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NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA
Revised: 4/1/2017
The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines.
PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
DIAGNOSTIC
Clinical Oral Evaluations D0120–D0191
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
Image capture with interpretation D0210–D0371
Image Capture only D0380–D0386
Interpretation and Report only D0391–D0395
CPT codes: 70486, 70487, 70488, 76376 and 76377
Documentation in the member record. Diagnostic, clear, readable images, dated with member name.
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 DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Diagnostic Imaging (continued)
determine whether CBCT improves treatment decision making and health outcomes.
Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP002.02)
Bacterial And Viral Testing D0414, D0415, D0416
Provider narrative including clinical reason/diagnosis for test and type of test performed.
Criteria for codes D0414, D0415, D0416
Collection of Microorganisms for Culture and Sensitivity
Collection of microorganisms for culture and sensitivity is indicated for the following:
For odontogenic infections that do not respond to rational antibiotic empiric therapy and/or incision and drainage in a timely manner
For odontogenic infections in patients with comorbidities including but not limited to impaired healing response, and compromised immune system
Collection of microorganisms for culture and sensitivity is not indicated for the following:
As a routine procedure for all infections (unless patient has multiple comorbidities or infection is resistant to conventional therapy)
If infection is small and limited to localized area
If infection is draining on its own with no evidence of spread of infection
For fungal infections
For viral culturing (this procedure has its own reporting code)
Viral Culture
Viral culturing is indicated for the presence of oral and perioral vesicles and ruptured vesicles resulting in lesions that may or may not be crusted over.
Viral culturing is not indicated for suspected cytomegalovirus (CMV) oral lesions (an incisional biopsy and testing is indicated).
Refer to coverage guideline: Bacterial And Viral Testing (DCG039.01)
Salivary Testing D0417, D0418
Provider narrative including clinical reason/diagnosis for test and type of test performed.
Criteria for codes D0417, D0418
Collection, Preparation and Analysis of Saliva Sample for Laboratory Diagnostic Testing
Collection, preparation and analysis of saliva sample for laboratory diagnostic testing may be indicated as part of oral disease risk assessment and management, including but not limited to caries, periodontal disease and xerostomia.
Refer to clinical policy: Salivary Testing (DCG037.01)
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Genetic Testing for Oral Disease D0422, D0423
Provider narrative including clinical reason/diagnosis for test and type of test performed.
Criteria for codes D0422, D0423
Collection and Preparation of Genetic Sample Material for Laboratory Analysis and Report
Genetic Test for Susceptibility to Diseases – Specimen Analysis
The collection, preparation and testing of genetic samples are indicated for patients who have known human papilloma virus (HPV) infection, or have other related risk factors, to identify if the strain of HPV known to be related to oral and oropharyngeal cancers is present.
The clinical utility of genetic testing for susceptibility to periodontal diseases has not been established. Additionally, there is a lack of objective, high quality clinical evidence to support these tests.
Refer to clinical policy: Genetic Testing for Oral Disease (DCP036.01)
Miscellaneous Diagnostic Procedures D0425, D0460, D0470
Criteria for codes D0425, D0460, D0470
Caries Susceptibility Tests
There is a lack of objective, high quality clinical evidence to support or refute the efficacy or superiority of this specific testing method as a tool for caries risk assessment and management.
Pulp Vitality Tests
Pulp vitality tests are indicated for the following:
For traumatic injuries to teeth
Teeth with deep caries or defective restorations
Pulp vitality tests are not indicated for the following:
Sensitivity of exposed dentin without evidence of pulp pathosis
Teeth with no evidence of caries, resorption, defective restorations, or otherwise asymptomatic
As part of routine dental examinations
Diagnostic Casts
Combined with clinical and radiographic findings, diagnostic casts may be useful for select cases, as they can provide a further understanding of the overall dentition. They may be helpful in developing the treatment plan without the patient present, and can serve as an additional tool for educating the patient. They provide an opportunity for a more thorough evaluation of the following:
Tooth interdigitation
Functional occlusion, and any occlusal abnormalities
Wear facets and defective restorations, coronal contours, proximal contacts and embrasure spaces between teeth
Refer to coverage guideline: Miscellaneous Diagnostic Procedures (DCG040.01)
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Non-Ionizing Diagnostic Procedures D0600
Provider narrative including clinical reason/diagnosis for test and type of test performed.
Criteria for code D0600
There is inadequate evidence demonstrating the efficacy of these devices, limiting their use as a principal diagnostic tool. A non-ionizing diagnostic procedure refers to a device specifically designed to identify, quantify, monitor, and record changes in structure of enamel, dentin and cementum. These devices may be used as an adjunctive tool by the dental provider to identify high caries risk areas, and create non-invasive treatment plans for remineralization before caries begins. Visual and radiographic examinations remain the standard diagnostic methods for diagnosing active caries.
Refer to clinical policy: Non-Ionizing Diagnostic Procedures (DCP041.01)
Tests and Examinations D0431
caries risk assessment D0601–D0603
Oral Pathology Laboratory D0472–D0502
Unspecified diagnostic procedure by report D0999
Provider narrative including clinical reason/diagnosis for test and type of test performed.
PREVENTIVE
Dental Prophylaxis D1110–D1120
Services performed must be documented in the member record.
Topical Fluoride Treatment D1206, D1208
CPT code: 99188
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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Topical Fluoride Treatment (continued)
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.
Sealants D1351, D1352, D1353
Documentation Sealant: Tooth numbers.
Criteria for codes: D1351, D1352, D1353
Sealants
Dental caries is the most common pediatric disease. Dental sealants are recognized as an effective preventive approach to preventing pit and fissure caries in children and adolescents.
Sealants are indicated for the following:
Caries prevention in pit and fissures on permanent molars of children and adolescents
Non-cavitated carious lesions on permanent teeth in children and adolescents
Caries prevention for primary teeth in children with documented high caries risk with a reasonable prognosis for retention anticipated. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver have 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 o Deep pits and fissures o Patients with special needs
Sealants are not generally indicated for the following:
Widespread cavitated carious lesions
Presence for interproximal or smooth surface lesions
Occlusal surfaces that are already carious with involvement of the dentin that requires restoration
Extrinsic staining of pits and fissures
For placement on premolars, buccal and lingual pits of molars and cingula of anterior teeth
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Sealants (continued)
Preventive Resin Restoration (PRR)
Preventive resin restoration is done on an active cavitated lesion in a pit or fissure that does not extend into the dentin. This includes placement of a sealant in any radiating non-carious fissures or pits.
Preventive resin restorations are indicated for the restoration of pit and fissures carious lesions contained to enamel in moderate to high caries risk patients.
