride – Excluding Varnish
Topical fluoride treatments in the form of gel, foam and rinses applied as a
caries preventive agent in the dental office are benefitted twice per consecutive
twelve months for children up to age 15. Patients at low risk of developing
caries may not need additional topical fluorides other than over-the-counter
fluoridated toothpaste and fluoridated water.
Topical Application of Fluoride Varnish
Fluoride varnish is indicated for the following:

As the preferred caries prevention agent for children under age 6

For head and neck radiation therapy patients

Sensitivity that does not resolve with an over-the-counter desensitizing
dentifrice

For moderate to high caries risk patients with a medical or cognitive
impairment that limits cooperation with a tray or rinse delivery method

Xerostomia due to systemic disease or medication

For patients in active orthodontic treatment

For the remineralization of incipient or white spot enamel carious lesions
Refer to clinical policy: Topical Fluoride Treatment (DCP018.01)
Other Preventive Services
D1310–D1330
Documentation/narrative in member record that service was performed
and materials supplied to member.
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PROCEDURE
Sealants
D1351–D1352
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Sealant: Tooth numbers.
Provider responsible for three years for repair or Preventive Resin Restoration:
replacement. No decay or restorations – the occlusal surface must be intact.
Sealant cannot be done on the same tooth as a preventive resin.
Space Maintenance
D1510–D1555
Radiographs of the involved arch.
For primary dentition only. Should be submitted for primary tooth that has been
extracted.
All adjustments for 6 months are included.
No benefit if permanent tooth is ready to erupt.
If bilateral teeth are missing, benefit given for bilateral space maintainer, even if
two unilateral space maintainers are requested.
RESTORATIVE
Direct Restorations:
Amalgam Restorations
D2140–D2161
Documentation
Tooth number and surface.
Caries removal documented in member record.
Inclusive components:
Local anesthesia; tooth prep; liners/bases; restorative material;
polishing/sealing; adjustments; tooth etching.
Criteria:
Primary teeth should not be ready to exfoliate and requests are subject to
review based on the age of the patient and the tooth number.
Resin-Based Composite
Restorations – Direct
D2330–D2394
Gold Foil Restorations
D2410–D2340
Indirect Restorations:
Inlay/Onlay Restorations
D2510–D2664 (Inlay/onlays)
Crowns – Single Restorations Only
D2710–D2799
Documentation
Pre-operative x-rays. If endodontic therapy has been performed, a
periapical radiographic image clearly showing the apex of the completed
treatment is required; otherwise, bitewing x-rays may be sufficient at
the discretion of the reviewer.
A narrative or photograph may provide additional information,
especially for replacement of existing crowns.
“Cracked tooth syndrome” requires adequate documentation of extent
of fracture, location and how it was diagnosed. Tooth must be
symptomatic.
Restorations for members under age 15 require statement of medical
necessity.
Inclusive
Local anesthesia; tooth preparation; temporary crown; fitting;
cementation; post-op adjustments, impressions; bases.
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Criteria for codes D2510–D2664, D2710–D2799
Indications for Coverage
Five-year longevity should be evident, periodontium must be healthy or have
documentation the member has periodontal disease under control for a period
of at least 6 months, and no evidence of endodontic pathology or potential
endodontic issues on the radiographic image. Coverage includes local
anesthetic, impressions, tooth preparation, temporary restoration, fitting,
cementation, adjustment and any liners or bases.
Crowns
Crowns are indicated for the following:

Extensive caries on three or more surfaces or 50% loss of clinical crown

Large, >50% of the tooth, defective restoration that can be seen on the
radiographic image

Fracture of cusps

Endodontically treated teeth, unless minimal access opening on anterior
tooth

Documentation that a direct restoration is not possible

Crown/root ratio must be favorable
PROCEDURE
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COVERAGE GUIDELINE
DOCUMENTATION
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Documentation/narrative that the failing existing crown can only be
resolved with a new crown if not visible on radiographic image
50% bone support with no ligament or root pathology unless patient has
undergone periodontal therapy/surgery
Anterior teeth: at least 50% involvement of incisal portion
Bicuspids and molars: 3 or more surfaces and one or more cusps involved
Anterior teeth: at least 50% involvement of incisal portion
Bicuspids and molars: 3 or more surfaces and one or more cusps involved
Symptomatic “cracked tooth syndrome” (not enamel “craze lines”)
Full coverage restoration of a primary tooth without a permanent
successor
Crowns are not indicated for the following:

If a lesser means of restoration is acceptable

If root resorption is present

Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure,
discoloration)

For alteration of vertical dimension

For purposes of preventing future fracture, or to eliminate enamel craze
lines (Cracked tooth syndrome must be diagnosed with documented
diagnostic tests and supported by a narrative. Tooth must be
symptomatic).

To treat non-pathologic wear/abrasion, or abfraction lesions in the absence
of decay

For molars exhibiting bone loss with a class III furcation involvement

Periodontally compromised teeth, even with successful endodontics, unless
the patient has undergone previous periodontal therapy/surgery and
progress notes/periodontal notes indicate the tooth is stable

Fracture of porcelain not involving the margin or a functional ridge is not
sufficient for replacement
Onlays
Onlays are indicated for the following:

Extensive caries on three or more surfaces or 50% loss of clinical crown

Large, >50% of the tooth, defective restoration that can be seen on the
radiographic image

Fracture of cusps

Endodontically treated teeth, unless minimal access opening on anterior
tooth

Documentation that a direct restoration is not possible

Crown/root ratio must be favorable

Documentation/narrative that the failing existing crown can only be
resolved with a new crown if not visible on radiographic image

50% bone support with no ligament or root pathology unless patient has
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COVERAGE GUIDELINE
DOCUMENTATION
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undergone periodontal therapy/surgery
Anterior teeth: at least 50% involvement of incisal portion
Bicuspids and molars: 3 or more surfaces and one or more cusps involved
Benefitted for primary teeth without permanent successor
Bicuspids and molars: 3 or more surfaces and one or more cusps involved
Symptomatic “cracked tooth syndrome”
Onlays are not indicated for the following:

If a lesser means of restoration is acceptable

If root resorption is present

Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure,
discoloration)

For alteration of vertical dimension

For purposes of preventing future fracture, or to eliminate enamel craze
lines (Cracked tooth syndrome must be diagnosed with documented
diagnostic tests and supported by a narrative. Tooth must be
symptomatic).

To treat non-pathologic wear/abrasion, or abfraction lesions in the absence
of decay

For molars exhibiting bone loss with a class III furcation involvement

Periodontally compromised teeth, even with successful endodontics, unless
the patient has undergone previous periodontal therapy/surgery and
progress notes/periodontal notes indicate the tooth is stable

Fracture of porcelain not involving the margin or a functional ridge is not
sufficient for replacement
Inlays
Inlays are unproven
Inlays have not been proven superior over direct restorations and are
alternative benefitted to amalgam restorations.
Coverage Limitations and Exclusions

Replacement of crowns if damage or breakage was directly related to
provider error or patient noncompliance is not covered.

Complete oral rehabilitation or reconstruction is not covered.

Procedures related to the reconstruction of a patient's correct vertical
dimension of occlusion is not covered.
Refer to coverage guideline: Single Tooth Indirect Restorations (DCG008.01)
Other Restorative Services
D2910–D2999
Documentation
Tooth number
Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934
Prefabricated Crowns are indicated for the following:

For the restoration of teeth with more than two surfaces affected with
carious lesions, or where extensive one or two surface lesions are present.

For one and two surface carious lesions in documented high caries risk
Porcelain/Ceramic Crown
D2929
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PROCEDURE
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COVERAGE GUIDELINE
DOCUMENTATION
Stainless Steel Crown
D2930, D2931, D2932, D2933,
D2934
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children. Risk factors must be thoroughly documented by the provider in
the dental record, and include:
o Mother or primary caregiver has active caries;
o White spot lesions or enamel defects;
o Visible caries or previous restorations;
o Poor oral hygiene;
o Sub-optimal systemic fluoride intake;
o Frequent exposure to cavity-producing foods and drinks;
o Patients with special health care needs;
o Low socioeconomic status;
o Xerostomia;
o More than one interproximal lesion;
o Other factors identified by professional literature;
Cervical decalcification, and/or developmental defects (hypoplasia,
hypocalcification, enamel hypoplasia, Amelogenesis imperfecta,
Dentinogenesis imperfecta etc.).
Interproximal caries extending beyond line angles.
Following pulpotomy or pulpectomy.
For restoring a primary tooth that is to be used as an abutment for a space
maintainer.
For the intermediate restoration of fractured teeth.
Restoration and protection of teeth exhibiting extensive tooth surface loss
due to attrition, abrasion or erosion.
In patients with impaired oral hygiene in which the breakdown of intracoronal restorations is likely.
When the tooth cannot be effectively isolated for amalgam or composite
restorations.
Prefabricated Crowns are not indicated for the following:

A primary molar that is close to exfoliation, with more than half the roots
resorbed.

Excessive tooth crown loss resulting in the inability for mechanical
retention.

Loss of space due to tipping of neighboring teeth into carious defect
interfering with the ability to attain proper fit.

As a definitive restoration on a permanent tooth.

For low and moderate caries risk patients, when a more conservative
restoration is indicated.

Solely for cosmetic purposes.

