Clinical Criteria Grid

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0120

PERIODIC ORAL EVALUATION

none

Twice during a rolling year (RY) without PA per servicing provider/group and a maximum of four times during a rolling year for Special Health Care Needs (SHCN) or ECC Members which may require prior authorization. Not within 6 months of D0150 per servicing

provider/group.

Medical diagnosis or clinical presentation required for increased frequency; all documentation to be included in dental records.

Subsequent oral evaluation for patient of record.

D0140

LIMIT ORAL EVAL PROBLM FOCUS

none

Twice in a RY, per servicing provider/group more require PA with documentation of medical necessity

(DMN).

Documentation of medical necessity (DMN) to be included in dental records.

For use in emergent/urgent situations.

D0145

ORAL EVALUATION PATIENT < 3yrs

Under 3 years of age

Twice during a rolling year (RY) without PA and a maximum of four times during a rolling year per servicing provider/group for Special Health Care Needs (SHCN) or ECC Members which may require prior

authorization.

Medical diagnosis or clinical presentation required for increased frequency; all documentation to be included in dental records.

Oral evaluation and continual counselling of primary caregiver.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0150

COMPREHENSIVE ORAL EVALUATION

Age 3 and older

Once every three years per servicing provider/group unless medical necessity can be documented for additional

service.

Medical diagnosis or clinical presentation required for increased frequency.

For new patient or 3 years post previous comprehensive oral evaluation by same provider.

D0160

EXTENSV ORAL EVAL PROB FOCUS

none

Twice per RY per servicing provider/group.

DMN; to develop a treatment plan for a specific problem; only radiographs and/or other non-evaluation diagnostic codes provided on same date

of service (DOS).

DMN; May be used by general dentists for second opinion for same complaint, condition or diagnosis.

D0170

RE-EVAL,EST PT, PROBLEM FOCUS

none

Twice per RY

DMN; only additional services allowed on same DOS are radiographs (D0220, D0240, D0270, D0277

and D0330).

For follow-up of recent prior visit for same complaint, condition or diagnosis.

D0171

RE-EVAL POST-OP VISIT

none

Twice a RY per servicing provider/group; additional units require prior

authorization.

DMN; only additional services allowed on same DOS are radiographs (D0220, D0270, D0277 and

D0330).

For follow-up of recent prior oral surgical or periodontal surgery visit.

D0180

COMP PERIODONTAL EVALUATION

none

Once every three years unless medical necessity can be documented for more

frequent service.

Recent full mouth perio charting and radiographs as needed for diagnosis; narrative and photos if bone loss not visible on x-rays.

Evidence of periodontal disease.

D0190

SCREENING OF A PATIENT

Under 19 years of age

Allowed once per RY to same member

Service must be provided in non-office setting.

No other services on same DOS.

D0210

INTRAORAL COMPLETE FILM SERIES

none

Complete series D0210 allowed once every three years per servicing provider/group unless medical necessity can be documented for additional

service.

DMN; for additional service-documentation of extreme change in medical or dental condition.

Radiographic evaluation for diagnosis.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0220

INTRAORAL PERIAPICAL FIRST

none

AMN for diagnosis

Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and

bitewings (D0270, D0272) may be taken as needed for diagnosing a

condition.

For diagnosing.

D0230

INTRAORAL PERIAPICAL EACH ADDITIONAL

none

AMN for diagnosis

Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and

bitewings (D0270, D0272) may be taken as

needed for diagnosing a condition.

For diagnosing.

D0240

INTRAORAL OCCLUSAL FILM

none

2 per RY

DMN in dental records; image covers a larger area than a periapical view; based on image,

not size of film.

For diagnosing. Differential diagnosis supports image.

D0250

EXTRA ORAL 2D PROJECT IMAGE

none

2 per RY

Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and

bitewings (D0270, D0272) may be taken as needed for diagnosing a

condition; one per DOS.

For diagnosing.

D0251

EXTRA ORAL POSTERIOR IMAGE

none

AMN for diagnosis

Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and

bitewings (D0270, D0272) may be taken as

needed for diagnosing a condition.

For diagnosing. For complete view of posterior teeth, both arches.

D0270

DENTAL BITEWING SINGLE IMAGE

none

AMN for diagnosis

Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and

bitewings (D0270, D0272) may be taken as

needed for diagnosing a condition.

For diagnosing.

D0272

DENTAL BITEWINGS TWO

IMAGES

none

1 per RY, then AMN for

diagnosis

When same DOS as D0330, consider as full

mouth series.

For diagnosing.

D0273

BITEWINGS - THREE IMAGES

none

1 per RY, then

AMN for diagnosis

When same DOS as

D0330, consider as full mouth series.

For diagnosing.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0274

BITEWINGS FOUR IMAGES

none

1 per RY, then AMN for

diagnosis

When same DOS as D0330, consider as full

mouth series.

For diagnosing.

D0277

VERT BITEWINGS 7 TO 8 IMAGES

Age 21 and older

1 per RY, then AMN for diagnosis

When same DOS as D0330, consider as full mouth series; may be taken as needed for

diagnosing condition.

For diagnosing.

D0310

DENTAL SIALOGRAPHY

none

AMN

Surgical narrative or dental records.

Salivary gland pathology diagnosis and treatment.

D0320

DENTAL TMJ ARTHROGRAM

INCL INJECTION

none

AMN

Surgical narrative or dental records.

TMJD diagnosis and treatment.

D0321

OTHER TMJ IMAGES BY

REPORT

none

AMN

DMN

TMJD diagnosis and treatment.

D0322

DENTAL TOMOGRAPHIC SURVEY

none

AMN-PA

required

DMN; surgical narrative or dental records

Must demonstrate that tomographic survey improves treatment decisions and

outcome/prognosis.

D0330

PANORAMIC IMAGE

none

D0330 allowed once every three years per servicing provider/group unless medical necessity can be documented for additional service. Is equivalent to full mouth series with 2, 3 or 4 BWs on

same DOS.

Medical diagnosis, clinical presentation, orthodontic narrative. Additional service as needed to diagnose extensive oral surgery; interceptive or comprehensive orthodontic treatment; extreme change in medical or dental condition.