Preventive resin restorations are not indicated for the following:
When no caries is evident in pits and fissures
When a sealant is clinically indicated
For carious lesions that extend into dentin
Coverage Limitations
Sealants and PRRs are limited to one per tooth per 36 months. Refer to coverage guideline: Sealants (DCG026.01)
Space Maintenance D1510, D1515, D1520, D1525, D1550, D1555, D1575, D1999
Radiographs of the involved arch. Criteria for codes D1510, D1515, D1520, D1525, D1550, D1555, D1575, D1999
Space maintainers are indicated for the following:
Maintaining space due to premature loss of a primary tooth (teeth)
To regain space
Space maintainers are contraindicated for the following:
When tooth/teeth is/are close to eruption
Patient is not compliant or has poor oral hygiene
Severe crowing already exists
Space has already been lost
If sufficient amount of space already exists
Coverage Limitations and Exclusions
Limited to one per tooth per consecutive 60 months
Any space maintainer adjustments are inclusive for 6 months
Limited to persons under the age of 16
Refer to coverage guideline: Space Maintenance (DCG035.01)
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE
RESTORATIVE
Direct Restorations D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2941, D2990, D2999
Amalgam Restorations D2140–D2161
Resin-Based Composite Restorations – Direct D2330–D2394
Gold Foil Restorations D2410–D2430
Documentation Tooth number and surface. Caries removal documented in member record.
Criteria for codes D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2941, D2990, D2999
Direct Restorations
Direct restorations are indicated for the following:
To replace a tooth structure lost to caries or trauma
To replace restorative material lost in the course of accessing pulp chamber for endodontic therapy
To replace existing restorations that exhibit recurrent decay, fracture or marginal defects
In addition to the above, glass ionomer restorations are indicated for the following:
When teeth cannot be isolated properly to allow placement of resin restorations
As an alternative to resin sealants when the teeth cannot be properly isolated (patient cooperation, partially erupted teeth)
Class I,II, III and V restorations on primary teeth
Class III and V restorations on permanent teeth that cannot be isolated in high risk patients
As a caries control plan for high risk patients using atraumatic techniques
Direct restorations are not indicated for the following:
Teeth with a hopeless prognosis in which extraction is indicated
Incipient enamel only lesions extending less than halfway to the dentinoenamel junction (DEJ)
When there is sufficient loss of tooth structure that a crown or onlay is indicated
When used as part of comprehensive or interceptive orthodontics to maintain an open bite
For primary teeth that are near exfoliation or less than 50% of the tooth root remains
Composite resin restorations are not indicated for patients with heavy bruxism
Composite resin restorations are not indicated for patients with extensive active caries, or high caries risk
Amalgam restorations are not indicated for placement on teeth in which they will have contact with gold restorations
In addition to the above, glass ionomer restorations are not indicated for the following:
As a definitive, long term restoration in permanent teeth
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Direct Restorations (continued)
When a sealant is indicated
Required Documentation
When a metal allergy is suspected, documentation from an allergist is required to support replacement of amalgam with composite.
Protective Restoration
Protective restoration is indicated for the following:
To relieve pain
To promote healing
To prevent further deterioration
To retain tissue form
Protective restoration is not indicated for the following:
As a liner or base for a definitive restoration
Not for endodontic access closure
Not for pulp capping
As a definitive restoration
Interim Therapeutic Restoration-Primary Dentition
Interim therapeutic restorations are indicated for the following:
For very young, uncooperative or special needs patients
When traditional tooth preparation for an amalgam or composite restoration is not feasible or must be postponed
As a caries control plan for high risk patients using atraumatic techniques
Resin Infiltration of Incipient Smooth Surface Lesions
Resin infiltration of incipient smooth surface lesions is typically used for aesthetic purposes. It is used to describe a proprietary product, and there is a lack of established objective evidence to support its use.
Coverage Limitations and Exclusions
Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Any dental procedure not directly associated with dental disease
Posterior composites may be alternately benefitted to amalgam coverage unless specified in member plan
Gold foil restorations are benefitted to amalgam unless specified in member plan, or used to replace material lost on a gold crown due to endodontic therapy
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: Single Tooth Direct Restorations (DCG023.01)
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE 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.
Criteria for codes D2510, D2520 D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2799
Indications for Coverage
For indirect restorations, the following clinical parameters apply:
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.
Crowns
Crowns are indicated for the following:
Extensive caries on three or more surfaces or 50% loss of clinical crown
Large, >50% of the tooth, defective restoration that can be seen on the radiographic image
Fracture of cusps
Endodontically treated teeth, unless minimal access opening on anterior tooth
Documentation that a direct restoration is not possible
Crown/root ratio must be favorable
Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image
50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery
Anterior teeth: at least 50% involvement of incisal portion
Bicuspids and molars: 3 or more surfaces and one or more cusps involved
Anterior teeth: at least 50% involvement of incisal portion
Bicuspids and molars: 3 or more surfaces and one or more cusps involved
Symptomatic “cracked tooth syndrome” (not enamel “craze lines”)
Full coverage restoration of a primary tooth without a permanent successor
Crowns are not indicated for the following:
If a lesser means of restoration is acceptable
If root resorption is present
Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration)
For alteration of vertical dimension
For purposes of preventing future fracture, or to eliminate enamel craze lines (cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative; tooth must be symptomatic)
To treat non-pathologic wear/abrasion, or abfraction lesions in the absence
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Indirect Restorations (continued)
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 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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Indirect Restorations (continued)
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 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.
Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).
Any Dental Procedure performed solely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance).
Refer to coverage guideline: Single Tooth Indirect Restorations (DCG008.02)
Other Restorative Services D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2982, D2999
Repairs necessitated by restorative material failure D2980–D2999
Criteria for codes: D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2982, D2999
Recement and Rebond of Single Tooth Indirect Restorations
Recement and rebond of single tooth indirect restorations are subject to frequency limitations. Please refer to member specific benefit plan document for guidance.
Repair of Single Tooth Indirect Restorations
Repair of single tooth indirect restorations is indicated to repair a fractured inlay, onlay, crown or veneer in which the functional area is involved due to restorative material failure.
Repair of single tooth indirect restorations is not indicated solely for cosmetic/aesthetic purposes.
Reattachment of Tooth Fragment
Reattachment of tooth fragment is indicated for a tooth fracture confined to enamel and dentin with loss of structure, but not exposing the pulp.
Reattachment of tooth fragment is not indicated for the following:
Tooth fractures involving pulpal exposure
Fractures involving roots
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Other Restorative Services (continued)
Coping
Coping is considered inclusive to the preparation of crowns and bridge abutments unless and indicated a separate procedure for the following:
If insufficient natural tooth structure remains to retain the crown
To allow a common path of insertion when retainer teeth are tipped or misaligned
Coverage Limitations and Exclusions
Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Repairs are limited to those performed more than 12 months after the initial insertion.