As a prophylactic measure for teeth with no evidence of pathology.
Refer to clinical policy: Prefabricated Crowns (DCP012.01)
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PROCEDURE
Protective restoration
D2940
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Documentation
Recorded in member chart.
Criteria
Direct placement of a restorative material to protect tooth and/or tissue form.
Used to relieve pain, promote healing, or prevent further deterioration.
Covered as a separate procedure only if no other service other than
radiographic images and exam were performed on the same tooth on the same
day.
Not to be used for endodontic access closure, or as a base or liner under a
restoration
Core buildup
D2950
Documentation
Bitewing unless tooth has had root canal therapy, then a periapical
should be submitted.
Note
out of numerical order to keep
code by crown procedures
Criteria
Evidence of extensive caries or at least three surfaces of the tooth have severe
breakdown.
Must be necessary for retention of the crown.
Not covered when procedure only involves a filler to eliminate any undercut,
box form, or concave irregularity in the preparation.
Vertical height of clinical crown must be adequate to support a prosthetic
crown.
Evidence of radiographic decay around an existing restoration and removal of
the filling is clinically indicated.
Not benefited with post/core.
Pin retention per tooth
D2951
Documentation in member record
One per lifetime per tooth
Post and Core
D2952, D2953, D2954, D2957
Post-op endodontic radiographic image required showing adequate root
canal treatment.
Criteria
Only for retention or reinforcement when inadequate tooth structure remains
for retention or to resist masticatory forces.
An anterior tooth with minimal access opening may not require a post/core.
There must be sufficient tooth structure to support a crown.
No periodontal disease and at least 50% bony support.
No benefit for post preparation.
Labial Veneer
D2960–D2962
Documentation
Radiographic image and narrative of medical necessity.
Intraoral photo helpful.
Criteria
May be benefited if the destruction is such that a crown is not recommended
but a direct restoration will not suffice.
Not covered when strictly cosmetic.
Coping
D2975
Documentation
Bitewing or periapical if tooth has had root canal therapy
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Criteria
Only if insufficient natural tooth structure remains to retain the crown or
alignment is a problem.
PROCEDURE
Repairs necessitated by
restorative material failure
D2980–D2999
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Documentation
Narrative required, radiographic images if indicated
ENDODONTICS
Endodontic therapy
D3230, D3240, D3310, D3320,
D3330, D3331, D3332, D3333,
D3346, D3347, D3348
Documentation
Pre and post-operative radiographic image and provider narrative if
pathology is not evident on the film.
Criteria for codes D3110–D3240, D3310–D3333, D3346–D3348, D3351–D3357
Endodontic codes:
D3110–D3240
D3310–D3333
D3346–D3348
D3351–D3357
General documentation requirements
Pre and post endodontic periapical radiographic images showing apex of
tooth.
For retreatment, surgical endodontics, cracked tooth syndrome and
other procedures: pre and post-op images, taken within one year and
narrative if the reason for treatment is not evident on films.
Criteria for codes D3110–D3240, D3310–D3333, D3346–D3348, D3351–D3357
Diagnosis
Diagnostic tests used to determine a diagnosis of irreversible pulpitis or
periapical pathology must be documented in the record.
Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01)
Indications for Coverage – Vital Pulp Therapy
Direct Pulp Cap
Direct pulp capping is indicated for the following:

Tooth has a vital pulp or been diagnosed with reversible pulpitis

All caries has been removed

Mechanical exposure of a clinically vital and asymptomatic pulp occurs

Bleeding is controlled at the exposure site

Exposure permits the capping material to make direct contact with the vital
pulp tissue

Exposure occurs when the tooth is under dental dam isolation
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Adequate seal of the coronal restoration can be maintained

Patient has been fully informed that endodontic treatment may be
indicated in the future
Direct Pulp capping is not indicated for the following:

A carious exposure in primary teeth
Indirect Pulp Cap
Indirect pulp capping is indicated for the following:

Tooth has a vital pulp or been diagnosed with reversible pulpitis

Tooth has a deep carious lesion that is considered likely to result in pulp
exposure during excavation

No history of subjective pretreatment symptoms

Pretreatment radiographs should not show periradicular pathosis
Coverage Limitations and Exclusions for Direct and Indirect Pulp Cap

Limited to once every 36 months

Not to be billed on same day as any definitive restoration

Not to be billed when a liner or a base is placed

Not to be billed as a liner or base when the likelihood of pulpal exposure is
absent
Therapeutic Pulpotomy
Therapeutic pulpotomy is indicated for the following:
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PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
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Exposed vital pulps or irreversible pulpitis of primary teeth
Any bleeding was controlled within several minutes
As an emergency procedure in permanent teeth until root canal treatment
can be accomplished
As an interim procedure for permanent teeth with immature root
formation to allow continued root development
In primary teeth, where there is a reasonable period of retention expected
(approximately one year)
Therapeutic pulpotomy is not indicated for the following:

Primary teeth with insufficient root structure, internal resorption, furcal
perforation or periradicular pathosis that may jeopardize the permanent
successor

As the first stage of complete root canal therapy

Removal of pulp apical to the dentinocemental junction

For primary teeth that are near exfoliation or less than 50% of the tooth
root remains
Coverage Limitations and Exclusions for Therapeutic Pulpotomy

Not to be billed on same day as root canal therapy
Partial Pulpectomy for Apexogenesis
A partial pulpotomy for Apexogenesis is indicated for the following:

In a young permanent tooth for a carious pulp exposure

When the pulpal bleeding is controlled within several minutes

A vital tooth, with a diagnosis of normal pulp or reversible pulpitis
Coverage Limitations and Exclusions for Partial Pulpectomy for Apexogenesis

Not to be billed on same day as any definitive restoration

Not to be billed on same day as a surgical endodontic procedure
Apexification/Recalcification
Apexification/recalcification is indicated for the following and includes all
appointments needed to complete treatment, including intra-operative
radiographs. When closure or repair is complete, nonsurgical root canal
treatment should be completed:

Incomplete apical closure in a permanent tooth root

External root resorption or when the possibility of external root resorption
exists.

Necrotic pulp, irreversible pulpitis or periapical lesion

For prevention or arrest of resorption

Perforations or root fractures that do not communicate with oral cavity
Apexification/recalcification is not indicated for the following:

Tooth with a completely closed apex
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If patient compliance or long term follow up may be questionable
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CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Pulpal Regeneration
Pulpal regeneration is indicated for the following and involves two or more
separate appointments:

Permanent tooth with immature apex

Necrotic pulp

Pulp space not needed for post/core or final restoration

When tooth is not restorable
Pulpal regeneration is not indicated for the following:

Primary teeth

The pulp space would be needed for final restoration
Indications for Coverage – Non Vital Pulp Therapy
Pulpal Debridement (Pulpectomy)
Pulpal Debridement (Pulpectomy) is indicated for the following:

For a restorable permanent tooth with irreversible pulpitis or a necrotic
pulp in which the root is apexified

For the relief of acute pain prior to complete root canal therapy

For a primary tooth, where there is a reasonable period of retention
expected (approximately one year)
Pulpal Debridement (Pulpectomy) is not indicated for the following:

Complete root canal therapy of an infected or necrotic tooth

For primary teeth that are near exfoliation or less than 50% of the tooth
root remains
Coverage Limitations and Exclusions for Pulpal Debridement (Pulpectomy)

Not to be billed on same day as any definitive restoration

Not to be billed on same day as a surgical or non-surgical endodontic
procedure
Pulpal Therapy (resorbable filling) – Primary Teeth
Pulpal Therapy for primary teeth is indicated for the following and includes all
appointments need to complete treatment, as well as intra-operative
radiographs:

For a restorable primary tooth with irreversible pulpitis or a necrotic pulp in
which the root is apexified

The prognosis for keeping the tooth is up to one year and the tooth root
lies in at least 25% bone
Pulpal Therapy is not indicated for the following:

For primary teeth that are near exfoliation or less than 50% of the tooth
root remains

For permanent teeth
Coverage Limitations and Exclusions for Pulpal Therapy – Primary Teeth
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DOCUMENTATION
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Indicated to age 15
Endodontic Therapy
Endodontic Therapy is indicated for the following and includes all appointments
needed to complete treatment including intra-operative radiographs:

For a restorable mature, completely developed permanent or primary
tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure

For teeth with radiographic periapical pathology

For primary teeth without a permanent successor

Trauma

When needed for prosthetic rehabilitation
Endodontic Therapy is not indicated for the following:

Teeth with a poor long term prognosis

Teeth that are considered non-restorable

Teeth with inadequate bone support or advanced or untreated periodontal
disease

Teeth with incompletely formed root apices
Coverage Limitations and Exclusions for Endodontic Therapy

Not for third molars, unless necessary as bridge abutment with a good
prognosis, or if tooth will be in functional occlusion

Not covered solely for cosmetic/aesthetic reasons
Treatment of root canal obstruction; non-surgical access
Treatment of a root canal obstruction is indicated for the following and includes
all appointments needed to complete treatment, including intra-operative
radiographs:

When there is an obstruction of the root canal system, (biological,
iatrogenic ledges or post removal) and endodontic retreatment is needed

Removal of obstruction is complex and/or requires significant time
Treatment of a root canal obstruction is not indicated for the following:

When there is no obstruction evident
Coverage Limitations and Exclusions for Treatment of root canal obstruction

Limited to once per tooth per lifetime

Not billable if tooth has a history of incomplete endodontic therapy or
internal root repair of perforation defects
Incomplete endodontic therapy: inoperable, unrestorable or fractured tooth
Incomplete endodontic therapy is indicated for the following and includes all
appointments needed to complete treatment including intra-operative
radiographs:

During endodontic treatment of a tooth, it becomes apparent that the
procedure cannot be successfully completed

The tooth will not be able to be restored, or the tooth fractures,
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COVERAGE GUIDELINE
DOCUMENTATION
necessitating discontinuation of treatment
Coverage Limitations and Exclusions for Incomplete endodontic therapy

Limited to once per tooth per lifetime
Internal root repair of perforation defects
Internal root repair of perforation defects is indicated for the following and
includes all appointments needed to complete treatment including intraoperative radiographs:

There is a root perforation caused by pathology such as resorption or decay

A communication between the pulp space and external root surface as a
result of internal root resorption.
Internal root repair of perforation defects is not indicated for the following:
Teeth that are considered non-restorable
Teeth with inadequate bone support or advanced untreated periodontal disease
Coverage Limitations and Exclusions for Internal root repair of perforation
defects

Limited to once per tooth per lifetime

Not billable for iatrogenic root perforation
Retreatment of previous root canal therapy
Retreatment of previous root canal therapy is indicated for the following and
includes all appointments needed to complete treatment, including intraoperative radiographs:

Canal fill appears to extend to a point shorter than 2millimeters from the
apex, or extends significantly beyond the apex

Fill appears to be incomplete

Tooth is sensitive to pressure and percussion or other subjective symptoms

The existing endodontics is poor

Placement of a post has the potential to compromise the existing
obturation or apical seal of the canal system

The canal is accessible and allows for retreatment with a non-surgical
procedure
Coverage Limitations and Exclusions for Retreatment of previous root canal
therapy

Original treatment must be at least 8 weeks prior to the retreatment date

Not benefited within 12 months of original treatment if by same dentist
Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01)
Surgical Endodontics
D3410–D3950, D3999
Documentation
Pre and post-operative radiograph image. Provider narrative may be
requested if pathology is not visible.
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Criteria for codes D3410–D3950, D3999
Apicoectomy
Apicoectomy is indicated for the following:

Failed retreatment of endodontic therapy
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION

Date of last root canal treatment if needed.