Diagnosis and treatment

D0340

2D CEPHALOMETRIC IMAGE

none

1 per RY per servicing provider/group.

DMN for use by OMFS; Orthodontists may take D0330 and D0340 as needed for diagnosing and must document rationale for this in

dental records.

DMN for use by OMFS; case evaluation for interceptive or comprehensive orthodontics.

D0350

ORAL/FACIAL PHOTO IMAGES

none

Maximum 4 per RY

Documentation of medical necessity when radiographs cannot be provided for SHCN members or LTCF residents; orthodontic treatment included with

orthodontic case rate.

Diagnosis and treatment

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0351

3D PHOTOGRAPHIC IMAGE

none

1 per RY per provider/group per DOS

DMN; differential diagnosis, medical and dental history associated with

treatment request

For OMFS diagnosis.

D0364

CONE BEAM CT CAPTURE & INTERPRETATION LIMITED VIEW

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, assessment of cracked teeth when subgingival or furcational, large bony lesions, complex impactions, TMJ treatment where

indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0365

CONE BEAM CT INTERPRETATION MANDIBLE

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where

indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0366

CONE BEAM CT INTERPRETATION MAXILLA

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where

indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0367

CONE BEAM CT INTERP BOTH JAW

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where

indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0368

CONE BEAM CT CAPTURE AND INTERPRETE TMJ

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. May be included in TMJ case

rate.

For TMJD Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0380

CONE BEAM CT IMAGE CAPTURE LIMITED

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, assessment of cracked teeth when subgingival or furcational, large bony lesions, complex impactions, TMJ treatment where indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0381

CONE BEAM CT CAPT MANDIBLE

none

AMN-PA

required

PA to DMN with periapical view,

narrative and service to

be provided; for use in

diagnosis and treatment

planning based on

medical necessity for

complex cases: implant

placement, complex

endodontic procedures,

large bony lesions,

complex impactions,

TMJ treatment where

indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

included in TMJ case rate.

 

D0393

TREATMENT SIMULATION 3D IMAGE

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where

indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0394

DIGITAL SUBTRACTION- 2 OR MORE IMAGES

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions,

TMJ treatment where indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0395

FUSION 2 OR MORE 3D IMAGES

none

AMN-PA

required

PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where

indicated.

Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

D0411

HBA1C IN OFFICE TESTING

none

Once per RY

Medical history positive for diabetes, clinical presentation.

For planned perio or OMFS service. Limited to teaching facilities to include residencies and hygiene schools. W/obesity, history of DM, poor glycemic

control; referral to PCP.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0416

VIRAL CULTURE

none

AMN

Lab report, clinical rationale for test, biopsy and test requested/performed dental records;

maximum 2 per DOS.

Diagnosis and treatment

D0417

COLLECTION & PREPARE SALIVA SAMPLE

none

AMN;

Maximum 1 per DOS

Differential diagnosis, medical and dental history associated with

treatment request

Diagnosis and treatment

D0470

DIAGNOSTIC CASTS

none

AMN

Reimbursement and approval of service cannot be limited to orthodontic cases but allowed based on medical necessity. Prior authorization may be required with documentation supporting the procedure. Service is included in payment for services that have a laboratory component.

Documentation of diagnosis (malocclusion, traumatic occlusal relationships), clinical presentation to include involved quadrants and purpose as noted in dental records.

D0472

GROSS EXAM, PREP & REPORT

none

AMN

Lab report, clinical rationale for test, biopsy and test requested/performed

dental records; Maximum 8 per DOS.

Diagnosis and treatment

D0473

MICRO EXAM, PREP & REPORT

none

AMN

Lab report, clinical rationale for test, biopsy and test requested/performed dental records;

Maximum 8 per DOS.

Diagnosis and treatment

D0474

MICRO EXAM OF SURGICAL MARGINS

none

AMN

Lab report, clinical rationale for test, biopsy and test requested/performed dental records;

Maximum 8 per DOS.

Diagnosis and treatment

D0480

CYTOLOGY SMEAR PREP AND REPORT

none

AMN

Lab report, clinical rationale for test, biopsy and test requested/ performed dental records; Max. 4 per

DOS.

Diagnosis and treatment

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D0502

OTHER ORAL PATHOLOGY

PROCEDURE

none

DMN

BR

Diagnosis and treatment

D0601

CARIES RISK ASSESS LOW RISK

Under 21 years of age

Once per RY

CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and

D0150).

Diagnosis and treatment

D0602

CARIES RISK ASSESS MODERATE RISK

Under 21 years of age

Once per RY

CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and

D0150).

Diagnosis and treatment

D0603

CARIES RISK ASSESS HIGH RISK

Under 21 years of age

Once per RY

CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and

D0150).

Diagnosis and treatment

D0999

UNSPECIFIED DIAGNOSTIC PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation of provided service.

Service not described by CDT code

D1110

DENTAL PROPHYLAXIS ADULT

Age 16 and older

Allowed twice during a RY and a maximum of four times during a RY per servicing provider/group for SHCN Members which may require prior authorization.

DMN for increased frequency. Prophylaxes will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or

any periodontal surgical code.

Evidence of plaque, stains, calculus on tooth structure of permanent or transitional dentition.

D1120

DENTAL PROPHYLAXIS CHILD

Under age 16

Allowed twice during a RY and a maximum of four times during a RY per servicing provider/group for SHCN or ECC Members which may require prior

authorization.

DMN for increased frequency. Prophylaxes will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or

any periodontal surgical code.

Evidence of plaque, stains, calculus on tooth structure of primary or transitional dentition.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D1206

TOPICAL FLUORIDE VARNISH

none

Can be provided to members twice in a RY per servicing provider/group under 21 with moderate to high risk on CRA; SHCN and

ECC members up to four times annually with documentation of medical necessity; LTCF residents with high caries incidence and/or root caries.

Will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or

any periodontal surgical code. DMN for increased frequency.

Applied same day as D1110 or D1120; not same DOS as D1208.To prevent caries.

D1208

TOPICAL APPLICATION OF FLUORIDE EXCLUDING VARNISH

none

Can be provided to members of all ages (children and adults) twice in a RY per servicing provider/group; considered for SHCN and ECC members every 3 months with consideration based on documentation of medical

necessity.