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: Other Restorative Services (DCG024.01)
Prefabricated Crowns Porcelain/Ceramic Crown D2929 Stainless Steel Crown D2930, D2931, D2932, D2933, D2934
Documentation Tooth number
Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934
Prefabricated Crowns are indicated for the following:
For the restoration of teeth with more than two surfaces affected with carious lesions, or where extensive one or two surface lesions are present.
For one and two surface carious lesions in documented high caries risk children. Risk factors must be thoroughly documented by the provider in the dental record, and include: o Mother or primary caregiver has active caries; o White spot lesions or enamel defects; o Visible caries or previous restorations; o Poor oral hygiene; o Sub-optimal systemic fluoride intake; o Frequent exposure to cavity-producing foods and drinks; o Patients with special health care needs; o Low socioeconomic status; o Xerostomia; o More than one interproximal lesion; o Other factors identified by professional literature;
Cervical decalcification, and/or developmental defects (hypoplasia, hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.).
Interproximal caries extending beyond line angles.
Following pulpotomy or pulpectomy.
For restoring a primary tooth that is to be used as an abutment for a space maintainer.
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Prefabricated Crowns (continued)
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 intra-coronal 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 (DCP012.02)
Protective restoration D2940
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, Post and Core and Pin Retention D2949
Core buildup: D2950
Pin retention per tooth: D2951
Post and Core: D2952, D2953, D2954, D2955, D2957 D2999
Documentation Bitewing unless tooth has had root canal therapy, then a periapical should be submitted.
Criteria for codes D2949, D2950, D2951, D2952, D2953, D2954, D2957, D2955, D2999
Restorative Foundation for an Indirect Restoration
Restorative foundation for an indirect restoration is indicated as a filler to eliminate undercuts, voids and other irregularities that have occurred during tooth preparation to create a more favorable tooth form for the retention of an indirect restoration.
Core Buildup (Including Any Pins When Required)
Core buildup is indicated for teeth with significant loss of coronal tooth structure (> 50%) due to caries or trauma to aid in retention of an indirect
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Core Buildup, Post and Core and Pin Retention (continued)
restoration.
Core buildup is not indicated for the following:
When adequate tooth structure remains to retain a crown
As a filler to correct irregularities in preparation
As a definitive composite or amalgam restoration
For retention of intracoronal restorations
Post and Core
Post and core are indicated for the following:
For teeth with significant loss of coronal tooth structure due to caries or trauma in endodontically treated teeth (> 50%) to aid in retention of an indirect restoration
Post and Core is not indicated for the following:
For vital teeth
For a post, when anatomic features are available to retain the core (e.g., for molars, as canals and pulp chamber can usually retain a core)
For teeth with short roots
Pin Retention
Pin retention is indicated for teeth with significant loss of coronal tooth structure due to caries or trauma, to allow retention of a direct restoration when preparation design alone is insufficient.
Pin retention is not indicated for the following:
For restoration of teeth with significant malocclusion
If the tooth cannot be properly restored with a direct restoration due to anatomic or functional considerations
Post Removal
Post removal is indicated for the following:
When there has been loss of adequate retention
In the case of fracture of tooth and/or post and core
When there is recurrent caries associated with post and core
When access is needed to root canal system for non-surgical endodontics
When the tooth has a reasonable long term prognosis for a new restoration
Coverage Limitations and Exclusions
Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.
Pin retention is limited to 2 pins per tooth; not covered in addition to cast restoration.
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Core Buildup, Post and Core and Pin Retention (continued)
Post and core is covered only for teeth that have had root canal therapy.
Post removal is considered inclusive to retreatment procedure, and not covered
Restorative foundation for an Indirect Restoration is not covered
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: Core Buildup, Post and Core and Pin Retention (DCG021.01)
Labial Veneer D2960, D2961, D2962
Documentation Radiographic image and narrative of medical necessity. Intraoral photo helpful.
Criteria for codes D2960, D2961, D2962
A labial veneer is a thin layer of material placed over a tooth to protect it from further damage or for aesthetic reasons. For most plans, veneers are not covered, but for those plans that do have coverage, the following identify guidelines for placement.
Labial Veneers
Labial veneers are indicated for the following:
For coverage of enamel only fractures
Teeth with enamel defects including but not limited to enamel hypoplasia, severe decalcification, enamel hypocalcification and fluorosis
Labial veneers are not indicated for the coverage of fractures that extend into dentin.
Coverage Limitations and 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.)
Refer to coverage guideline: Labial Veneers (DCG025.01)
ENDODONTICS
Non-Surgical Endodontics
Endodontic codes: D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, 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.
Diagnosis Diagnostic tests used to determine a diagnosis of irreversible pulpitis or periapical pathology must be documented in the record.
Criteria for codes D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357
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
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Exposure permits the capping material to make direct contact with the vital pulp tissue
Exposure occurs when the tooth is under dental dam isolation
Adequate seal of the coronal restoration can be maintained
Patient has been fully informed that endodontic treatment may be indicated in the future
Direct Pulp capping is not indicated for 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
Therapeutic Pulpotomy
Therapeutic pulpotomy is indicated for the following:
Exposed vital pulps or irreversible pulpitis of primary teeth
Any bleeding was controlled within several minutes
As an emergency procedure in permanent teeth until root canal treatment can be accomplished
As an interim procedure for permanent teeth with immature root formation to allow continued root development
In primary teeth, where there is a reasonable period of retention expected (approximately one year)
Therapeutic pulpotomy is not indicated for the following:
Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor
As the first stage of complete root canal therapy
Removal of pulp apical to the dentinocemental junction
For primary teeth that are near exfoliation or less than 50% of the tooth root remains
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
Apexification/Recalcification
Apexification/recalcification is indicated for the following:
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Incomplete apical closure in a permanent tooth root
External root resorption or when the possibility of external root resorption exists.
Necrotic pulp, irreversible pulpitis or periapical lesion
For prevention or arrest of resorption
Perforations or root fractures that do not communicate with oral cavity
Apexification/recalcification is not indicated for the following:
Tooth with a completely closed apex
If patient compliance or long term follow up may be questionable
Pulpal Regeneration
Pulpal regeneration is indicated for the following:
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
Non-Vital Pulp Therapy
Pulpal Debridement (Pulpectomy)
Pulpal debridement (pulpectomy) is indicated for the following:
A restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified
The relief of acute pain prior to complete root canal therapy
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
Primary teeth that are near exfoliation or less than 50% of the tooth root remains
Pulpal Therapy (Resorbable Filling) – Primary Teeth
Pulpal therapy for primary teeth is indicated for the following:
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:
Primary teeth that are near exfoliation or less than 50% of the tooth root
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remains
Permanent teeth
Endodontic Therapy
Endodontic therapy is indicated for the following:
A restorable mature, completely developed permanent or primary tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure
Teeth with radiographic periapical pathology
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
Treatment of Root Canal Obstruction; Non-Surgical Access
Treatment of a root canal obstruction is indicated for the following:
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 when there is no obstruction evident.