When the apex of tooth cannot be accessed due to calcification or other
anomaly
Where visualization of the periradicular tissues and tooth root is required
when perforation or root fracture is suspected
Diagnosis of accessory canals or small fractures when post endodontic
therapy symptoms persist
When individual patient considerations make prolonged non-surgical
treatment not practical
A marked over extension of obturating materials interfering with healing
Apicoectomy is not indicated for the following:

Unusual bony or root configurations resulting in lack of surgical access

The possible involvement of neurovascular structures

Teeth that are considered non-restorable

Teeth with inadequate bone support or advanced or untreated periodontal
disease

When non-surgical endodontic treatment has not been attempted or was
not indicated
Periradicular Surgery without Apicoectomy (includes surgery and periradicular
curettage)
Periradicular surgery without apicoectomy is indicated for the following:

Failed retreatment of endodontic therapy

When the apex of tooth cannot be accessed due to calcification or other
anomaly

When a biopsy of periradicular tissue is necessary

Where visualization of the periradicular tissues and tooth root is required
when perforation or root fracture is suspected

Diagnosis of accessory canals or small fractures when post endodontic
therapy symptoms persist

When individual patient considerations make prolonged non-surgical
treatment not practical

A marked overextension of obturating materials interfering with healing
Periradicular surgery without apicoectomy is not indicated for the following:

Unusual bony or root configurations resulting in lack of surgical access

The possible involvement of neurovascular structures

Teeth that are considered non-restorable

Teeth with inadequate bone support or advanced or untreated periodontal
disease

When non-surgical endodontic treatment has not been attempted or was
not indicated
Retrograde Filling
Retrograde filling is indicated for the following:

Periradicular pathosis and a blockage of the root canal system that could
13
PROCEDURE
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DOCUMENTATION



not be obturated by nonsurgical root canal treatment
Persistent periradicular pathosis resulting from an inadequate apical seal
that cannot be corrected nonsurgically.
Root perforations
Resorptive defects
Retrograde filling is not indicated for the following:

When canals are successfully obturated and no evidence of radiographic
pathology or clinical symptoms persist

When a tooth has an overall poor prognosis with or without retrograde
filling placement
Root Amputation
Root amputation is indicated for the following:

Class III furcation involvement

Untreatable bony defect (of one root)

Root fracture

Root caries

Root resorption

Persistent sinus tract or recurrent apical pathology

When there is greater than 75% bone supporting remaining root(s)

The tooth has had successful endodontic treatment on remaining root(s)
Root Amputation is not indicated for the following:

Teeth with an overall poor prognosis with or without root amputation

Vital teeth
Intentional Reimplantation
Intentional replantation is indicated when all of the following clinical conditions
exist:

Persistent periradicular pathosis following endodontic treatment

Nonsurgical retreatment is not possible or has an unfavorable prognosis

Periradicular surgery is not possible or involves a high degree of risk to
adjacent anatomical structures

The tooth presents a reasonable opportunity for removal without fracture

The tooth has an acceptable periodontal status prior to the replantation
procedure
Intentional replantation is not indicated when any of the above criteria are not
met.
Hemisection
Hemisection of multirooted teeth is indicated for the following:

Class III or Class IV periodontal furcation defect

Infrabony defect of one root of a multi-rooted tooth that cannot be
successfully treated periodontally.

Coronal fracture extending into the furcation
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PROCEDURE
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DOCUMENTATION




Vertical root fracture confined to the root to be separated and removed
Carious, resorptive root or perforation defects that are inoperable or
cannot be corrected without root removal
Persistent periradicular pathosis where nonsurgical treatment or
periradicular surgery is not possible and the problem is confined to one
root
The tooth has had successful endodontic treatment on remaining portion
of tooth
Hemisection of multirooted teeth is not indicated for the following:

Teeth with overall poor prognosis with or without hemisection

Vital teeth
Bone Graft in Conjunction With Periradicular Surgery
Bone Graft in conjunction with periradicular surgery is unproven for the
treatment of lesions that are endodontic in origin.
Biologic Materials to Aid In Soft and Osseous Tissue Regeneration in
Conjunction With Periradicular Surgery
Biologic materials to aid in soft and osseous tissue regeneration in conjunction
with periradicular surgery are unproven for the treatment of lesions that are
endodontic in origin.
Guided Tissue Regeneration Resorbable Barrier in Conjunction with
Periradicular Surgery
Guided tissue regeneration, resorbable barrier, per site, in conjunction with
periradicular surgery is unproven for the treatment of lesions that are
endodontic in origin.
Refer to coverage guideline: Surgical Endodontics (DCG010.01)
PERIODONTICS
Surgical Periodontics –
Resective Procedures
D4210
D4211
D4212
D4230
D4231
D4240
D4241
D4245
D4249
D4261
D4274
Documentation/Other for codes D4210, D4211, D4212, D4230, D4231,
D4240, D4241, D4245, D4249, D4261
Full radiographic images (panoramic with bitewings or full periapical
series with bitewings) taken within 24 months. The reviewer will
determine what type of radiographic images are appropriate, given that
the practical reality is that many offices take only panoramic and
bitewing films.
Tooth numbers or site designations.
Periodontal charting performed within 12 months, including six point
probing, furcation, mucogingival relationship, bleeding, case type, oral
hygiene status.
15
Criteria for codes D4210–D4261, D4274
Gingivectomy/Gingivoplasty
Gingivectomy/Gingivoplasty is indicated for the following:

Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is
fibrous and firm and there is an adequate zone of keratinized tissue;

Elimination of gingival enlargements/overgrowth due to medications,
medical conditions or tooth position;

Elimination of suprabony periodontal abscesses;

For exposure of soft tissue impacted teeth to aid in eruption;

To reestablish gingival contour following an episode of acute necrotizing
ulcerative gingivitis;

To allow restorative access, including root surface caries.
PROCEDURE
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Documentation for code D4274
Pre-surgical radiograph images.
Grafts:

One soft tissue graft per two contiguous teeth.

Bone graft and guided tissue regeneration: only one or the other
allowed.

Evidence of mobility, bruxism and/or hyperocclusion may
contraindicate grafting
Gingivectomy/Gingivoplasty is not indicated for the following:

When bone surgery is required for infrabony defects, or for the purpose of
examining bone shape and morphology;

Situations in which the bottom of the pocket is apical to the mucogingival
junction;

Areas where aesthetics are a concern (particularly in the anterior maxilla);

In areas with a shallow palatal vault or prominent external oblique ridge;

Severely edematous or inflamed tissue;

Patients with poor plaque control or non-compliance with non-surgical
procedures;

Patients with an uncontrolled underlying medical condition;

Solely for cosmetic/aesthetic purposes.
Anatomical Crown Exposure
Anatomical Crown exposure is indicated for the following:

In an otherwise periodontally healthy area to facilitate the restoration of
subgingival caries;

In an otherwise periodontally healthy area to allow proper contour of
restoration;

In an otherwise periodontally healthy area to allow management of a
fractured tooth in which the fracture extends subgingivally.
Anatomical Crown exposure is not indicated for the following:

Solely for cosmetic/aesthetic purposes;

Patients with an uncontrolled underlying medical condition.
Gingival Flap Procedure
Gingival flap procedure is indicated for the following (includes root planing):

The presence of moderate to deep probing depths;

Loss of attachment;

The need for increased access to root surface and/or alveolar bone when
previous non-surgical attempts have been unsuccessful;

The diagnosis of a cracked tooth, fractured root or external root resorption
when this cannot be accomplished by non-invasive methods.
Gingival flap procedure is not indicated for the following:

Solely for cosmetic/aesthetic purposes;

Patients with an uncontrolled underlying medical condition;

Patients who have been non-compliant with previous periodontal
therapies.
Apically Positioned Flap Procedure
Apically Positioned Flap Procedure is indicated for the following:

The presence of moderate to deep probing depths;

Loss of attachment;
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PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
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DOCUMENTATION



The need for increased access to root surface and/or alveolar bone when
previous non-surgical attempts have been unsuccessful;
The diagnosis of a cracked tooth, fractured root or external root resorption
when this cannot be accomplished by non-invasive methods;
To preserve keratinized tissue in conjunction with osseous surgery.
Apically Positioned Flap Procedure is not indicated for the following:

Solely for cosmetic/aesthetic purposes;

Patients with an uncontrolled underlying medical condition;

Patients who have been non-compliant with previous periodontal
therapies.
Clinical Crown Lengthening-Hard Tissue
Clinical Crown Lengthening-Hard Tissue is indicated for the following:

In an otherwise periodontally healthy area to allow a restorative procedure
on a tooth with little to no crown exposure.
Clinical Crown Lengthening-Hard Tissue is not indicated for the following:

As treatment for periodontal disease;

Solely for cosmetic/aesthetic purposes;

Patients with an uncontrolled underlying medical condition.
Osseous Surgery
Osseous surgery is indicated for the following:

Patients with a diagnosis of moderate to advanced periodontal disease;

For cases of refractory periodontal disease;

When less invasive therapy (i.e. non-surgical periodontal therapy, flap
procedures) has failed to eliminate disease.
Osseous surgery is not indicated for the following:

Patients with a diagnosis of mild periodontal disease;

For teeth with a hopeless prognosis (more than 80% bone loss and Class 3
or higher mobility);

Patients with an uncontrolled underlying medical condition;

Patients who have been non-compliant with previous periodontal
therapies.
Distal or Proximal Wedge (when not performed in conjunction with surgical
procedures in the same anatomical area)

Distal or Proximal Wedge procedure is indicated for the following:

The presence of moderate to deep probing depths (greater than 5mm) on a
surface adjacent to an edentulous/terminal tooth area;

The need for increased access to root surface and/or alveolar bone when
previous non-surgical attempts have been unsuccessful on a surface
adjacent to an edentulous/terminal tooth area;

The diagnosis of a cracked tooth, fractured root or external root resorption
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PROCEDURE
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on a surface adjacent to an edentulous/terminal tooth area, when this
cannot be accomplished by non-invasive methods.
Distal or Proximal Wedge procedure is not indicated for the following:

Solely for cosmetic/aesthetic purposes;

Patients with an uncontrolled underlying medical condition;

Patients who have been non-compliant with previous periodontal
therapies;

In areas in which there are teeth with proximal contact.
Refer to clinical policy: Surgical Periodontics: Resective Procedures (DCP013.01)
Surgical Periodontics –
Regenerative Procedures
D4263
D4264
D4265
D4266
D4267
D4268
D4999
Codes D4265, D4266, D4267 and
D4999 are each addressed in the
Regenerative, Mucogingival and
Resective Surgical Periodontics
clinical policies.
Documentation
Full radiographic images (panoramic image) with bitewings or full
periapical series with bitewings) taken within 24 months. The reviewer
will determine what type of radiographic images are appropriate, given
that the practical reality is that many offices take only panoramic and
bitewing films.
Tooth numbers or site designations.
Periodontal charting performed within 12 months, including six point
probing, furcation, mucogingival relationship, bleeding, case type, oral
hygiene status.
Criteria for codes D4263–D4268, D4999
Bone Replacement Grafts
Bone Replacement Grafts are indicated for the following:

Infrabony/Intrabony vertical defects;

Class II furcation involvements.
Bone Replacement Grafts are not indicated for the following:

Class I furcation involvement;

Class III or higher furcation involvement;

Non-vertical defects;

Patients with an uncontrolled underlying medical condition;

Patients who have been non-compliant with previous periodontal
therapies;

Patients with poor oral hygiene;

Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or
higher mobility).
Biologic Materials to Aid in Soft and Osseous Tissue Regeneration
Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated
for the following:

Intrabony/Infrabony vertical defects;

Class II furcation involvements.
Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are not
indicated for the following:

Class I and Class III or higher furcation involvement;

Non-vertical defects;

Patients with an uncontrolled underlying medical condition;

Patients who have been non-compliant with previous periodontal
therapies;

Patients with poor oral hygiene;

Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or
higher mobility).
18
PROCEDURE
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Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier
(includes membrane removal)
Guided Tissue Regeneration is indicated for the following:

Intrabony/infrabony vertical defects;

Class II furcation involvements.
Guided Tissue Regeneration is not indicated for the following:

Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or
higher mobility);

Class I furcation involvement;

Class III or higher furcation involvement;

Horizontal bone loss;

Non-vertical defects;

Patients with an uncontrolled underlying medical condition;

Patients who have been non-compliant with previous periodontal
therapies;

Patients with poor oral hygiene;

Crater defects.
Surgical Revision Procedure (per tooth)
Surgical Revision Procedure is indicated to correct an abnormal healing response
that interferes with the therapeutic goals of the original regenerative surgical
procedure.
Surgical Revision Procedure is not indicated solely for cosmetic/aesthetic
purposes.
Refer to clinical policy: Surgical Periodontics: Regenerative Procedures
(DCP014.01)
Surgical Periodontics –
Mucogingival Procedures
D4270
D4273
D4275
D4276
D4277
D4278
D4283
D4285
Codes D4265, D4266, D4267 and
D4999 are each addressed in the
Regenerative, Mucogingival and
Resective Surgical Periodontics
clinical policies.
Documentation/Other
Criteria for codes D4265–D4267, D4270–D4273, D4275–D4278, D4283, D4285,
D4999
Pedicle soft tissue graft (D4270) is not benefited at the same time with
other periodontal surgery.
Soft tissue grafts are benefitted once per two contiguous teeth
Documentation (see Note)
Full radiographic images (panoramic with bitewings or full periapical
series with bitewings) taken within 24 months. The reviewer will
determine what type of radiographic images are appropriate, given that
the practical reality is that many offices take only panoramic and
bitewing films.
Tooth numbers or site designations.
19
Pedicle Soft Tissue Graft Procedure
Pedicle Soft Tissue Graft Procedure is indicated for the following:

Areas with less than 2 mm of attached gingiva;

Unresolved sensitivity in areas of recession;

Progressive recession or chronic inflammation;

For teeth with subgingival restorations where there is little or no attached
gingiva to improve plaque control;

Ridge augmentation;

To increase vestibular depth for the correct fit of prosthesis;

To widen zone of attached gingiva for prosthetic abutment teeth;

To increase vestibular depth to allow proper oral hygiene techniques;

Gingival clefting.
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
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DOCUMENTATION
Periodontal charting performed within 12 months, including six point
probing, furcation, mucogingival relationship, bleeding, case type, oral
hygiene status.
Pedicle Soft Tissue Graft Procedure is not indicated for the following:

Roots covered with thin bony plates;

Patients with an untreated medical condition.
Note
No radiographs required for the following codes:
D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285
Autogenous Connective Tissue Graft
Autogenous connective tissue graft is indicated for the following:

Areas with less than 2 mm of attached gingiva;

Unresolved sensitivity in areas of recession;

Progressive recession or chronic inflammation;

For teeth with subgingival restorations where there is little or no attached
gingiva to improve plaque control;

Ridge augmentation;

To increase vestibular depth for the correct fit of prosthesis;

To widen zone of attached gingiva for prosthetic abutment teeth;

To increase vestibular depth to allow proper oral hygiene techniques;

Gingival clefting.
Autogenous connective tissue graft is not indicated for the following:

Broad, shallow palatal donor site;

Excessively glandular or fatty submucosal tissue in donor site;

A donor site with roots covered with thin bony plates;

Patients with an untreated medical condition.
Non-Autogenous Connective Tissue Graft
Non-autogenous connective tissue graft is indicated for the following:

Areas with less than 2 mm of attached gingiva;

Unresolved sensitivity in areas of recession;

Progressive recession or chronic inflammation;

For teeth with subgingival restorations where there is little or no attached
gingiva to improve plaque control;

Ridge augmentation;

To increase vestibular depth for the correct fit of prosthesis;

To widen zone of attached gingiva for prosthetic abutment teeth;

To increase vestibular depth to allow proper oral hygiene techniques;

Gingival clefting.
Non-autogenous connective tissue graft is not indicated for the following:

When indications for connective tissue grafting are not met;

Patients with an untreated medical condition.
Combined Connective and Double Pedicle Graft
Combined Connective and Double Pedicle Graft is indicated for the following:

Areas with less than 2 mm of attached gingiva;

Unresolved sensitivity in areas of recession;

Progressive recession or chronic inflammation;
20
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION






For teeth with subgingival restorations where there is little or no attached
gingiva to improve plaque control;
Ridge augmentation;
To increase vestibular depth for the correct fit of prosthesis;
To widen zone of attached gingiva for prosthetic abutment teeth;
To increase vestibular depth to allow proper oral hygiene techniques;
Gingival clefting.
Combined Connective and Double Pedicle Graft is not indicated for the
following:

Roots covered with thin bony plates;

Patients with an untreated medical condition.
Free Soft Tissue Graft Procedure (including donor site surgery)
Free Soft Tissue Graft Procedure is indicated for the following:

Unresolved sensitivity in areas of recession;

Progressive recession or chronic inflammation;

For teeth with subgingival restorations where there is little or no attached
gingiva to improve plaque control;

To increase vestibular depth for the correct fit of prosthesis;

To widen zone of attached gingiva for prosthetic abutment teeth;

To increase vestibular depth to allow proper oral hygiene techniques;

Gingival clefting.
Free Soft Tissue Graft Procedure is not indicated for the following:

Broad, shallow palatal donor site;

Excessively glandular or fatty submucosal tissue in donor site;

A donor site with roots covered with thin bony plates;

Patients with an untreated medical condition.
Biologic Materials to Aid in Soft and Osseous Tissue Regeneration
Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated
for the following:

To enhance periodontal tissue regeneration and healing for mucogingival
defects in conjunction with mucogingival surgeries with or without guided
tissue regeneration.
Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier
(includes membrane removal)
Guided Tissue Regeneration is indicated for the following:

For sensitivity in areas of recession;

Progressive recession or chronic inflammation;

Areas of bone dehiscence and fenestration’

Single tooth, wide and deep localized recession;

For areas associated with failed cervical restorations.
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Guided Tissue Regeneration is not indicated for the following:

Multiple adjacent tooth sites of root coverage required;

Solely for cosmetic/aesthetic purposes.
Refer to clinical policy: Surgical Periodontics: Mucogingival Procedures
(DCP015.01)
Provisional Splinting
D4320, D4321
Full radiographic images (panoramic image with bitewings or full
periapical series with bitewings) taken within 24 months. The reviewer
will determine what type of radiographic images are appropriate, given
that the practical reality is that many offices take only panoramic and
bitewing films.
Criteria for codes D4320–D4321
Tooth numbers or site designations.
Provisional Splinting using these codes is not indicated for the following:

Tooth transplantation;

Trauma resulting in the reimplantation of completely avulsed tooth/teeth;

Trauma resulting in displacement or fracture of tooth/teeth.
Periodontal charting performed within 12 months, including six point
probing, furcation, mucogingival relationship, bleeding, case type, oral
hygiene status.
Provisional Splinting using these codes is indicated for the following:

Multiple teeth that have become mobile due to loss of alveolar bone loss
and periodontium;

During surgical and healing phases of regenerative periodontal therapy.
Coverage Limitations and Exclusions for Provisional Splinting

Limited to once per 36 months per same tooth/teeth.

Not to be billed on same day as any restoration, prostheses or implant for
same tooth/teeth.
Refer to coverage guideline: Provisional Splinting (DCG011.01)
Non-Surgical Periodontal Therapy
D4341, D4342, D4381, D4910
Documentation
Full radiographic images (panoramic image with bitewings or full
periapical series with bitewings) taken within 24 months. The reviewer
will determine what type of radiographic images are appropriate, given
that the practical reality is that many offices take only panoramic and
bitewing films.
Tooth numbers or site designations.
Periodontal charting performed within 12 months, including six point
probing, furcation, mucogingival relationship, bleeding, case type, oral
hygiene status.
Criteria for codes D4341, D4342, D4381, D4910
Scaling and Root Planing
Scaling and Root planing is indicated for any of the following:

Localized or generalized mild chronic periodontal disease-characterized by
1-2 millimeters of clinical attachment loss (CAL).

Localized or generalized moderate chronic periodontal diseasecharacterized by 3-4 millimeters clinical attachment loss (CAL). In molars,
furcation involvement not to exceed Class 1.

Localized or generalized severe periodontal disease-characterized by more
than 5 millimeters of CAL.

Chronic refractory mild or moderate periodontal disease-characterized by
patients who demonstrate additional attachment loss despite being
longitudally monitored with periodontal maintenance.

Periodontal abscess characterized by localized swelling and/or increased
probing depth and loss of periodontal attachment.
Scaling and root planing is not indicated for the following:

In the absence of diagnosed periodontal disease.

For the removal of heavy deposits of calculus and plaque.

Gingivitis defined as inflammation of the gingival tissue without loss of
22
PROCEDURE
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DOCUMENTATION


attachment (bone and tissue).
As a sole treatment for chronic periodontitis with advanced loss of support
demonstrated by pockets greater than 6 millimeters with CAL greater than
4 millimeters, and radiographic bone loss. Mobility may or may not be
present.
As a sole treatment for refractory chronic, aggressive or advanced
periodontal diseases.
Localized Delivery of Antimicrobial Agents
Localized Delivery of Antimicrobial Agents is indicated as an adjunct to scaling
and root planing in cases of refractory disease and/or residual probing depths
greater than or equal to 5 millimeters with inflammation that are still present
following conventional therapies.
Localized Delivery of Antimicrobial Agents is unproven and not indicated in the
absence of periodontal scaling and root planing (SRP) procedure.
Periodontal Maintenance
Periodontal Maintenance is indicated for the following:

To maintain the results of non-surgical periodontal scaling and root planing
therapy and prevent recurrent disease.