Will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or

any periodontal surgical code. DMN for increased frequency.

Applied same day as D1110 or D1120; not same DOS as D1206. To prevent caries.

D1351

DENTAL SEALANT PER TOOTH

Under age 17

May be provided every 3 years for children through the age of 16. Age restriction does not apply to

SHCN.

Diagnostic periapical or bitewing; provide documentation of medical necessity.

Moderate to high CRA score; previous history of restorations and/or caries.

D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. Deep fissures and grooves with no evidence of caries.

D1352

PREVENTIVE RESIN REST, PERMENENT TOOTH

none

Once per tooth

Diagnostic periapical or bitewing; caries risk assessment.

Moderate to high caries risk; active cavitated pit or fissure lesion not extended into

dentin; includes sealant on same tooth.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D1353

SEALANT REPAIR PER TOOTH

Under age 17

May be provided every 3 years for children through the age of 16. Age restriction does not apply to

SHCN.

Diagnostic periapical or bitewing; provide documentation of medical necessity.

D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. For damaged sealant in the absence of caries Includes primary molars.

D1354

INTTERIM CARIES MED APPLICATION PER

TOOTH

none

Twice per RY without PA

Medical history, clinical presentation

Primary and permanent teeth; ECC/rampant decay, SHCN members, root caries,

LTCF residents.

D1510

SPACE MAINTAINER- FIXED- UNILATERAL PER QUADRANT

Under age 15

Once per quadrant without PA

Diagnostic periapicals or bitewings.

For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement;

includes adjustments.

D1516

SPACE MAINTAINER- FIXED BILATERAL, MAXILLARY

Under age 15

Once without PA

Diagnostic periapicals or bitewings

For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to

prevent tooth movement; includes adjustments.

D1517

SPACE MAINTAINER- FIXED-BILATERAL, MANDIBULAR

Under age 15

Once without PA

Diagnostic periapicals or bitewings

For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement;

includes adjustments.

D1526

SPACE MAINTAINER- REMOVABLE- BILATERAL, MAXILLARY

Under age 15

Once without PA

Diagnostic periapicals or bitewings

For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to

prevent tooth movement; includes adjustments.

D1527

SPACE MAINTAINER- REMOVABLE- BILATERAL, MANDIBULAR

Under age 15

Once without PA

Diagnostic periapicals or bitewings

For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement;

includes adjustments.

D1551

RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER- MAX

Under age 15

Once without PA

Diagnostic periapicals or bitewings

Dislodged appliance for premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes

adjustments.

D1552

RE-CEMENT OR

RE-BOND BILATERAL SPACE

Under age 15

Once without PA

Diagnostic periapicals or bitewings

Dislodged appliance for

premature loss of primary tooth; permanent tooth not

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

MAINTAINER- MAND

 

 

 

ready to erupt; congenitally missing teeth; to prevent tooth movement; includes

adjustments.

D1553

RE-CEMENT or RE- BOND UNILATERAL SPACE MAINTAINER-PER QUAD

Under age 15

Once without PA

Diagnostic periapicals or bitewings

Dislodged appliance for premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes

adjustments.

D1556

REMOVAL OF FIXED UNILATERAL SPACE

MAINTAINER-PER QUAD

none

Once per space maintainer

Diagnostic periapicals or bitewings Not to same provider who placed appliance.

Treatment completed, appliance broken, causing problem.

D1557

REMOVAL OF FIXED BILATERAL SPACE MAINTAINER-

MAX

none

Once per space maintainer

Diagnostic periapicals or bitewings Not to same provider who placed appliance.

Treatment completed, appliance broken, causing problem.

D1558

REMOVAL OF FIXED BILATERAL SPACE MAINTAINER-

MAND

none

Once per space maintainer

Diagnostic periapicals or bitewings Not to same provider who placed appliance.

Treatment completed, appliance broken, causing problem.

D1575

DISTAL SHOE SPACE MAINT, FIXED- UNILATERAL-PER QUAD

Under age 11

Once without PA

Diagnostic periapicals or bitewings

For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement;

includes adjustments.

D1999

UNSPECIFIED PREVENTIVE PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation of provided service.

Service not described by CDT code.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D2140

AMALGAM ONE SURFACE PERMANENT

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

D2150

AMALGAM TWO SURFACES PERMANENT

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit

with documentation for PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

D2160

AMALGAM THREE SURFACES PERMANENT

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If

due to trauma or recurrent decay, submit

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

with documentation for

PA consideration.

 

D2161

AMALGAM 4 OR > SURFACES PERMANENT

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit

with documentation for PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

D2330

RESIN ONE SURFACE- ANTERIOR

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit

with documentation for PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored.

Restoration may be limited to incisal, mesial, distal, facial or lingual surface. Extension to self-cleansing areas not additional surfaces.

D2331

RESIN TWO SURFACES- ANTERIOR

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If

due to trauma or

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored.

Restoration extends onto one third of facial/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

recurrent decay, submit with documentation for

PA consideration.

 

D2332

RESIN THREE SURFACES- ANTERIOR

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s Replacement one year

after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored.

Restoration extends onto one third of facial/ lingual. Extension to self-cleansing areas not additional surfaces.

D2335

RESIN 4/> SURF OR W INCISAL ANGLE

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored.

Restoration must include incisal angle or at least four of the five tooth surfaces. Extension to self-cleansing areas not additional surfaces.

D2390

ANT RESIN- BASED COMPSITE CROWN

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at

provider’s expense. If

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

due to trauma or recurrent decay, submit with documentation for

PA consideration.

 

D2391

POST 1 SURFACE RESIN BASED COMPOSITE

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

D2392

POST 2 SURFACE RESIN BASED COMPOSITE

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

D2393

POST 3 SURFACE RESIN BASED COMPOSITE

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

 

D2394

POST>=4 SURFACE RESIN BASED COMPOSITE

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

D2542

DENTAL ONLAY METALLIC 2 SURFACE

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

Restoration is lab fabricated, covers one or more cusp tips and adjoining occlusal surfaces, but not entire occlusal surface; reimbursable to dental schools and dental residency programs only.

D2543

DENTAL ONLAY METALLIC 3 SURFACE

none

There are no limits for replacement of restorations when medical necessity can be documented.

Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s).

Replacement one year after placement will be reimbursed.

Replacement within one year will not be reimbursed to same

Restoration is lab fabricated, covers one or more cusp tips and adjoining occlusal surfaces, but not entire occlusal surface; reimbursable to dental schools and dental residency programs only.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for

PA consideration.

 

D2710

CROWN RESIN- BASED INDIRECT

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture.

Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

D2720

CROWN RESIN W/HIGH NOBLE METAL

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture.

Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense

unless accidental

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

trauma or recurrent decay can be

documented.

 

D2721

CROWN RESIN W/BASE METAL

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture.

Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent

decay can be documented.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

D2722

CROWN RESIN W/NOBLE METAL

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture.

Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D2740

CROWN PORCELAIN/ CERAMIC

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture.

Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

D2750

CROWN PORCELAIN w/HIGH NOBLE METAL

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture.

Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

D2751

CROWN PORCELAIN FUSED

BASE METAL

none

There are no time limits on

replacement or

For single crowns, recent, diagnostic full

mouth radiographs or

Tooth is fully erupted and restorable, but lacks at least

50% tooth structure or

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

re-

panoramic image. If

cannot retain direct

cementations

tooth has no occlusion,

restoration; is in occlusion,

when medical

narrative documenting

or will be utilized as an

necessity can

that there is an

abutment to a prosthesis;

be

opposing denture or

Crown to root ratio at least

documented.

tooth will be used as an

50%; bone support at least

 

abutment to a fixed or

50%, without mobility or

 

removable denture.

furcation involvement; RCT

 

Documentation of caries

(if present) is clinically

 

control. If required

acceptable. Not for esthetics.

 

within a year of

 

 

placement, these

 

 

services will generally

 

 

not be reimbursed to

 

 

the same

 

 

provider/group. They

 

 

are replaced at

 

 

provider’s expense

 

 

unless accidental

 

 

trauma or recurrent

 

 

decay can be

 

 

documented.

 

D2752

CROWN

none

There are no

For single crowns,

Tooth is fully erupted and

 

PORCELAIN

 

time limits on

recent, diagnostic full

restorable, but lacks at least

 

W/NOBLE METAL

 

replacement or

mouth radiographs or

50% tooth structure or

 

 

 

re-

panoramic image. If

cannot retain direct

 

 

 

cementations

tooth has no occlusion,

restoration; is in occlusion,

 

 

 

when medical

narrative documenting

or will be utilized as an

 

 

 

necessity can

that there is an

abutment to a prosthesis;

 

 

 

be

opposing denture or

Crown to root ratio at least

 

 

 

documented.

tooth will be used as an

50%; bone support at least

 

 

 

 

abutment to a fixed or

50%, without mobility or

 

 

 

 

removable denture.

furcation involvement; RCT

 

 

 

 

Documentation of caries

(if present) is clinically

 

 

 

 

control. If required

acceptable. Not for esthetics.

 

 

 

 

within a year of

 

 

 

 

 

placement, these

 

 

 

 

 

services will generally

 

 

 

 

 

not be reimbursed to

 

 

 

 

 

the same

 

 

 

 

 

provider/group. They

 

 

 

 

 

are replaced at

 

 

 

 

 

provider’s expense

 

 

 

 

 

unless accidental

 

 

 

 

 

trauma or recurrent

 

 

 

 

 

decay can be

 

 

 

 

 

documented.

 

D2790

CROWN FULL

none

There are no

For single crowns,

Tooth is fully erupted and

 

CAST HIGH NOBLE

 

time limits on

recent, diagnostic full

restorable, but lacks at least

 

METAL

 

replacement or

mouth radiographs or

50% tooth structure or

 

 

 

re-

panoramic image. If

cannot retain direct

 

 

 

cementations

tooth has no occlusion,

restoration; is in occlusion,

 

 

 

when medical

narrative documenting

or will be utilized as an

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

necessity can

that there is an

abutment to a prosthesis;

be

opposing denture or

Crown to root ratio at least

documented.

tooth will be used as an

50%; bone support at least

 

abutment to a fixed or

50%, without mobility or

 

removable denture.

furcation involvement; RCT

 

Documentation of caries

(if present) is clinically

 

control. If required

acceptable. Not for esthetics.

 

within a year of

 

 

placement, these

 

 

services will generally

 

 

not be reimbursed to

 

 

the same

 

 

provider/group. They

 

 

are replaced at

 

 

provider’s expense

 

 

unless accidental

 

 

trauma or recurrent

 

 

decay can be

 

 

documented.

 

D2791

CROWN FULL

none

There are no

For single crowns,

Tooth is fully erupted and

 

CAST BASE METAL

 

time limits on

recent, diagnostic full

restorable, but lacks at least

 

 

 

replacement or

mouth radiographs or

50% tooth structure or

 

 

 

re-

panoramic image. If

cannot retain direct

 

 

 

cementations

tooth has no occlusion,

restoration; is in occlusion,

 

 

 

when medical

narrative documenting

or will be utilized as an

 

 

 

necessity can

that there is an

abutment to a prosthesis;

 

 

 

be

opposing denture or

Crown to root ratio at least

 

 

 

documented.

tooth will be used as an

50%; bone support at least

 

 

 

 

abutment to a fixed or

50%, without mobility or

 

 

 

 

removable denture.

furcation involvement; RCT

 

 

 

 

Documentation of caries

(if present) is clinically

 

 

 

 

control. If required

acceptable. Not for esthetics.

 

 

 

 

within a year of

 

 

 

 

 

placement, these

 

 

 

 

 

services will generally

 

 

 

 

 

not be reimbursed to

 

 

 

 

 

the same

 

 

 

 

 

provider/group. They

 

 

 

 

 

are replaced at

 

 

 

 

 

provider’s expense

 

 

 

 

 

unless accidental

 

 

 

 

 

trauma or recurrent

 

 

 

 

 

decay can be

 

 

 

 

 

documented.