Incomplete Endodontic Therapy: Inoperable, Unrestorable or Fractured Tooth
Incomplete endodontic therapy is indicated for the following:
During endodontic treatment of a tooth, it becomes apparent that the procedure cannot be successfully completed
The tooth will not be able to be restored, or the tooth fractures, necessitating discontinuation of treatment
Internal Root Repair of Perforation Defects
Internal root repair of perforation defects is indicated for the following:
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
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Retreatment of Previous Root Canal Therapy
Retreatment of previous root canal therapy is indicated for the following:
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
Refer to coverage guideline: Non-Surgical Endodontics (DCG009.02)
Surgical Endodontics D3410, D3421, D3425, D3426, D3427, D3430, D3450, D3470, D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, D3999
Documentation Pre and post-operative radiograph image. Provider narrative may be requested if pathology is not visible. Date of last root canal treatment if needed.
Criteria for codes D3410, D3421, D3425, D3426, D3427, D3430, D3450, D3470, D3920, D3428, D3429, D3431, D3432, D3460, D3910, D3950, D3999
Apicoectomy
Apicoectomy is indicated for the following:
Failed retreatment of endodontic therapy
When the apex of tooth cannot be accessed due to calcification or other anomaly
Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected
Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist
When individual patient considerations make prolonged non-surgical treatment not practical
A marked over extension of obturating materials interfering with healing
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
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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 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:
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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
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. Additional clinical studies are needed to further evaluate possible benefits of bone grafting in endodontic surgery.
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
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endodontic in origin. Additional clinical studies are needed to further evaluate possible benefits of biologic material to aid in tissue and osseous regeneration in endodontic surgery.
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. Additional clinical studies are needed to further evaluate possible benefits of guided tissue regeneration techniques in endodontic surgery.
Refer to coverage guideline: Surgical Endodontics (DCG010.02)
PERIODONTICS
Surgical Periodontics: Resective Procedures D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261, D4274
Documentation/Other for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261
Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films.
Tooth numbers or site designations.
Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.
Documentation for code D4274 Pre-surgical radiograph images.
Grafts:
One soft tissue graft per two contiguous teeth.
Bone graft and guided tissue regeneration: only one or the other allowed.
Evidence of mobility, bruxism and/or hyperocclusion may contraindicate grafting
Criteria for codes D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4261, D4274
Gingivectomy/Gingivoplasty
Gingivectomy/Gingivoplasty is indicated for the following:
Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is fibrous and firm and there is an adequate zone of keratinized tissue;
Elimination of gingival enlargements/overgrowth due to medications, medical conditions or tooth position;
Elimination of suprabony periodontal abscesses;
For exposure of soft tissue impacted teeth to aid in eruption;
To reestablish gingival contour following an episode of acute necrotizing ulcerative gingivitis;
To allow restorative access, including root surface caries.
Gingivectomy/Gingivoplasty is not indicated for the following:
When bone surgery is required for infrabony defects, or for the purpose of examining bone shape and morphology;
Situations in which the bottom of the pocket is apical to the mucogingival junction;
Areas where aesthetics are a concern (particularly in the anterior maxilla);
In areas with a shallow palatal vault or prominent external oblique ridge;
Severely edematous or inflamed tissue;
Patients with poor plaque control or non-compliance with non-surgical procedures;
Patients with an uncontrolled underlying medical condition;
Solely for cosmetic/aesthetic purposes.
Anatomical Crown Exposure
Anatomical Crown exposure is indicated for the following:
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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;
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
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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 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 (DCP013.03)
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COVERAGE GUIDELINE 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, D4264, D4265, D4266, D4267, 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).
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;
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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 (DCP014.03)
Surgical Periodontics: Mucogingival Procedures D4265, D4266, D4267, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4999
Codes D4265, D4266, D4267 and D4999 are each addressed in the Regenerative, Mucogingival and Resective Surgical Periodontics clinical policies.
Documentation/Other
Pedicle soft tissue graft (D4270) is not benefited at the same time with other periodontal surgery.
Soft tissue grafts are benefitted once per two contiguous teeth
Documentation (see Note) Full radiographic images (panoramic with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and bitewing films.
Tooth numbers or site designations.
Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.
Note No radiographs required for the following codes: D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285
Criteria for codes D4265, D4266, D4267, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4999
Pedicle Soft Tissue Graft Procedure
Pedicle Soft Tissue Graft Procedure is indicated for the following:
Areas with less than 2 mm of attached gingiva;
Unresolved sensitivity in areas of recession;
Progressive recession or chronic inflammation;
For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control;
Ridge augmentation;
To increase vestibular depth for the correct fit of prosthesis;
To widen zone of attached gingiva for prosthetic abutment teeth;
To increase vestibular depth to allow proper oral hygiene techniques;
Gingival clefting.
Pedicle Soft Tissue Graft Procedure is not indicated for the following:
Roots covered with thin bony plates;
Patients with an untreated medical condition.
Autogenous Connective Tissue Graft
Autogenous connective tissue graft is indicated for the following:
Areas with less than 2 mm of attached gingiva;
Unresolved sensitivity in areas of recession;
Progressive recession or chronic inflammation;
For teeth with subgingival restorations where there is little or no attached
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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;
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:
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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.
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 (DCP015.02)
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COVERAGE GUIDELINE 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. Tooth numbers or site designations. Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.
Criteria for codes D4320, D4321
Provisional Splinting using these codes is indicated for the following:
Multiple teeth that have become mobile due to loss of alveolar bone loss and periodontium;
During surgical and healing phases of regenerative periodontal therapy.
Provisional Splinting using these codes is not indicated for the following:
Tooth transplantation;
Trauma resulting in the reimplantation of completely avulsed tooth/teeth;
Trauma resulting in displacement or fracture of tooth/teeth.
Coverage Limitations and Exclusions
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 (DCG011.02)
Non-Surgical Periodontal Therapy D4341, D4342, D4346, D4381, D4910, D4921
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, D4346, D4381, D4910, D4921
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 disease-characterized by 3-4 millimeters clinical attachment loss (CAL). In molars, furcation involvement not to exceed Class 1.
Localized or generalized severe periodontal disease-characterized by more than 5 millimeters of CAL.
Chronic refractory mild or moderate periodontal disease-characterized by patients who demonstrate additional attachment loss despite being longitudally monitored with periodontal maintenance.
Periodontal abscess characterized by localized swelling and/or increased probing depth and loss of periodontal attachment.