As an extension of active periodontal therapy at selected intervals.
Periodontal Maintenance is not indicated for the following:

No history of scaling and root planing (SRP) or surgical procedures.

Gingivitis – defined as inflammation of the gingival tissue without loss of
attachment (bone and tissue).
Gingival Irrigation Per Quadrant
Gingival Irrigation per quadrant is unproven.
There is limited evidence to support the efficacy of a single episode or multiple
in office irrigation appointments. The available studies show the greatest
problem with irrigation as an adjunctive therapy is that the antimicrobials are
quickly eliminated.
Refer to clinical policy: Non-Surgical Periodontal Therapy (DCP.004.01)
Full Mouth Debridement
D4355
Full radiographic images (panoramic image with bitewings or full
periapical series with bitewings) taken within 24 months. The reviewer
will determine what type of radiographic images are appropriate, given
that the practical reality is that many offices take only panoramic and
bitewing films.
Tooth numbers or site designations.
Periodontal charting performed within 12 months, including six point
probing, furcation, mucogingival relationship, bleeding, case type, oral
23
Criteria for codes D4355
Indications for Coverage
Full Mouth Debridement is a covered dental service and indicated when the
following criteria have been met:

Heavy calculus is present on teeth and usually visible on radiographs.

Due to the amount of calculus, plaque and debris, a comprehensive
examination and diagnosis is not possible.
Coverage Limitations and Exclusions

Limited to once every 36 months.
PROCEDURE
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
hygiene status.


Not to be billed on same day as any exam code or non-surgical periodontal
therapy code.
Not to be billed within 12 months of prophylaxis or periodontal
maintenance.
Not to be used as a therapeutic or preventive procedure such as scaling
and root planing or prophylaxis.
Refer to coverage guideline: Full Mouth Debridement (DCG.001.01)
Unscheduled Dressing Change
D4920
Gingival Irrigation – per quadrant
D4921
REMOVABLE PROSTHETICS
Removable Prosthodontics
D5110–D5899
Documentation
Full mouth radiographic images.
Criteria for codes D5110–D5140, D5211–D5281, D5410–D422, D5510, D5520,
D5610–D5671, D5710–D5721, D5730–D5761, D5810–D5821, D5850–D5875
Complete dentures
D5110–D5140
Tooth numbers for missing teeth to be replaced, and other missing
teeth.
Partial dentures
D5211–D5281
Date of extractions if indicated.
Removable prosthodontic appliances are indicated for replacement of missing
teeth loss to disease or injury. The following outlines indications and coverage
guidelines for complete and partial removable prosthodontics.
Adjustments to Dentures
D5410–D5422
Age of existing prosthesis.
Immediate denture: X-rays showing at least one tooth present and
severe periodontal disease or caries.
Repair to Complete Dentures
D5510, D5520
Repair to Partial Dentures
D5610–D5671
Complete Dentures
Complete dentures are indicated for the following:

To replace teeth that are non-restorable due to gross caries and/or
advanced periodontal disease

To replace teeth lost due to orofacial trauma

To replace teeth lost due to oral cancer surgery and subsequent
reconstruction
Complete Dentures are not indicated for the following:

When there is no evidence of dental disease

When teeth appear to be restorable

When there has been extensive bone atrophy resulting in an inadequate
edentulous ridge for retention of appliance

Patient convenience
Denture Rebase Procedures
D5710–D5721
Denture Reline Procedures
D5730–D5761
Coverage Limitations

Limited to once per 60 months from initial or supplemental placement

Not allowed if within 60 months of an existing partial denture, interim
partial denture, removable partial denture, pontic, retainer, inlay
abutment, crown abutment, onlay abutment, or an interim retainer crown
for same tooth

Not allowed if there is a history of an implant, implant abutment, denture,
or interim partial for the same tooth
Interim partial dentures
D5810–D5821
Other Removable Prosthetic
Services
D5850–D5875
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Partial Dentures
Partial Dentures are indicated for the following:

To replace teeth that are non-restorable due to gross caries and/or
advanced periodontal disease

To replace teeth lost due to trauma or injury

When a fixed partial denture is contraindicated (e.g., immediately following
extractions, for a long edentulous span, distal extension needs, a
periodontally involved dentition, resorption and loss of edentulous ridge)
Partial Dentures are not indicated for the following:

Chronic poor oral hygiene

Severe periodontal disease with questionable ability to support a partial
denture
Coverage Limitations

Limited to once per 60 months

Not allowed if within 60 months of an existing partial denture, interim
partial denture, removable partial denture, pontic, retainer, inlay
abutment, crown abutment, onlay abutment, or an interim retainer crown
for same tooth

Not allowed if there is a history of an implant, implant abutment, denture,
or interim partial for the same tooth
Complete and Partial Denture Rebase Procedures
Rebasing of removable appliances is considered inclusive for the first 6 months,
and then subject to frequency limitations. For immediate dentures, one rebase
covered in the first six months; then additional rebasing subject to frequency
limitations.
Denture Rebasing is indicated for the following:

When there is a space between base and residual ridge

When appliance has become mobile or unstable

When replacing or rearranging teeth on the appliance

When the base has fractured or cracked
Denture Rebasing is not indicated for the following:

When the appliance is broken or worn to the extent that replacement is
warranted

When the occlusion or structural integrity of the denture teeth are no
longer functional

When reline is sufficient
Complete and Partial Denture Reline Procedures
Relining of removable appliances is considered inclusive for the first 6 months,
and then subject to frequency limitations. For immediate dentures, one reline
covered in the first six months; then additional relining subject to frequency
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limitations.
Denture Relining is indicated for the following:

When appliance has become mobile or unstable

To reestablish a soft tissue base for a distal extension appliance when
denture rotation is evident

When there has been loss of occlusal contact with opposing arch
Denture Relining is not indicated for the following:

When the appliance is broken or worn to the extent that replacing the
appliance is warranted

When the occlusion or structural integrity of the denture teeth are no
longer functional
Interim Prosthesis
Interim Prostheses are indicated for the following:

While tissue is healing following extractions

For the maintenance of a space for future permanent treatment such as an
implant, bridge or definitive fixed appliance

To condition teeth and ridge tissue for optimum support of a definitive
removable partial denture

To maintain established jaw relation until all restorative treatment has
been completed and a definitive partial denture can be constructed
Interim Prostheses are not indicated for the following:

As a permanent, definitive prosthesis
Overdentures
Overdentures are indicated for the following:

To preserve the integrity of the edentulous ridge

When there are teeth available as abutments that have a good long term
prognosis
Overdentures are not indicated for the following:

When there has been significant deterioration of the edentulous ridge

When the teeth available as abutments do not have a good long term
prognosis

For patients with poor oral hygiene and non-compliance
Tissue Conditioning
Tissue Conditioning is considered inclusive for the first 12 months, and is then
subject to frequency limitations.
Tissue Conditioning is indicated for the following:

In the presence of inflammation and irritation of the mucosa covering denture-bearing areas

When there is distortion of normal anatomic structures, such as incisive
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

papillae, rugae, and retromolar pads
A burning sensation in residual ridge areas, the tongue, and the cheeks and
lips not related to a systemic medical condition
Subsequent to placement of immediate dentures to facilitate short term
denture retention
Tissue Conditioning is not indicated for the following:

For long term appliance stability and/or comfort
Repairs and Adjustments
Repairs and adjustments of removable appliances are considered inclusive for
the first 12 months, and are then subject to frequency limitations. Adding teeth
to appliances is also subject to frequency limitations.
Maxillofacial Prosthetics
These are removable appliances for the loss of orofacial structures due to
trauma, congenital deformity or destruction of structures due to cancer and
resection. This code section also includes radiation shields, carriers for fluoride,
radiation carriers, as well as specific medicaments. These removable prosthetics
are considered to be medical in nature and are typically covered under the
member’s medical plan. Please see appropriate medical policy.
Exclusions
The following are excluded from coverage:

Any Dental Procedure performed solely for cosmetic/aesthetic reasons.
(Cosmetic procedures are those procedures that improve physical
appearance.)

Replacement of complete dentures, and fixed and removable partial
dentures or crowns, if damage or breakage was directly related to provider
error. This type of replacement is the responsibility of the Dentist. If
replacement is necessary because of patient non-compliance, the patient is
liable for the cost of replacement.

Fixed or removable prosthodontic restoration procedures for complete oral
rehabilitation or reconstruction.

Attachments to conventional removable prostheses or fixed bridgework.
This includes semi-precision or precision attachments associated with
partial dentures, crown or bridge abutments, full or partial overdentures,
any internal attachment associated with an implant prosthesis, and any
elective endodontic procedure related to a tooth or root involved in the
construction of a prosthesis of this nature.

Procedures related to the reconstruction of a patient's correct vertical
dimension of occlusion (VDO).

Placement of fixed partial dentures solely for the purpose of achieving
periodontal stability.
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Clinical situations that can be effectively treated by a less costly dental
appropriate alternative procedure will be assigned a benefit based on the least
costly procedure.
Refer to coverage guideline: Removable Prosthodontics (DCG020.01)
MAXILLOFACIAL PROSTHETICS
Maxillofacial Prosthetics
D5900–D5999
Documentation
Narrative
Radiographic images if indicated
IMPLANTS
D6010–D6013, D6040–D6050,
D6104, D6199
Documentation

Single implant: periapical acceptable; request full mouth images or
panoramic image if needed.

More than one implant: full mouth images or panoramic image
required.

Bone graft at time of implant placement: periapical pre-op
radiograph, request full mouth images or panoramic image if
needed.
Criteria for codes D6010–D6013, D6040–D6050, D6104, D6199
A dental implant is an artificial tooth root that is placed into the jaw to hold a
replacement tooth or bridge. Adequate bone in the jaw is needed to support the
implant, and recipients should have healthy gum tissues that are free of
periodontal disease. For most plans, implants are not covered, but for those
plans that do have coverage, the following identify guidelines for implant
placement:

The implant site must be osseointegrated prior to loading.

Implant must have adequate crown/root ratio.

Must not have more than two threads above the alveolar crest.

Implant must not be closer than 1-1.5mm to adjacent roots.

Same day implant placement at time of extraction considered acceptable.

No direct loading of abutment and/or fixed prosthesis on date of implant
placement.