 

D2792

CROWN FULL

none

There are no

For single crowns,

Tooth is fully erupted and

 

CAST NOBLE

 

time limits on

recent, diagnostic full

restorable, but lacks at least

 

METAL

 

replacement or

mouth radiographs or

50% tooth structure or

 

 

 

re-

panoramic image. If

cannot retain direct

 

 

 

cementations

tooth has no occlusion,

restoration; is in occlusion,

 

 

 

when medical

narrative documenting

or will be utilized as an

 

 

 

necessity can

that there is an

abutment to a prosthesis;

 

 

 

be

opposing denture or

Crown to root ratio at least

 

 

 

documented.

tooth will be used as an

50%; bone support at least

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

abutment to a fixed or

50%, without mobility or

removable denture.

furcation involvement; RCT

Documentation of caries

(if present) is clinically

control. If required

acceptable. Not for esthetics.

within a year of

 

placement, these

 

services will generally

 

not be reimbursed to

 

the same

 

provider/group. They

 

are replaced at

 

provider’s expense

 

unless accidental

 

trauma or recurrent

 

decay can be

 

documented.

 

D2910

RECEMENT INLAY

none

There are no

For single crowns,

Restoration intact, absence

 

ONLAY OR PART

 

time limits on

recent, diagnostic full

of decay or additional loss of

 

 

 

replacement or

mouth radiographs or

tooth structure.

 

 

 

re-

panoramic image. If

 

 

 

 

cementations

tooth has no occlusion,

 

 

 

 

when medical

narrative documenting

 

 

 

 

necessity can

that there is an

 

 

 

 

be

opposing denture or

 

 

 

 

documented.

tooth will be used as an

 

 

 

 

 

abutment to a fixed or

 

 

 

 

 

removable denture.

 

 

 

 

 

Documentation of caries

 

 

 

 

 

control. If required

 

 

 

 

 

within a year of

 

 

 

 

 

placement, these

 

 

 

 

 

services will generally

 

 

 

 

 

not be reimbursed to

 

 

 

 

 

the same

 

 

 

 

 

provider/group. They

 

 

 

 

 

are replaced at

 

 

 

 

 

provider’s expense

 

 

 

 

 

unless accidental

 

 

 

 

 

trauma or recurrent

 

 

 

 

 

decay can be

 

 

 

 

 

documented.

 

D2915

RECEMENT CAST

none

There are no

For single crowns,

Restoration intact, absence

 

OR

 

time limits on

recent, diagnostic full

of decay or additional loss of

 

PREFABRICATED

 

replacement or

mouth radiographs or

tooth structure.

 

POST

 

re-

panoramic image. If

 

 

 

 

cementations

tooth has no occlusion,

 

 

 

 

when medical

narrative documenting

 

 

 

 

necessity can

that there is an

 

 

 

 

be

opposing denture or

 

 

 

 

documented.

tooth will be used as an

 

 

 

 

 

abutment to a fixed or

 

 

 

 

 

removable denture.

 

 

 

 

 

Documentation of caries

 

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

 

D2920

RE-CEMENT OR RE-BOND CROWN

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture.

Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

Restoration intact, absence of decay or additional loss of tooth structure.

D2921

REATTACH TOOTH FRAGMENT

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

Recent diagnostic photographs and radiographs, clinical findings and dental history associated with treatment request.

No pulpal involvement, for incisal edge or single cusp fracture.

Tooth is fully erupted and restorable. Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present)

is clinically acceptable.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D2929

PREFABRICATED PORCELAIN/ CERAMIC CROWN PRIMARY

TOOTH

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity.

Primary tooth cannot retain direct restoration. Exfoliation is not imminent.

D2930

PREFABRICATED STAINLESS STEEL CROWN, PRIMARY TOOTH

none

There are no time limits on replacement or re- cementations when medical necessity can be

documented.

Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity.

Primary tooth cannot retain direct restoration. Exfoliation is not imminent.

D2931

PREFABRICATED STAINLESS STEEL CROWN, PERMANENT TOOTH

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

For permanent tooth

D2932

PREFABRICATED RESIN CROWN

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity for permanent or primary tooth.

Tooth cannot retain direct restoration. If for primary tooth, exfoliation is not imminent. Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present)

is clinically acceptable.

D2933

PREFABRICATED STAINLESS STEEL CROWN

none

There are no time limits on replacement or

re-

Diagnostic radiographs. Allowed for SHCN members regardless of

age or with

Primary tooth cannot retain direct restoration.. If for primary tooth, exfoliation is

not imminent. Tooth is fully

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

cementations

demonstration of

erupted and restorable, but

when medical

medical necessity.

lacks at least 50% tooth

necessity can

 

structure or cannot retain

be

 

direct restoration; is in

documented.

 

occlusion, or will be utilized

 

 

as an abutment to a

 

 

prosthesis; Crown to root

 

 

ratio at least 50%; bone

 

 

support at least 50%,

 

 

without mobility or furcation

 

 

involvement; RCT (if present)

 

 

is clinically acceptable. .

D2934

PREFABRICATED

Under

There are no

Diagnostic radiographs.

Primary anterior tooth

 

ESTHETIC

age 9

time limits on

Allowed for SHCN

cannot retain direct

 

COATED

unless

replacement or

members regardless of

restoration. Exfoliation is not

 

STAINLESS STEEL

SHCN

re-

age or with

imminent.

 

CROWN PRIMARY

 

cementations

demonstration of

 

 

TOOTH

 

when medical

medical necessity.

 

 

 

 

necessity can

 

 

 

 

 

be

 

 

 

 

 

documented.

 

 

D2940

PROTECTIVE

none

There are no

Diagnostic radiographs;

To relieve pain, promote

 

RESTORATION

 

time limits on

for tooth in occlusion or

healing or prevent further

 

 

 

replacement or

planned abutment;

deterioration, preserve tooth

 

 

 

re-

diagnosis and reason for

and/or tissue form; for

 

 

 

cementations

treatment

primary and permanent

 

 

 

when medical

 

teeth.

 

 

 

necessity can

 

 

 

 

 

be

 

 

 

 

 

documented.

 

 

D2941

INTERIM

none

There are no

Diagnostic radiographs

Adhesive restorative material

 

THERAPEUTIC

 

time limits on

 

placed to arrest caries in

 

RESTORATION

 

replacement or

 

primary teeth; not a

 

PRIMARY

 

re-

 

definitive restoration; for

 

DENTITION

 

cementations

 

early childhood caries or

 

 

 

when medical

 

provided in non-office

 

 

 

necessity can

 

setting. Exfoliation is not

 

 

 

be

 

imminent.