Scaling and root planing is not indicated for the following:
In the absence of diagnosed periodontal disease.
For the removal of heavy deposits of calculus and plaque.
Gingivitis defined as inflammation of the gingival tissue without loss of attachment (bone and tissue).
As a sole treatment for chronic periodontitis with advanced loss of support demonstrated by pockets greater than 6 millimeters with CAL greater than 4 millimeters, and radiographic bone loss. Mobility may or may not be present.
As a sole treatment for refractory chronic, aggressive or advanced
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Non-Surgical Periodontal Therapy (continued)
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).
Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation – Full Mouth
Scaling in presence of generalized moderate or severe gingival inflammation is indicated for the removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing.
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 (DCP004.02)
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.
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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Full Mouth Debridement (continued)
Periodontal charting performed within 12 months, including six point probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status.
examination and diagnosis is not possible.
Coverage Limitations and Exclusions
Limited to once every 36 months.
Not to be billed on same day as any exam code or non-surgical periodontal therapy code.
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 (DCG001.02)
Unscheduled Dressing Change D4920
REMOVABLE PROSTHETICS
Removable Prosthodontics D5110–D5899
Complete dentures D5110–D5140
Partial dentures D5211–D5281
Adjustments to Dentures D5410–D5422
Repair to Complete Dentures D5510, D5520
Repair to Partial Dentures D5610–D5671
Denture Rebase Procedures D5710–D5721
Denture Reline Procedures D5730–D5761
Interim partial dentures D5810–D5821
Other Removable Prosthetic Services D5850–D5875
Documentation Full mouth radiographic images.
Tooth numbers for missing teeth to be replaced, and other missing teeth.
Date of extractions if indicated.
Age of existing prosthesis. Immediate denture: X-rays showing at least one tooth present and severe periodontal disease or caries.
Criteria for codes D5110, D5120, D5130, D5140, D5211, D5212, D5213, D5214, D5221, D5222, D5223, D5224, D5225, D5226, D5281, D5410, D5411, D5421, D5422, D5510, D5520, D5610, D5620, D5630, D5640, D5650, D5660, D5670, D5671, D5710, D5711, D5720, D5721, D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761, D5810, D5811, D5820, D5821, D5850, D5851, D5862, D5863, D5864, D5865, D5866, D5867, D5875, D5899
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.
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
Coverage Limitations and Exclusions
Limited to once per 60 months from initial or supplemental placement
Not allowed if within 60 months of an existing partial denture, interim
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Removable Prosthodontics (continued)
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
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 and Exclusions
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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Removable Prosthodontics (continued)
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 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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Removable Prosthodontics (continued)
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 den-ture-bearing areas
When there is distortion of normal anatomic structures, such as incisive 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.
Coverage Limitations and 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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Removable Prosthodontics (continued)
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.
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
Implants D6010, D6011, D6012, D6013, D6040, D6050, D6051, D6052, D6055, D6056, D6057, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6080, D6081, D6085, D6090, D6091, D6092, D6093, D6094, D6095, D6100, D6101, D6102, D6103, D6104, D6110, D6111, D6112, D6113, D6114, D6115, D6116, D6117, D6190, D6194, 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, D6011, D6012, D6013, D6040, D6050, D6051, D6052, D6055, D6056, D6057, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6080, D6081, D6085, D6090, D6091, D6092, D6093, D6094, D6095, D6100, D6101, D6102, D6103, D6104, D6110, D6111, D6112, D6113, D6114, D6115, D6116, D6117, D6190, D6194, 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, subsequent implant supported restorations, and any necessary treatment of peri-implant defects:
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:
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Implants (continued)
Location of tooth/teeth;
Bone quality/quantity;
Periodontal status;
Restorability;
Patient cost;
Patient age (implants not appropriate for patients under age 15);
Patients undergoing strong chemotherapy;
Myocardial infarction: within 6 months of an attack;
Anticoagulant therapy;
Severe neuropsychiatric disease, mental disability, and narcotic drug addicts ;
Severe blood diseases;
Systemic Risk Factors: o Smoking o Diabetes o Hypertension o Decreased estrogen levels in postmenopausal women o Use of IV bisphosphonates
Refer to coverage guideline: Implants (DCG007.03)
FIXED PROSTHETICS
Fixed Prosthodontics D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6549, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6793, D6794, D6920, D6930, D6940, D6950, D6980, D6985, 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, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6549, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6793, D6794, D6920, D6930, D6940, D6950, D6980, D6985, 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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Fixed Prosthodontics (continued)
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 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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Fixed Prosthodontics (continued)
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.
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
Coverage Limitations and Exclusions
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
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
39
PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Fixed Prosthodontics (continued)
dimension of occlusion (VDO)
Placement of fixed partial dentures solely for the purpose of achieving periodontal stability
Refer to coverage guideline: Fixed Prosthodontics (DCG017.01)
ORAL SURGERY
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. Panoramic, periapicals, or tomography for third molar extractions is indicated by the clinical presentation. Treatment notes if radiographic information not conclusive.
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;
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 non-surgical extraction unsafe or cause harm;
When fused to an adjacent tooth;
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Surgical Extraction of Erupted Teeth and Retained Roots (continued)
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 (DCG005.02)
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 is 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.
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;
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;
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Surgical Extraction of Impacted Teeth (continued)
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;
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
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Surgical Extraction of Impacted Teeth (continued)
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 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;
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Surgical Extraction of Impacted Teeth (continued)
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 (DCP006.02)
Oral Surgery: Alveoloplasty and Vestibuloplasty D7310, D7311, D7320, D7321, D7340, D7350 CPT codes: 40840, 40842, 40843, 40844, 40845, 40899, 41874
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 for codes D7310, D7311, D7320, D7321, D7340, D7350
Alveoloplasty
Alveoloplasty is indicated for the following:
For bone recontouring and smoothing as part of the tooth extraction process
For bone recontouring and smoothing as a standalone procedure prior to fixed or removable prosthetic construction
To provide stability for implant placement
For debulking procedures for pathologic conditions of the bone
Alveoloplasty is not indicated for the following:
When performed solely for cosmetic/aesthetic reasons
When removing bone would harm vital structures
When there is diminished volume or atypical architecture of bone
For patients who have undergone radiation therapy to the head and neck
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Oral Surgery: Alveoloplasty and Vestibuloplasty (continued)
For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response
Vestibuloplasty
Vestibuloplasty is indicated for the following:
Ridge extension, or lowering or altering submucous displacing attachments prior to prosthetic construction
To complement and complete osseous procedure when reconstructing edentulous bone
To correct inadequate or inappropriate soft tissue drape where a resection has been previously performed and prosthetic restoration requires improvement
For overall stability of a dental implant and the maintenance of bone health around an implant
Vestibuloplasty is not indicated for the following:
When performed solely for cosmetic/aesthetic reasons
For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response
When there is minimal alveolar ridge height
For patients who have undergone radiation therapy to the head and neck
Coverage Limitations and Exclusions
Alveoloplasty and vestibuloplasty procedures are subject to frequency limitations. Please refer to the member specific benefit plan document.