Periodontal health of existing dentition must be favorable.

Long term prognosis must be favorable.

Site is free of acute infection.
Factors to consider in treatment planning for implants:

Location of tooth/teeth;

Bone quality/quantity;

Periodontal status;

Restorability;

Patient cost;

Patient age (implants not appropriate for patients under age 15);

Patients undergoing strong chemotherapy;

Myocardial infarction: within 6 months of an attack;

Anticoagulant therapy;

Severe neuropsychiatric disease, mental disability, and narcotic drug
addicts ;

Severe blood diseases;
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
Systemic Risk Factors:
o Smoking
o Diabetes
o Hypertension
o Decreased estrogen levels in postmenopausal women
o Use of IV bisphosphonates
Refer to coverage guideline: Implant Placement (DCG.007.01)
D6101–D6103
Interim abutment
D6051
Documentation
Pre-op periapical; request full mouth images or panoramic image if
needed.
Review for medical necessity
Documentation/Criteria

Post of radiograph to confirm interim abutment.

Includes placement and removal.

Healing cap is not an interim abutment.

Loading of interim abutment on the same day as implant placement
is acceptable for anterior teeth to allow for an esthetic temporary
crown/bridge.
FIXED PROSTHETICS
Fixed Prosthodontics
D6205–D6999
Documentation
Radiographic images: full periapical set with bitewings. Panoramic with
bitewings and PA of area (not preferable/panoramic needs to be high
quality) of involved teeth, as well as contralateral and opposing sites.
Pontic must be at least 2/3 the size of the tooth being replaced.
Repair: Reviewer may request narrative if needed.
Replacement: Reviewer may request narrative if needed.
Criteria for codes D6205–D6999
Fixed Partial Dentures (FPD)
Fixed partial dentures are indicated for the following:

For the replacement of missing teeth in which the retainer teeth have a
favorable long term prognosis

For the replacement of one to two missing posterior teeth in a tooth
bounded space
In addition to the above, the following applies:

Resin bonded appliances are indicated for the replacement of one missing
tooth and an unrestored abutment tooth with significant clinical crown
length
Fixed partial dentures are not indicated for the following:

Patients with rampant caries

Patients with poor oral hygiene

When retainer teeth have untreated endodontic pathology or periodontal
disease or an unfavorable crown: root ratio

When teeth intended as retainers have inadequate remaining tooth
structure

For the primary dentition

When an arch or dentition is deemed terminal

When tooth to be used as a retainer has tipped or drifted into edentulous
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space, rendering seating of retainer difficult or impractical
In addition to the above, the following applies:

Cantilever FPD is not indicated in an area with significant malocclusion,
heavy occlusion or parafunctional habits (e.g., nail biting, bruxism,
clenching)

Resin bonded FPD is not indicated when there is a pontic width
discrepancy, in patients with parafunctional habits (e.g., nail biting,
bruxism, clenching), in an area with significant malocclusion or heavy
occlusion

Resin bonded FPD is not indicated as a temporary prosthesis
Provisional Fixed Partial Dentures
Provisional Fixed Partial Dentures are indicated for the following:

When the prognosis of a permanent fixed partial denture is questionable
due to periodontal involvement, endodontic pathology or patient
compliance

To replace a lost tooth in young patients to allow maturity of the dentition
and jaws before constructing a definitive fixed prosthetic appliance

When a systemic medical condition prohibits the placement of a definitive
fixed prosthetic appliance
Provisional Fixed Partial Dentures are not indicated for the following:

As a definitive fixed partial denture unless indicated by above criteria
Fixed Partial Denture Repair (Necessitated by Restorative Material Failure)
Fixed partial denture repair is indicated for the following:

When the appliance to be repaired is functional and has a favorable long
term prognosis
Fixed partial denture repair is not indicated for the following:

For porcelain fracture if margins are intact and functional area not involved
Precision Attachments
Precision attachments are indicated for the following:

When aesthetics need to be considered

For the redistribution of occlusal forces

To minimize trauma to soft tissue

For the control of loading and rotational forces

When it is not possible to prepare two abutments with a common path of
placement

When the prognosis of an abutment is uncertain
Connector Bar
Connector bars are indicated to brace individual abutment teeth with
considerable coronal length for enhances stabilization of removable partial
dentures, complete dentures and overdentures.
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Stress Breaker (a non-rigid connector)
Stress Breakers are indicated for the following:

When it is not possible to prepare two abutments with a common path of
placement

When the prognosis of an abutment is uncertain

Control of loading and rotational forces

For the redistribution of occlusal forces
Exclusions
The following are excluded from coverage:

Any Dental Procedure performed solely for cosmetic/aesthetic reasons.
(Cosmetic procedures are those procedures that improve physical
appearance.)

Replacement of complete dentures, and fixed and removable partial
dentures or crowns, if damage or breakage was directly related to provider
error. This type of replacement is the responsibility of the Dentist. If
replacement is necessary because of patient non-compliance, the patient is
liable for the cost of replacement.

Fixed or removable prosthodontic restoration procedures for complete oral
rehabilitation or reconstruction.

Attachments to conventional removable prostheses or fixed bridgework.
This includes semi-precision or precision attachments associated with
partial dentures, crown or bridge abutments, full or partial overdentures,
any internal attachment associated with an implant prosthesis, and any
elective endodontic procedure related to a tooth or root involved in the
construction of a prosthesis of this nature.

Procedures related to the reconstruction of a patient's correct vertical
dimension of occlusion (VDO).

Placement of fixed partial dentures solely for the purpose of achieving
periodontal stability.
Coverage Limitations

Replacement of complete dentures, fixed or removable partial dentures,
crowns, inlays or onlays previously submitted for payment under the plan is
limited to 1 time per consecutive 60 months from initial or supplemental
placement.

Limited to repairs or adjustments performed more than 12 months after
the initial insertion. Limited to 1 per consecutive 6 months.

Limited to 1 time per tooth per consecutive 60 months.

Stress breakers, and connector bars are not covered

Clinical situations that can be effectively treated by a less costly alternative
procedure will be assigned a benefit based on the least costly procedure.
Refer to coverage guideline: Fixed Prosthodontics (DCG017.01)
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ORAL SURGERY
D7111–D7999
Documentation
Dated and labeled radiographic images including panoramic image or
periapicals usually taken within one year and appropriate to document
the case.
Alternate benefit permitted if submitted code is not supported by
documentation.
Panoramic, periapicals, or tomography for third molar extractions are
indicated by the clinical presentation.
Narrative:

If reason for extraction is not apparent

For bicuspid with no apparent pathology, to determine if
orthodontic extractions

D7241, full bony impaction with complications

D7260, oroantral closure

D7270, reimplantation (copy of accident report helpful)

D7340, 7350, vestibuloplasty

D7953, bone graft for ridge preservation

D7970, excision of hyperplastic tissue
Cyst removal (D7450, 7451, 7460, 7461): Documentation of special
services; size greater than 1.25mm and/or unrelated to tooth removal;
operative notes and pathology report.
Treatment notes if radiographic information not conclusive.
Extractions
D7210–D7250
Criteria




Inappropriate removal of teeth to construct full dentures is excluded.
Patient preference in the absence of clinical indications, is not sufficient
Must be pathology involved (non-restorable caries, untreatable periodontal
disease, untreatable endodontic disease)
Exception to above may be made based on underlying medical condition
Extraction of bicuspids may be ortho-related and fall under that benefit
Bone graft with extraction is not a benefit unless a significant residual defect is
present
Inclusive components
Sutures, local anesthesia, normal post-op care
Third molar removal
Classification is based on anatomic position of the tooth, not the technique
required for its removal. Classification is based on ADA CDT descriptor for the
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code submitted. See codes for specific guidelines.
Extraction includes removal of soft tissue including but not limited to
granulomatous, follicular or minor cystic tissue associated with the tooth.
No bone graft is allowed unless a significant residual defect remains and is
radiographically documented post op.
ERUPTED THIRD MOLAR – one that is so positioned that the entire clinical crown
in visible
PARTIALLY ERUPTED THIRD MOLAR – one that is so positioned that only a
portion of the clinical crown is visible
UNERUPTED/IMPACTED THIRD MOLAR – one that has not penetrated through
bone and/or soft tissue and entered the oral cavity.
Non-Surgical Extractions
D7111, D7140
Documentation
Pre-operative radiographic images
Criteria for codes D7111, D7140
Non-Surgical Extractions
Non-surgical extractions are indicated for the following:

For non-restorable teeth

For teeth in which previous restorative, endodontic or periodontal
treatment has failed

Teeth with periapical pathology evident

Supernumerary teeth

Crowding/nonfunctional teeth

Orthodontic considerations

For primary teeth with roots retained in bone or soft tissue that is
interfering with eruption of permanent teeth

For primary canines to correct eruption pattern of a permanent canine that
is palatally displaced

Interference with prosthodontic needs
Non-surgical extractions are not indicated when the clinical condition requires a
surgical procedure (e.g., tooth impaction). Please refer to the Surgical Extraction
of Impacted Teeth and Surgical Extraction of Erupted Teeth and Retained Roots
dental policies.
Coverage Limitations
Limited to one extraction per tooth, per lifetime
Refer to coverage guideline: Non-Surgical Extractions (DCG022.01)
Surgical Extraction of Erupted
Teeth and Retained Roots
D7210, D7250
Documentation
Dated and labeled radiographic images including panoramic image or
periapicals usually taken within one year and appropriate to document
the case.
33
Criteria for codes D7210, D7250
Surgical Extraction of an Erupted Tooth
Surgical extraction of an erupted tooth is indicated for any of the following:

No clinical crown is visible in the mouth;
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
Panoramic, periapicals, or tomography for third molar extractions are
indicated by the clinical presentation.
Treatment notes if radiographic information not conclusive.