 

 

 

documented.

 

 

D2950

CORE BUILDUP

none

There are no

Diagnostic radiographs

Tooth meets criteria for full

 

INCLUDING ANY

 

time limits on

 

coverage restoration.

 

PINS

 

replacement or

 

 

 

 

 

re-

 

 

 

 

 

cementations

 

 

 

 

 

when medical

 

 

 

 

 

necessity can

 

 

 

 

 

be

 

 

 

 

 

documented.

 

 

 

 

 

Not same day

 

 

 

 

 

as D2952,

 

 

 

 

 

D2954.

 

 

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D2951

TOOTH PIN RETENTION

none

There are no time limits on replacement or re- cementations when medical necessity can be

documented.

Diagnostic radiographs

Tooth to receive direct restoration 3 or more surfaces as definitive restoration.

D2952

CAST POST AND CORE IN ADDITION TO CROWN

none

There are no time limits on replacement or re- cementations when medical necessity can be

documented.

Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.

Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown.

D2953

EACH ADDTIONAL CAST POST

none

There are no time limits on replacement or re- cementations when medical necessity can be

documented.

Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.

Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown for

molars only.

D2954

PREFABRICATED POST/CORE IN ADDITION TO CROWN

none

There are no time limits on replacement or re- cementations when medical necessity can be

documented.

Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.

Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown.

D2955

POST REMOVAL

none

AMN

Diagnostic radiographs demonstrating failed endo or restoration Is included in service and reimbursement for endodontic retreatment codes, but can be billed as separate rate when different provider is doing retreatment.

Failure of RCT requires post removal for retreatment. Post is not clinically acceptable.

D2957

EACH ADDTIONAL PREFABRICATED POST

none

There are no time limits on replacement or re- cementations

when medical

Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.

Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3)

length of root; does not

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

necessity can be

documented.

 

include crown; meets clinical criteria for a crown.

D2971

ADDITIONAL PROCEDURE TO CONSTRUCT NEW CROWN UNDER RPD

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

BR. Diagnostic radiographs, presence of removable partial denture (RPD).

Tooth will receive crown (to be billed separately) and serve as abutment to existing functional RPD. Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not

for esthetics.

D2975

COPING

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

Diagnostic radiographs, planned full-coverage restoration.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically

acceptable. Not for esthetics.

D2980

CROWN REPAIR

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

BR; diagnostic image.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing crown is otherwise

clinically acceptable.

D2981

INLAY REPAIR

none

There are no time limits on replacement or

re- cementations

BR; diagnostic image.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or

cannot retain direct restoration; is in occlusion,

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

when medical necessity can be documented.

 

or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

Existing inlay is otherwise clinically acceptable.

D2982

ONLAY REPAIR

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

BR; diagnostic image.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing onlay is otherwise

clinically acceptable.

D2983

VENEER REPAIR

none

There are no time limits on replacement or re- cementations when medical necessity can be documented.

BR; diagnostic image.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing veneer is otherwise

clinically acceptable.

D2999

UNSPECIFIED RESTORATIVE PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation of provided service.

Service not described by CDT code.

D3220

THERAPUTIC PULPOTOMY

none

Once per tooth

Emergency procedure

For pain relief; primary or permanent tooth; not first stage of RCT or for apexogenesis. Tooth is

restorable.

D3221

GROSS PULPAL DEBRIDEMENT

none

Once per tooth

Emergency procedure not same DOS as RCT performed in one visit.

For pain relief; primary or permanent tooth; not first stage of RCT or for

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

 

apexogenesis. Tooth is restorable.

D3222

PART PULPOTOMY FOR APEXOGENESIS

To age 19

Once per tooth

Diagnostic radiographs

Restorable permanent tooth with incomplete root formation; open apex.

D3230

PULPAL THERAPY ANTERIOR

PRIM ARY TOOTH

none

Once per tooth

Diagnostic radiographs

Restorable tooth, good prognosis; space preservation.

D3240

PULPAL THERAPY POSTERIOR

PRI MARY TOOTH

none

Once per tooth

Diagnostic radiographs

Restorable tooth, good prognosis; space preservation.

D3310

ENDO THERAPY ANTERIOR TOOTH

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in

reimbursement.

Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP.

D3320

ENDO THERAPY PREMOLAR TOOTH

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs

included in reimbursement.

Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D3330

ENDO THERAPY MOLAR TOOTH

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in

reimbursement.

Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP.

D3331

NON SURGICAL TREATMENT ROOT CANAL OBSTRUCTION

none

Once per tooth

BR. To include diagnostic image.

Tooth is restorable, canal(s) blocked by calcification or foreign body for at least 50% of length. Pulpal exposure or caries.

D3332

INCOMPLETE ENDODONTIC TREATMENT

none

Once per tooth

BR. To include diagnostic image.

Tooth found to be unrestorable during the course of RCT.

D3333

INTERNAL ROOT REPAIR

none

Once per tooth

BR. To include diagnostic image.

To correct resorption or carious perforation; not iatrogenic.

D3346

RETREAT ROOT CANAL ANTERIOR

none

Once per tooth

Not benefited to same provider of D3310 within 36 months; there is no timeframe for consideration of an endodontic retreatment.

Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or otherwise symptomatic.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D3347

RETREAT ROOT CANAL PREMOLAR

none

Once per tooth

Not benefited to same provider of D3320 within 36 months; there is no timeframe for consideration of an endodontic retreatment.

Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or

otherwise symptomatic.

D3348

RETREAT ROOT CANAL MOLAR

none

Once per tooth

Not benefited to same provider of D3330 within 36 months; there is no timeframe for consideration of an endodontic retreatment.

Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or

otherwise symptomatic.

D3351

APEXIFICATION/R ECALCIFICATION INITIAL

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in

reimbursement.

Vital pulp, insufficient apical development.

D3352

APEXIFICATION/R ECALC INTERIM MEDICATION REPLACEMENT

none

Once per tooth includes all visits

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All

treatment radiographs

Vital pulp, insufficient apical development.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

included in

reimbursement.