Oral surgery procedures may be covered under the member’s medical benefit when determined to be medical in nature. Refer to the member’s Certificate of Coverage and/or member specific benefit plan document for coverage guidelines.
Refer to coverage guideline: Oral Surgery: Alveoloplasty and Vestibuloplasty (DCG028.01)
Oral Surgery: Miscellaneous Surgical Procedures D7260, D7261, D7270, D7272, D7290, D7921, D7951, D7952, D7953, D7999
CPT codes: 21210, 21215, 30580, 41899
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 for codes D7260, D7261, D7270, D7272, D7290, D7921, D7951, D7952, D7953, D7999
Oroantral Fistula Closure
Oroantral fistula closure is indicated for the closure of an oroantral fistula not related to cleft palate repair surgery
Primary Closure of a Sinus Perforation
Primary closure of a sinus perforation is generally indicated for large (> 2mm) defects resulting from routine tooth extraction, retrieval of root tips, or implant placement.
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Oral Surgery: Miscellaneous Surgical Procedures (continued)
Primary closure of a sinus perforation is generally not indicated for defects less than 2mm in diameter.
Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth are indicated for the following:
Subluxation injuries to permanent teeth
Lateral luxation injuries of primary and permanent teeth
Extrusion injuries of <3mm in an immature developing primary tooth
Avulsion of permanent teeth
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth are not indicated for the following, and extraction is recommended:
For primary teeth if injury is severe or tooth is near exfoliation
For intrusion injuries to primary teeth when the apex is displaced toward the permanent tooth germ
For extrusion injuries to primary teeth > 3mm, or primary tooth is fully formed, mobile, near exfoliation, or the child is unable to cope with an emergency situation
For avulsion of primary teeth
When a tooth has been out of the oral cavity for 60 minutes or more
For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response
Lack of alveolar integrity
Surgical Repositioning of Teeth
Surgical repositioning of teeth is indicated for the following:
For the treatment of intrusion injuries to permanent teeth
Extrusion of teeth with crown/root fractures to prepare for restoration of permanent teeth
Surgical repositioning of teeth is not indicated for the treatment of injuries to primary teeth.
Bone Replacement Graft for Ridge Preservation
Bone replacement graft for ridge preservation is indicated for the following:
When bone has been lost in extraction site, or site of implant removal to prepare for new implant
When there has been loss of alveolar ridge needed to support a removable prosthesis or fill space under the pontic of a fixed partial denture
Bone replacement graft for ridge preservation is not indicated for the following:
As a routine procedure to fill extraction sites
For patients with unmanaged medical conditions that result in excessive or
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Oral Surgery: Miscellaneous Surgical Procedures (continued)
uncontrolled bleeding, reduced resistance to infection, or poor healing response
Collection and Application of Autologous Blood Concentrate Product
Evidence in the published scientific literature is inconsistent and does not lend strong support to the clinical utility of using platelet rich plasma (PRP) to augment bone or soft tissue healing for oral surgery applications.
Sinus Augmentation Procedures
Sinus augmentation or sinus lift is a procedure associated with implant placement. For most plans, implants are not covered, but for those plans that do have coverage, the following identify guidelines for this procedure.
Sinus augmentation is indicated for the following:
To prevent the displacement of dental implants in the posterior maxilla due to pneumatization of the maxillary sinus
When there is poor bone quality that prevents adequate initial stability during implant placement
Sinus augmentation is not indicated for the following:
Conditions blocking the ventilation and clearance of the maxillary sinus. (Many of these causes are reversible and should be treated before the sinus lift procedure, and include, but are not limited to: history of smoking; allergic rhinitis; previous nasal surgery or trauma; a history of chronic and/or recurrent sinusitis; chronic nasal obstruction and/or rhinorrhea; chronic hyposmia and/or hypogeusia; previous treatment for head and neck neoplasms; and comorbidities, particularly systemic diseases and pathologies that interfere with mucosal composition or ciliary movements)
For patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response
Coverage Limitations and Exclusions
Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.
Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).
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.
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Oral Surgery: Miscellaneous Surgical Procedures (continued)
Refer to clinical policy: Oral Surgery: Miscellaneous Surgical Procedures (DCP027.01)
Oral Surgery: Non-Pathologic Excisional Procedures D7291, D7471, D7472, D7473, D7960, D7963, D7970, D7971, D7972, D7999 CPT codes: 21031, 21032, 40806, 40819, 41010, 41115, 41520, 41821, 41822, 41828
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.
Frenectomy or frenotomy (D7960) and Frenuloplasty (D7963) Narrative if applicable
Excision of periocoronal gingival (D7971) and Surgical reduction of fibrous tuberosity (D7972) Narrative and radiographic images to document the clinical need
Criteria for codes D7291, D7471, D7472, D7473, D7960, D7963, D7970, D7971, D7972, D7999
Frenulectomy
Frenulectomy is indicated for the following:
When attachment of the frenum is coronal to the mucogingival junction, within the free gingiva, or in the papilla causing a diastema, gingival recession or stripping
When the position attachment of the frenum is interfering with proper oral hygiene
Prior to the construction of a removable denture replacing teeth in the area of frenum attachment
When there is a functional disturbance, including, but not limited to mastication, swallowing and speech
For ankyloglossia or severe papillary penetrating attachment of maxillary labial frenum in newborns when there is interference with feeding
Frenuloplasty
Frenuloplasty is indicated for the following:
When attachment of the frenum is coronal to the mucogingival junction, within the free gingiva, or in the papilla causing a diastema, gingival recession or stripping and its depth or width requires surgical restoration of physiologic function
When the position attachment of the frenum is interfering with proper oral hygiene
Prior to the construction of a removable denture replacing teeth in the area of aberrant frenal attachment
When there is a functional disturbance, including, but not limited to mastication, swallowing and speech
For ankyloglossia or severe papillary penetrating attachment of maxillary labial frenum in newborns when there is interference with feeding
Excision of Hyperplastic Tissue – Per Arch
Excision of hyperplastic tissue is indicated when the presence of hyperplastic tissue (fibrous tuberosities, loose ridges, folds of redundant tissues in vestibule or floor of mouth, and palatal papillomatosis) interferes with the fit of a partial or complete denture (existing or new).