There is insufficient remaining clinical crown to allow a non-surgical
extraction;
The fracture of a tooth or roots during a non-surgical extraction procedure;
Erupted teeth with unusual root morphology (dilacerations, cementosis);
Erupted teeth with developmental abnormalities that would make nonsurgical extraction unsafe or cause harm;
When fused to an adjacent tooth;
In the presence of periapical lesions;
For maxillary posterior teeth whose roots extend into the maxillary sinus;
When severe crowding or ectopic position of the tooth is present;
When tooth has been crowned or been treated endodontically;
Other conditions as deemed necessary by a licensed dentist.
Surgical extraction is not proven or indicated for the following:

When a conservative non-surgical procedure is possible;

When the Indications for Coverage criteria above are not met.
Surgical Removal of Residual Tooth Roots
Surgical removal of residual tooth roots is indicated for the following:

When tooth roots, or fragments of tooth roots remain in the bone
following a previous incomplete tooth extraction;

Extreme tooth decay resulting in the destruction of the dentition to the
extent that only root tips remain.
Refer to coverage guideline: Surgical Extraction of Erupted Teeth and Retained
Roots (DCG.005.01)
Surgical Extraction of Impacted
Teeth
D7220
D7230
D7240
D7241
D7251
Documentation
Dated and labeled radiographic images including panoramic image or
periapicals usually taken within one year and appropriate to document
the case.
Panoramic, periapicals, or tomography for third molar extractions are
indicated by the clinical presentation.
Narrative:

If reason for extraction is not apparent

For bicuspid with no apparent pathology, to determine if
orthodontic extractions

D7241, full bony impaction with complications
Cyst removal (D7450, 7451, 7460, 7461): Documentation of special
services; size greater than 1.25mm and/or unrelated to tooth removal;
operative notes and pathology report.
Treatment notes if radiographic information not conclusive.
34
Criteria for codes D7220, D7230, D7240–D7241, D7251
The prophylactic extraction of impacted third molars that are asymptomatic and
disease free remains highly controversial. In the absence of strong clinical
evidence to support or refute prophylactic extractions of asymptomatic and
disease free third molars, the following coverage rationale has been adopted.
Surgical extraction of soft tissue impacted teeth
Surgical extraction of soft tissue impacted teeth is indicated for the following:

Extraction of premolars, third molars and other teeth as deemed necessary
for the facilitation of orthodontic treatment when this service is benefitted;

For a tooth/teeth in the line of a jaw fracture or complicating fracture
management;

As part of comprehensive treatment in orthognathic surgery;

Moderate to severe or acute pain, or recurrent episodes that do not
respond to conservative treatment (i.e. pain medication or antibiotics);

Non-restorable caries;

Management of, or limiting the progression of periodontal disease;
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







In the case of acute/chronic infection (abscess, cellulitis, pericoronitis);
Pulpal exposure;
Non-restorable pulpal or periapical lesion;
Internal resorption;
As a prophylactic procedure for an underlying medical or surgical condition
(e.g. organ transplants, alloplastic implants, chemotherapy, radiation
therapy prior to intravenous bisphosphonate therapy for cancer );
Tumor resection;
Ectopic position;
For purposes of prosthetic rehabilitation (partial dentures and complete
dentures).
Surgical extraction of soft tissue impacted teeth is not indicated for the
following:

For prophylactic reasons other than an underlying medical condition;

When a more conservative procedure can be performed;

For pain or discomfort related to normal tooth eruption.
Surgical extraction of partially bony impacted teeth
Surgical extraction of partially bony impacted teeth is indicated for the
following:

Extraction of premolars, third molars and other teeth as deemed necessary
for the facilitation of orthodontic treatment when this service is benefitted;

Tooth/teeth in the line of a jaw fracture or complicating fracture
management;

As part of comprehensive treatment in orthognathic surgery;

Moderate to severe or acute pain, or recurrent episodes that do not
respond to conservative treatment (i.e. pain medication or antibiotics);

Non-restorable caries;

Management of, or limiting the progression of periodontal disease;

In the case of acute/chronic infection (abscess, cellulitis, pericoronitis);

Pulpal exposure;

Non-restorable pulpal or periapical lesion;

Internal resorption;

As a prophylactic procedure for an underlying medical or surgical condition
(e.g. organ transplants, alloplastic implants, chemotherapy, radiation
therapy prior to intravenous bisphosphonate therapy for cancer );

Tumor resection;

Ectopic position;

For purposes of prosthetic rehabilitation (partial dentures and complete
dentures).
Surgical extraction of partially bony impacted teeth is not indicated for the
following:

For prophylactic reasons other than an underlying medical condition;
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

When a more conservative procedure can be performed;
For pain or discomfort related to normal tooth eruption.
Surgical extraction of completely bony impacted teeth
Surgical extraction of completely bony impacted teeth is indicated for the
following:

For extraction of premolars, third molars and other teeth as deemed
necessary for the facilitation of orthodontic treatment when this service is
benefitted;

Tooth/teeth in the line of a jaw fracture or complicating fracture
management;

As part of comprehensive treatment in orthognathic surgery;

Moderate to severe or acute pain, or recurrent episodes that do not
respond to conservative treatment (i.e. pain medication or antibiotics);

Non-restorable caries;

Management of, or limiting progression of periodontal disease;

In the case of acute/chronic infection (abscess, cellulitis, pericoronitis);

Pulpal exposure or periapical lesion;

Resorption of adjacent tooth;

As a prophylactic procedure for an underlying medical or surgical
condition(e.g. organ transplants, alloplastic implants, chemotherapy,
radiation therapy prior to intravenous bisphosphonate therapy for cancer);

Tumor resection

Ectopic position

For purposes of prosthetic rehabilitation (partial dentures an complete
dentures);

Pathology associated with tooth follicle (e.g. cysts and tumors) or other
related pathology (e.g. dentigerous cyst).
Surgical extraction of completely bony impacted teeth not indicated for the
following:

For prophylactic reasons other than an underlying medical condition;

When a more conservative procedure can be performed;

For pain or discomfort related to normal tooth eruption.
Surgical extraction of completely bony impacted teeth with unusual surgical
complications
Surgical extraction of completely bony impacted teeth with unusual surgical
complications is indicated for the following:

For extraction of premolars, third molars and other teeth as deemed
necessary for the facilitation of orthodontic treatment when this service is
benefitted;

Tooth/teeth in the line of a jaw fracture

As part of comprehensive treatment in orthognathic surgery;

Moderate to severe or acute pain, or recurrent episodes that do not
36
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION











respond to conservative treatment (i.e. pain medication or antibiotics);
Non-restorable caries;
Management of, or limiting progression of periodontal disease;
In the case of acute/chronic infection (abscess, cellulitis, pericoronitis);
Pulpal exposure;
Periapical lesion;
Internal resorption;
As a prophylactic procedure for an underlying medical condition (e.g. organ
transplants, alloplastic implants, chemotherapy, radiation therapy prior to
intravenous bisphosphonate therapy for cancer);
Tumor resection;
Ectopic position;
For purposes of prosthetic rehabilitation (partial dentures an complete
dentures);
When complicated procedures are anticipated such as nerve dissection,
sinus closure, aberrant tooth position or anatomy, or are unanticipated and
arise during surgical extraction.
Surgical extraction of completely bony impacted teeth with unusual surgical
complications is not indicated for the following:

For prophylactic reasons other than an underlying medical condition;

When a more conservative procedure can be performed;

For pain or discomfort related to normal tooth eruption.
Coronectomy
Coronectomy is indicated for the following:

When clinical criteria for extraction of impacted teeth is met.

When the removal of complete tooth would likely result in damage to the
neurovascular bundle.
Coronectomy is not indicated for the following:

For routine extractions;

When clinical criteria for extraction of impacted teeth is not met;

For prophylactic reasons.
Refer to clinical policy: Surgical Extraction of Impacted Teeth (DCP006.01)
Oroantral fistula closure
D7260
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
37
Criteria
Benefitted if the condition cannot be treated by approximating the soft tissue
and suturing and requires excision of fistulous tract with closure by
advancement flap.
PROCEDURE
Primary closure of sinus
perforation
D7261
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Criteria
Subsequent to surgical removal of tooth, exposure of sinus requiring repair in
absence of fistulous tract.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Tooth reimplantation
D7270
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Surgical exposure of unerupted
tooth
D7280
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Criteria
Recent history of facial trauma.
Avulsion of tooth.
Performed within 3 hours of accident.
Includes splinting/stabilization.
Criteria
Tooth developing normally and in good position.
Adequate space to erupt.
Dense, fibrotic tissue appears to prevent eruption.
Part of orthodontic treatment plan.
Supernumeraries and third molars not benefited.
Mobilization of erupted or
malpositioned tooth to aid
eruption
D7282
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Tooth developing normally and in good position. Adequate space to erupt.. Hx.
Of 7280
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Placement of device to aid
eruption of impacted tooth
D7283
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Tooth developing normally and in good position. Adequate space to erupt.. Hx.
Of 7280
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Surgical placement of temporary
anchorage device
D7279, D7293, D7294
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
38
Tooth developing normally and in good position. Adequate space to erupt.. Hx.
Of 7280
PROCEDURE
Alveoloplasty with extractions
D7310, D7311
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Alveoloplasty without extractions
D7320, D7321
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Vestibuloplasty
D7340, D7350
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Excision of benign lesions
D7411, D7412
Narrative of procedure
Removal of benign odontogenic
cyst or tumor
D7450, D7451
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Criteria
Bone requires osteoplasty as preparation for prosthesis beyond that expected
during healing.
For full quad: at least four contiguous extractions.
Can be done up to 6 months post extraction of >4 teeth if indicated.
Criteria
Teeth removed sometime in the past.
Narrative that current prosthesis is causing irritation, sore spots or inflammatory
lesions due to thin or irregular alveolar crest.
Needed to remove spicules or exostoses that result in chronic irritation or
pathology.
Criteria
Sometimes performed for periodontal purposes when an abnormally shallow
vestibule threatens the attached gingiva.
May be performed to prepare an area for a denture.
Should be reviewed if on the same date as a soft tissue graft or periodontal
surgery.
Criteria
Cyst is not attached to or removed with tooth.
Size, color or consistency indicates need for pathology examination.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Removal of benign nonodontogenic cyst or tumor
D7460, D7461
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Criteria
Presence of hard, attached or freely movable raised or erythematous lesion.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Removal of exostoses or tori
D7471, D7472, D7473
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
39
Criteria
Impinges on speech or freeway space of tongue.
Prevents adequate extension of denture.
Frequent sore spots from denture.
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Prevents fabrication of denture.
Factor in periodontal disease.
Not with osseous surgery or alveoloplasty.
Incision and drainage
D7510, D7520
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Criteria
Not usually benefited when at same time as extraction.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Collection and application of
autologous blood concentrate
product
D7921
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Criteria
Must be history of extraction on same day
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Sinus augmentation via lateral
open approach
D7951
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Criteria
Usually for purposes of placement of an implant. Narrative and radiographic
images to document the clinical need.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Sinus augmentation via a vertical
approach
D7952
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Criteria
Medically necessary
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Bone graft for ridge preservation
D7953
Documentation
Dated and labeled radiographic images including panoramic or
periapicals usually taken within one year and appropriate to document
the case as applicable.
Treatment notes if radiographic information not conclusive or
radiographs are not applicable.
Criteria
The healing process normally repairs the defect following an extraction. In cases
such as a large defect after lesion removal, the graft may be allowed.
Implant note: if an implant is a covered procedure, this does not automatically
imply approval of a bone graft. Radiographic images and narrative should be
reviewed. SEE IMPLANT CRITERIA
If implant is placed at time of bone graft then use code D6104
40
PROCEDURE
Frenectomy or frenotomy
D7960
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Documentation
Narrative if applicable
Criteria/Documentation
Narrative may be requested from reviewer
Apparent cause of diastema.
Frenuloplasty
D7963
Causing recession.
Tissue hinders home care.
Pre-prosthetic.
Tongue movement limited.
Denture lacerates or irritates frenum and cannot be resolved by denture
adjustment.
Excision of hyperplastic tissue
D7970
Documentation
Narrative if applicable
Criteria (see also D4210)
Severe or gross overgrowth of tissue associated with ill-fitting denture.
Tissue not responsive to non-invasive therapy (conditioning, liners).
Pre-prosthetic purposes.
Hinders fit of existing prosthesis.
Tissue hinders home care.
Must be in an area of missing teeth where a full or partial denture or pontic will
rest.
Excision of periocoronal gingival
D7971
Narrative and radiographic images to document the clinical need
Medically necessary
Surgical reduction of fibrous
tuberosity
D7972
Narrative and radiographic images to document the clinical need
Medically Necessary
All of the following documentation must be received:

Panoramic imaging;

Cephalometric imaging;

5-7 intraoral photographs;

Other forms as required by the state.
Criteria for codes D8050–D8090, D8220, D8660–D8680, D8690–D8691, D8999
ORTHODONTICS
Medically Necessary Orthodontic
Treatment
D8050–D8090, D8220,
D8660–D8680, D8690–D8691,
D8999
Indications for Coverage
Orthodontic treatment is a covered dental service and medically necessary
when the following criteria have been met:

All services must be approved by the plan; and

The member is under the age 19 (through age 18, unless the benefit plan
document indicates a different age); and

Services are related to one of the following conditions:
o Cleft lip and/or cleft palate;
o Crouzon’s Syndrome;
o Treacher-Collins Syndrome;
41
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
o
o
o
o
o
Pierre-Robin Syndrome
Hemi-facial atrophy;
Hemi-facial hypertrophy
Severe craniofacial deformities that result in a physically handicapping
malocclusion; OR
Other clinical criteria based on state specific language.
All of the following documentation must be received:

Panoramic imaging;

Cephalometric imaging;

5-7 intraoral photographs;

Other forms as required by the state.
Coverage Limitations and Exclusions

Orthodontic services that do not meet the criteria listed above.

Orthodontic services that are specifically excluded.

Orthodontic services for crowded dentitions (crooked teeth), excessive
spacing between teeth, temporomandibular joint (TMJ) conditions and/or
horizontal/vertical discrepancies (overjet/overbite).
Refer to coverage guideline: Medically Necessary Orthodontic Treatment
(DCG.003.01)
ANESTHESIA SERVICES
General Anesthesia and Conscious
Sedation
D9210–D9212, D9215, D9219,
D9223, D9230, D9243, D9248
Documentation & Time Recommendations & Nitrous/Extraction
Recommendations
Provider notes including: duration, type of anesthetic, dosage.
If restorative/surgical procedures and age do not meet criteria: Narrative
documenting medical necessity, including description of underlying
medical problem; description of behavior problem and age of patient.
Criteria for codes D9210–D9212, D9215, D9219, D9223, D9230, D9243, D9248
Sedation for dentistry is proven to help decrease anxiety, diminish fear and
increase tolerance for dental procedures. It is necessary for the safe and
comprehensive dental treatment of patients that meet selection criteria. Local
anesthesia is not covered in conjunction with operative or surgical procedures.
Nerve blocks are not addressed in this coverage guideline; please refer to
appropriate medical policy.
Anesthesia time is defined as the period between the beginning of the
administration of the agent and the time that the anesthetist is no
longer in personal attendance.
Local Anesthesia is considered an inclusive component of any dental
procedure unless used for pain relief or if pain relief is required to make an
accurate diagnosis.
General Time Guidelines for IV sedation & General Anesthesia:
Regional and trigeminal block anesthesia is not a covered service.
3-4 Teeth D7230, D7240 1.5 hours
1-2 Teeth D7230, D7240 45 min
3-4 Teeth D7210, D7220 1 hour
1-2 Teeth D7210, D7220 45 min
Full Mouth Extractions or + Teeth D7111, D7140 1.5 hours
42
Nitrous Oxide

Coverage Limitations/Exclusions
o Limited to once per day
o Excluded when reported on same date of service as IV sedation, nonIV sedation or General Anesthesia
o Patient convenience

Nitrous Oxide is proven effective for sedation in adults and children for the
following:
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
3-6 Teeth D7111, D7140 45 min.
1-3 Teeth D7111, D7140 30 min.
Nitrous Oxide: Extraction Coverage Recommendations:

More than one soft tissue impacted tooth D7220

One or more partial or full bony D7230, D7240

More than six simple extractions D7140

Multiple surgical extractions D7210

o Ineffective local anesthesia
o Anxiety
o Special needs patients
o Lengthy procedures for special needs patients and children
o Behaviorally challenged or uncooperative patients
Nitrous Oxide is contraindicated for patients with but not limited to the
following:
o Severe underlying medical conditions ( e.g., severe chronic obstructive
pulmonary diseases, congestive heart failure, sickle cell anemia, acute
otitis media, recent tympanic membrane graft, acute severe head
injury)
o Severe emotional disturbances
o Drug related dependencies
o Pregnancy – first trimester
o Treatment with bleomycin sulfate (injection used in cancer patients)
o Methlenetetrahydropfolate reductase deficiency
o Vitamin B12 deficiency
Intravenous (IV) Sedation

Coverage Limitations/Exclusions
o Limited to once per day

IV sedation is proven and effective for the following:
o Anxiety/Fear
o Pain Control
o Oral Surgery
o Medically compromised patients or those with special needs

IV sedation is contraindicated for patients with but not limited to the
following:
o Allergy to IV medications
o Certain prescribe pharmaceuticals
o In any patient where IV sedation has been considered unsafe
Non-IV Sedation

Coverage Limitations/Exclusions
o Not allowed on same day as general anesthesia

Non-IV sedation is proven and effective for the following:
o Anxiety
o Uncooperative or unmanageable patient

Non-IV sedation is contraindicated for patients with but not limited to the
following:
o Patient or dentist convenience
Nerve Blocks are not covered for dental services; please refer to appropriate
medical policy for specifics regarding coverage for nerve blocks.
43
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
General anesthesia

General anesthesia is proven and effective. The decision to administer
should be made on an individual patient basis and should be limited to:
o Clinical procedures of extensiveness or complexity or situations that
require more than a local anesthetic
o At least 2 attempts using office technique and the failure documented
o Uncooperative or Unmanageable Patient
o Physical, Cognitive or Developmental Disabilities
o Significant underlying medical condition
o Allergy or sensitivity to local anesthesia
o Lengthy restoration procedures for pediatric patients
o A child who has resisted all other conventional management
procedures

General anesthesia is contraindicated for patients with but not limited to
the following:
o Patients with predisposing medical and/or physical conditions that
potentially make general anesthesia unsafe
o Cooperative patients with minimal dental needs
o Choice of an alternative option for treatment
o Language or cultural barriers
o Parental objection
Refer to coverage guideline: General Anesthesia Conscious Sedation
Services (DCG.016.01)
ADJUNCTIVE SERVICES
Palliative treatment
D9110
Criteria
Not payable with other services such as extraction, incision/drainage, sedative
on same date-of-service, with the exception of x-rays and exam (usually D0140).
For immediate relief of pain and not a definitive procedure
Bridge sectioning
D9120
Radiographic image required. Code for both preparing teeth for
extraction and for retaining part of fixed prosthesis.
Consultation
D9310
Criteria
A diagnostic service not by the practitioner providing the specific or on-going
treatment.
The condition may be out of the scope of practice, requiring second opinion.
Professional Visits
D9410–D9450
Documentation
Narrative from member record.
44
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Therapeutic parenteral drugs
D9610, D9612
Criteria
Inclusive when administered through the IV during IV sedation.
Covered when administered as a separate IV or intramuscular injection.
Other drugs
D9630
D9610 Single administration of antibiotics, steroids, anti-inflammatory drugs, or
other therapeutic medications. NOT to be used to report administration of
sedative, anesthetic or reversal agents.
D9612 Multiple administrations of drugs listed for D9610. Only used when two
or more drugs are used and no to be reported in addition to code D9610.
D9630 Dispensing of oral antibiotics/home fluoride, oral analgesics, not limited
to these drugs. Does not include writing of a prescription.
Application of Desensitizing
Medicament
D9910
Documentation
Narrative with explanation of symptoms.
Criteria
Typically used for root sensitivity per tooth. Not covered for bases/liners.
Desensitizing Resin
D9911
Documentation
Narrative with explanation of symptoms.
Criteria
Adhesive application for root sensitivity per tooth. Not covered for
bases/liners/adhesives under restorations.
Behavior management
D9920
Criteria
Appropriate in cases where substantial time and effort is expended in allaying
the patient’s fear and apprehension. Narrative required.
Treatment of complication
D9930
Criteria
Narrative and/or radiographic images required. Examples: dry socket, extensive
hemorrhage.
Occlusal guard
D9940
Documentation/Criteria
Provider narrative which includes a history of bruxism, grinding, &/or
clenching resulting in excessive wear. Should include occlusal analysis
and symptoms.
Athletic guard
D9941
Documentation
Narrative
Repair/Reline of Occlusal Guard
D9942
Documentation
Narrative
Not for temporomandibular joint treatment.
Indications: bruxism, grinding, clenching, excessive wear &/or myofascial pain
due to bruxing, grinding, clenching,
Occlusal analysis
D9950
Criteria
Not for TMJ treatment.
Occlusal adjustment
D9951, D9952
Criteria
Not for TMJ treatment, completed prosthetic appliance or with endodontic
therapy.
45
PROCEDURE
CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DOCUMENTATION
Enamel Microabrasion
D9970
Documentation
Narrative, intraoral photos helpful.
Criteria
Discolored surface enamel from altered mineralization/decalcification. Per visit
basis.
Odontoplasty
D9971
Documentation
Narrative, intraoral photos helpful.
Criteria
1-2 teeth –includes removal of enamel projections.
Bleaching and unspecified report
D9972–D9999
Documentation
Narrative, intraoral photos, images.
46