Excision of Pericoronal Gingiva
Excision of pericoronal gingiva is indicated for the following:
For recurrent infections of the operculum around impacted or partially
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Oral Surgery: Non-Pathologic Excisional Procedures (continued)
erupted lower third molars
When an erupted maxillary third molar is traumatizing soft tissue around opposing tooth
When the presence interferes with the fit of a partial or complete denture
Surgical Reduction of Fibrous Tuberosity
Surgical reduction of fibrous tuberosity is indicated when the presence interferes with the fit of a partial or complete denture.
Transseptal Fiberotomy/Supra Crestal Fiberotomy, By Report
Transseptal fiberotomy/supra crestal fiberotomy is indicated to reduce rotational relapse of individual teeth following orthodontic treatment.
Removal of Lateral Exostosis (Maxilla or Mandible)
Removal of lateral exostosis is indicated for the following:
If a partial or complete denture cannot be adapted successfully to the alveolar ridge
When causing soft tissue trauma with existing removable appliances
For unusually large exostoses that are prone to recurrent traumatic injury
Removal of lateral exostosis is not indicated for patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response.
Removal of Torus Palatinus
Removal of torus palatinus is indicated for the following:
When a dental prosthesis will cover the palate and a large palatal torus will interfere with fit
For unusually large tori that are prone to recurrent traumatic injury
When there is a functional disturbance, including, but not limited to mastication, swallowing and speech
Removal of torus palatinus is not indicated for patients with unmanaged medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response.
Removal of Torus Mandibularis
Removal of torus mandibularis is indicated for the following:
If a mandibular partial or complete denture cannot be adapted successfully to the alveolar ridge
For unusually large tori that are prone to recurrent traumatic injury
When the tori is so large that it interferes with normal tongue movement
When there is a functional disturbance, including, but not limited to mastication, swallowing and speech
Removal of torus mandibularis is not indicated for patients with unmanaged
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Oral Surgery: Non-Pathologic Excisional Procedures (continued)
medical conditions that result in excessive or uncontrolled bleeding, reduced resistance to infection, or poor healing response.
Coverage Limitations and Exclusions
Frenulectomy and frenuloplasty are considered incidental if performed on the same day, same area as gingivectomy/gingivoplasty, alveoloplasty and vestibuloplasty surgical procedures.
The following are excluded from coverage:
Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.
Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
Refer to coverage guideline: Oral Surgery: Non-Pathologic Excisional Procedures (DCG029.01)
Oral Surgery: Orthodontic Related Procedures D7280, D7282, D7283, D7292, D7293, D7294, D7997 CPT code: 41899
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 for codes D7280, D7282, D7283, D7292, D7293, D7294, D7997
For plans that have comprehensive orthodontic coverage, the following identify guidelines for the use of related oral surgery procedures.
Surgical Placement of Temporary Anchorage Device (Not Related to Distraction Osteogenesis or Orthognathic Surgery)
The surgical placement of temporary anchorage devices are used in conjunction with orthodontic treatment and are indicated for patients aged 12 and over for the following:
Intrusion of maxillary teeth
Molar distalization
Canine retraction and intrusion retraction mechanics
Correction of anterior open bite and deep overbite
Correction of canted occlusal planes
The surgical placement of a temporary anchorage device is not indicated for the following:
Patients with a known allergy to titanium alloy
Patients with a history of heavy tobacco use
Patients with advanced osteoporosis
Patients with uncontrolled immune or metabolic bone disorders
Patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response
Patients with poor oral hygiene
In areas with poor quality cortical bone density and volume
For ankylosed teeth
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Oral Surgery: Orthodontic Related Procedures (continued)
Surgical Access of Unerupted Tooth
Surgical access of unerupted tooth is indicated for the following:
When a tooth is in such a position that it is unable to erupt into a functional position within the dental arch
Tooth developing normally and appears to be in a good position to be moved into position orthodontically, or spontaneously
Only for labially impacted teeth when there will be 2-3 mm of gingival cuff present after eruption
Surgical access of unerupted tooth is not indicated for the following:
Teeth with abnormal development or positioning
For supernumerary teeth and third molars
For primary teeth
When surgical access of impacted tooth would threaten vital structures
Patients with unmanaged medical conditions that result in excessive bleeding, reduced resistance to infection, or poor healing response
Placement of Device to Facilitate Eruption of Impacted Tooth
This is the placement of an orthodontic bracket, band or other device and attached with a chain, on an unerupted tooth, after surgical exposure, to aid in its eruption. This procedure is done following the surgical access of an unerupted tooth.
Mobilization of Erupted or Malpositioned Tooth to Aid Eruption
Mobilization of erupted or malpositioned tooth to aid eruption is indicated for the treatment of ankylosed permanent teeth. Mobilization of erupted or malpositioned tooth to aid eruption is not indicated for primary teeth.
Refer to clinical policy: Oral Surgery: Orthodontic Related Procedures (DCP032.02)
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.
Treatment notes if radiographic information not conclusive or radiographs are not applicable.
Criteria Cyst is not attached to or removed with tooth.
Size, color or consistency indicates need for pathology examination.
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Removal of benign non-odontogenic 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.
Treatment notes if radiographic information not conclusive or radiographs are not applicable.
Criteria
Presence of hard, attached or freely movable raised or erythematous lesion.
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.
Treatment notes if radiographic information not conclusive or radiographs are not applicable.
Criteria Not usually benefited when at same time as extraction.
ORTHODONTICS
Medically Necessary Orthodontic Treatment D8050, D8060, D8070, D8080, D8090, D8220, D8660, D8670, D8680, D8690, D8691, D8999
All of the following documentation must be received:
Panoramic imaging;
Cephalometric imaging;
5-7 intraoral photographs;
Other forms as required by the state.
Criteria for codes D8050, D8060, D8070, D8080, D8090, D8220, D8660, D8670, 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; o Pierre-Robin Syndrome o Hemi-facial atrophy; o Hemi-facial hypertrophy o Severe craniofacial deformities that result in a physically handicapping
malocclusion; OR o Other clinical criteria based on state specific language.
Required Documentation
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.
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Medically Necessary Orthodontic Treatment (continued)
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 (DCG003.02)
ANESTHESIA SERVICES
General Anesthesia and Conscious Sedation D9210, D9211, 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. 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. General Time Guidelines for IV sedation & General Anesthesia: 3-4 Teeth D7230, D7240 1.5 hours 1-2 Teeth D7230, D7240 45 min 3-4 Teeth D7210, D7220 1 hour 1-2 Teeth D7210, D7220 45 min Full Mouth Extractions or + Teeth D7111, D7140 1.5 hours 3-6 Teeth D7111, D7140 45 min. 1-3 Teeth D7111, D7140 30 min. Nitrous Oxide: Extraction Coverage Recommendations:
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
Criteria for codes D9210, D9211, 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.
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.
Regional and trigeminal block anesthesia is not a covered service.
Nitrous Oxide
Nitrous oxide is proven effective for sedation in adults and children for the following:
Ineffective local anesthesia
Anxiety
Special needs patients
Lengthy procedures for special needs patients and children
Behaviorally challenged or uncooperative patients
Management of a severe gag reflex
Nitrous oxide is contraindicated for patients with but not limited to the following:
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)
Severe emotional disturbances
Severe behavioral disorders
Drug related dependencies
Pregnancy – first trimester
Treatment with bleomycin sulfate (injection used in cancer patients)
Methlenetetrahydropfolate reductase deficiency
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE General Anesthesia and Conscious Sedation (continued)
Vitamin B12 deficiency
Coverage Limitations and Exclusions
Limited to once per day
Excluded when reported on same date of service as IV sedation, non-IV sedation or general anesthesia
Patient convenience
Intravenous (IV) Sedation
IV sedation is proven and effective for the following:
Anxiety/fear
Pain control
Oral surgery
Medically compromised patients or those with special needs
IV sedation is contraindicated for patients with but not limited to the following:
Allergy to IV medications
Certain prescribed pharmaceuticals
In any patient where IV sedation has been considered unsafe
Coverage Limitations and Exclusions
Limited to once per day
Non-IV Sedation
Non-IV sedation is proven and effective for the following:
Anxiety
Uncooperative or unmanageable patient
Non-IV sedation is contraindicated for patients with but not limited to the following:
Patient or dentist convenience
Coverage Limitations and Exclusions
Not allowed on same day as general anesthesia
Nerve Blocks
Nerve blocks are not covered for dental services. Please refer to appropriate Medical Policy for specifics regarding coverage for nerve blocks.
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:
Clinical procedures of extensiveness or complexity or situations that require more than a local anesthetic
Minimum of 2 failed attempts at other office anesthetic techniques with the failures documented
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE General Anesthesia and Conscious Sedation (continued)
Uncooperative or Unmanageable Patient
Physical, Cognitive or Developmental Disabilities
Significant underlying medical condition
Allergy or sensitivity to local anesthesia
Lengthy restoration procedures for pediatric patients
A child who has resisted all other conventional management procedures
Patients with extreme anxiety or fear
General anesthesia is contraindicated for patients with but not limited to the following:
Patients with predisposing medical and/or physical conditions that potentially make general anesthesia unsafe
Cooperative patients with minimal dental needs
Choice of an alternative option for treatment
Language or cultural barriers
Parental objection
Refer to coverage guideline: General Anesthesia Conscious Sedation Services (DCG016.02)
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.
Therapeutic Parenteral Drug Administration and In-Office Dispensing of Medications D9610, D9612, D9630
Criteria for codes D9610, D9612, D9630
Therapeutic Parenteral Drug Administration (Single or Two or More Administrations)
Therapeutic parenteral drug administration may be indicated to enhance healing of surgical procedures, or reduce pain and/or risk of infection. Medications may include antibiotics, steroids or anti-inflammatory medications when administered as a separate IV or intramuscular injection.
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Therapeutic Parenteral Drug Administration and In-Office Dispensing of Medications (continued)
Other Drugs and/or Medicaments (By Report)
Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions.
Coverage Limitations and Exclusions
Therapeutic parenteral drug administration is inclusive when administered intravenously (IV) during IV sedation and general anesthesia.
Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
Refer to clinical policy: Therapeutic Parenteral Drug Administration and In-Office Dispensing of Medications (DCP033.01)
Application of Medicaments and Desensitizing Resins D1354, D9910, D9911
Documentation Narrative with explanation of symptoms.
Criteria for codes D1354, D9910, D9911
Application of Desensitizing Medicament or Resin
Application of desensitizing medicament or resin is indicated for the following:
For teeth with sensitivity that does not resolve with an over the counter desensitizing dentifrice
Application of desensitizing medicament or resin is not indicated for the following:
Placement on teeth with erosion, recession, cervical abrasion or abfraction when asymptomatic
As a base or liner prior to restoration placement
Interim Caries Arresting Medicament Application
Interim caries arresting medicament application is indicted for the following:
As conservative treatment for active, non-symptomatic carious lesions
Patients with extreme risk of caries (such as xerostomia or severe early childhood caries)
Patients that cannot tolerate standard treatment for medical or psychological reasons. These may be included but are not limited to the following: o An extremely uncooperative child o Frail elderly patients o Patients with severe cognitive or physical disability o Patients that are immunocompromised
Patients with multiple lesions that cannot be treated in one office visit
Recurrent caries that are difficult to treat
Patients without access to dental care
Interim caries arresting medicament application is not indicted for the following:
Patients with a silver allergy
Pregnant women
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Application of Medicaments and Desensitizing Resins (continued)
During the first six months of breast feeding
Coverage Limitations and Exclusions
Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
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.
These codes are for medicaments and resins, and not for the use of lasers for desensitization.
Refer to clinical policy: Application of Medicaments and Desensitizing Resins (DCP034.01)
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 D7880, D7881, D9940, D9941, D9942, D9943, D9950, D9951, D9952
Documentation/Criteria Provider narrative which includes a history of bruxism, grinding, &/or clenching resulting in excessive wear. Should include occlusal analysis and symptoms.
Criteria for codes D7880, D7881, D9940, D9941, D9942, D9943, D9950, D9951, D9952
Occlusal Guards
Occlusal guards are indicated for the following:
Bruxism or clenching either as a nocturnal parasomnia or during waking hours, resulting in excessive wear or fractures of natural teeth or restorations
To protect natural teeth when the opposing dentition has the potential to cause enamel wear such as the presence of porcelain or ceramic restorations
When nocturnal clenching or bruxism results in tooth sensitivity
Occlusal guards are not indicated for the following:
For treatment of temporomandibular disorders or myofacial pain disfunction
As an athletic mouthguard
As an appliance intended for orthodontic tooth movement
Coverage Limitations and Exclusions
Exclude when used for sports-related activities
Prefabricated occlusal guards are excluded
Limited to once per 36 months
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PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL
COVERAGE GUIDELINE Occlusal guard (continued)
Repair and relines are limited to once per 12 months
Adjustments are inclusive within the first 12 months and thereafter allowed once every 6 months
Fabrication of Athletic Mouthguard
Athletic mouthguards are intended to protect the dentition during athletic activities and not a covered service.
Occlusal Orthotic Devices
Occlusal orthotic devices are appliances intended for the management of orofacial pain or to reposition or stabilize the jaw for the treatment of temporomandibular disorders (TMD) and not a covered service under the dental plan. TMD and these appliances are considered to be medical in nature and are typically covered under the medical plans. Please see the appropriate medical policy for information.
Refer to coverage guideline: Occlusal Guards (DCG019.01)
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.