 

D3353

APEXIFICATION/R ECALCIFICATION

FINAL

none

Once per tooth

BR. To include diagnostic image.

Vital pulp, insufficient apical development

D3355

PULPAL REGENERATION INITIAL

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs

included in reimbursement.

Permanent tooth; necrotic pulp, insufficient apical development.

D3356

PULPAL REGENERATION INTERIM

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in

reimbursement.

Permanent tooth; necrotic pulp, insufficient apical development.

D3357

PULPAL REGENERATION COMPLETE

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment

and current images,

Permanent tooth; necrotic pulp, insufficient apical development.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in

reimbursement.

 

D3410

APICOECTOMY- ANTERIOR

none

Once per tooth

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. there is no timeframe for consideration of service.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or

otherwise symptomatic.

D3421

APICOECTOMY PREMOLAR (FIRST ROOT)

none

One treatment per initial root treated; all subsequent roots to be considered as D3426.

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is

sensitive to pressure or otherwise symptomatic.

D3425

APICOECTOMY MOLAR (FIRST ROOT)

none

One treatment per initial root treated; all

subsequent roots to be

Pre-treatment and when already provided, post treatment

radiographic images showing apex of tooth.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or

cannot retain direct restoration; is in occlusion,

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

considered as D3426.

Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.

or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or

otherwise symptomatic.

D3426

APICOECTOMY EACH ADDITIONAL ROOT

none

One treatment per additional tooth root(s)

Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or

otherwise symptomatic.

D3428

BONE GRAFT PERI RADICULAR PER TOOTH

none

One treatment allowed per tooth

BR; Provided w/D3427; includes non- autogenous graft

material.

To repair perforation, resorption, fracture, removal of foreign material or seal

accessory canals.

D3429

BONE GRAFT PERI RADICULAR EACH ADDL TOOTH

none

One treatment allowed per tooth

BR; Provided w/D3427; includes non-

autogenous graft material.

To repair perforation, resorption, fracture, removal

of foreign material or seal accessory canals.

D3430

RETROGRADE FILLING –PER ROOT

none

One treatment per tooth root

Provided w/ D3410, D3421, D3425, D3426.

To repair perforation, resorption, fracture, removal of foreign material or seal

accessory canals.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D3450

ROOT AMPUTATION

none

 

Once per root

Restorative treatment plan, full mouth radiographs.

Presence of root fracture, caries or resorption; bone support and crown: root ratio both at least 50%; remaining root(s) functional and restorable with good

long term prognosis.

D3471

SURGICAL REPAIR OF ROOT RESORPTION - ANTERIOR

none

One treatment allowed per tooth

Restorative treatment plan, full mouth radiographs. Surgery on root of anterior tooth; does not include restoration.

Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term

prognosis.

D3472

SURGICAL REPAIR OF ROOT RESORPTION - PREMOLAR

none

One treatment allowed per tooth

Restorative treatment plan, full mouth radiographs. Surgery on root of premolar tooth; does not include restoration.

Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term

prognosis.

D3473

SURGICAL REPAIR OF ROOT RESORPTION - MOLAR

none

One treatment allowed per tooth

Restorative treatment plan, full mouth radiographs. Surgery on root of molar tooth; does not include restoration.

Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in

function with good long term prognosis.

D3501

SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION - ANTERIOR

none

One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS.

BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs.

History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor.

D3502

SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION – PREMOLAR

none

One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS.

BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs.

History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D3503

SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION – MOLAR

none

One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS.

BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs.

History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor.

D3910

SURGICAL ISOLATION- TOOTH W/

RUBBER DAM

none

Once per tooth

BR. To include diagnostic image.

Insufficient supra-osseous tooth structure to retain rubber dam clamp.

D3920

TOOTH SPLITTING

none

Once per tooth

Diagnostic full mouth radiographs; does not include RCT.

Hemisection; tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable.

Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic tooth is restorable and required for occlusal function

or as an abutment.

D3950

CANAL PREP/ FITTING OF DOWEL

none

Once per tooth

Diagnostic periapical, restorative treatment plan; not to same provider as D2952, D2953, D2954, D2957.

Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable

tooth; calcification prevents

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

 

adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or

otherwise symptomatic.

D3999

UNSPECIFIED ENDODONTIC PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation of provided service.

Service not described by CDT code.

D4210

GINGIVECTOMY/ PLASTY 4 OR MORE TEETH

none

Periodontal surgical procedures will be allowed every 3 years.

Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases.

Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN

member.

Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.

D4211

GINGIVECTOMY/ PLASTY 1 TO 3 TEETH

none

Periodontal surgical procedures will be allowed every 3 years.

Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases.

Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN

member.

Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.

D4212

GINGIVECTOMY/ PLASTY ACCESS FOR RESTORATION

none

Periodontal surgical procedures will

be allowed every 3 years.

Diagnostic periapical or bitewing radiograph, restorative treatment plan.

To allow visualize & access for placement of restoration.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D4240

GINGIVAL FLAP PROCEDURE W/ ROOT PLANING 4 OR MORE TEETH

Age 18 and older

Periodontal surgical procedures will be allowed every 3 years.

Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases.

Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member, there is no requirement for prior scaling and root

planning.

Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable without recent history of scaling and root planning.

D4241

GINGIVAL FLAP W/ ROOT PLANING 1 -3 TEETH

Age 18 and older

Periodontal surgical procedures will be allowed every 3 years.

Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases.

Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member, there is no requirement for prior scaling and root

planning.

Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.

D4245

APICALLY POSITIONED FLAP

Age 18 and older

Once per tooth

Full mouth x-rays or photos, perio charting, oral hygiene status.

To preserve keratinized gingiva surrounding natural teeth or implant(s).

D4249

CLINICAL CROWN LENGTHENING HARD TISSUE

Age 18 and older

Once per tooth

Diagnostic periapical or bitewing radiograph, restorative treatment plan

To restore clinically acceptable crown root ratio or to create proper biologic width for crown margin;

tooth has good long term

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

 

prognosis and periodontium is healthy; RCT if present is

clinically acceptable.

D4260

OSSEOUS SURGERY 4 OR MORE TEETH

Age 18 and older

Periodontal surgical procedures will be allowed every 3 years.

Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases.

Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. Periodontal surgical procedures will be allowed every 3

years.

Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.

D4261

OSSEOUS SURGERY 1 TO 3 TEETH

Age 18 and older

Periodontal surgical procedures will be allowed every 3 years.

Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases.

Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. Periodontal surgical procedures will be allowed every 3

years.

Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D4263

BONE REPLACE GRAFT FIRST SITE IN QUAD

Age 18 and older

Once per tooth (each tooth = 1 site)

Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes.

Other procedures on same DOS documented by their own codes.

For regeneration of bone lost through periodontal disease to correct a deformity or defect; not for edentulous spaces or extraction sites.

For retained natural tooth, presence of bone loss.

D4264

BONE REPLACE GRAFT EACH ADDITIONAL SITE IN A QUADRANT

Age 18 and older

Once per tooth

Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases Not with implant cases. Performed with one or more bone replacement grafts; number of sites to be

documented

For regeneration of bone lost through periodontal disease to correct a deformity or defect; not for edentulous spaces or extraction sites.

For retained natural tooth, presence of bone loss.

D4265

BIOLOGIC MATERIALS TO AID SOFT TISSUE/ OSSEOUS REGENERATION

Age 18 and older

Once per tooth

Recent diagnostic images and periodontal charting.

Used alone or with other regenerative materials such as bone and barrier membranes; does not include surgical entry and closure, debridement, osseous contouring or placement of graft related materials and or membranes. Other procedures provided on same DOS to be reported with own

codes.

For the correction of periodontal defects involving restorable teeth in occlusion, presence of bone loss.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D4266

GUIDED TISSUE REGENERATION RESORBABLE

Age 18 and older

Once per tooth (each tooth = 1 site)

Recent diagnostic images and periodontal charting.

Does not include surgical entry and closure, wound debridement, osseous contouring or placement of barrier membranes or graft materials; other procedures provided on same DOS reported

using their own codes

For correction of periodontal and peri-implant defects involving restorable teeth or implant in occlusion presence of bone loss.

D4267

GUIDED TISSUE REGENERATION NONRESORBABLE

Age 18 and older

Once per tooth (each tooth = 1 site)

Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes.

Other procedures on same DOS documented by their own codes.

For correction of periodontal and peri-implant defects involving restorable teeth or implant in occlusion presence of bone loss.

D4268

SURGICAL REVISION PROCEDURE, PER TOOTH

Age 18 and older

Once per tooth

Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes.

Other procedures on same DOS documented

by their own codes.

To refine results of previous surgical procedure; presence of bone loss, may modify irregular contours of soft or hard tissue; muccoperiosteal flap to access alveolar bone; flap(s) replaced or repositioned and sutured.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D4270

PEDICLE SOFT TISSUE GRAFT PROCEDURE

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs and/or photographs, narrative.

Adjacent gingiva is used to replace absent alveolar mucosa as marginal tissue; for root coverage or correct gingival defects on

prominent teeth.

D4273

AUTO TISSUE GRAFT FIRST TOOTH

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs

and/or photographs, narrative.

For correction of gingival defects of tooth, implant or

dental ridge; utilizes donor site.

D4274

MESIAL/DISTAL WEDGE PROCEDURE

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs and/or photographs,

narrative.

To reduce pocket depth in edentulous area adjacent to erupted tooth.

D4275

NON-AUTOGEOUS GRAFT FIRST TOOTH

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs and/or photographs, narrative.

For correction of gingival defects of tooth (including recession), implant or dental ridge; eliminate pull of frena and muscle attachments; no

donor site.

D4276

CONNECTIVE TISSUE AND DOUBLE PEDICLE

GRAFT

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs and/or photographs,

narrative.

For advanced gingival recession, utilizes combined tissue grafting procedures.

D4277

SOFT TISSUE GRAFT FIRSTTOOTH

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs and/or photographs, narrative.

For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site.

D4278

SOFT TISSUE GRAFT ADDITIONAL

TOOTH

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs and/or photographs,

narrative.

For correction of gingival defects of tooth, implant or dental ridge; utilizes donor

site.

D4283

AUTO TISSUE GRAFT

ADDITIONAL TOOTH

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs

and/or photographs, narrative.

For correction of gingival defects of tooth, implant or

dental ridge; utilizes donor site.

D4285

NON-AUTO GRAFT ADDITIONAL TOOTH

Age 18 and older

Once per tooth

Recent perio charting, diagnostic radiographs and/or photographs, narrative.

For correction of gingival defects of tooth (including recession), implant or dental ridge; eliminate pull of frena and muscle attachments; no donor site; same graft site, used in conjunction with

D4275.

D4320

PROVISIONAL SPLINTING INTRACORONAL

none

AMN

Full mouth x-rays or photos and narrative if SHCN; perio charting to include presence of occlusal trauma and/or mobility; treatment

plan: per tooth

For interim stabilization of periodontally involved teeth; not for stabilization post- trauma (see D7270) presence of bone loss.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D4321

PROVISIONAL SPLINTING EXTRACORONAL

none

AMN

Full mouth x-rays or photos and narrative if SHCN; perio charting to include presence of occlusal trauma and/or mobility; treatment

plan: per tooth

For interim stabilization of periodontally involved teeth; not for stabilization post- trauma (see D7270) presence of bone loss.

D4341

PERIODONTAL SCALING & ROOT PLANING 4 OR MORE TEETH

Age 18 and older unless SHCN

Allowed every 3 years; can be considered once a year with DMN for SHCN members

Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate

radiographs.

Documentation of pocket depth, presence of bone loss inflammation, medical history or mobility supports procedure; pocket depths of 5mm. or greater.

D4342

PERIODONTAL SCALING 1-3 TEETH

Age 18 and older unless SHCN

Allowed every 3 years; can be considered once a year with DMN for SHCN members.

Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate

radiographs

Documentation of pocket depth, presence of bone loss inflammation, medical history or mobility supports procedure; pocket depths of 5mm. or greater.

D4346

SCALING W/GINGIVAL INFLAMATION

Age 10 and older (unless SHCN)

Once per RY; up to four times per RY for SHCN with documentation of medical necessity.

Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate radiographs; not allowed within 6 months of D4341, D4342, D4355, D4210,

D4211, D4910.

Pocket depths of 4mm. or greater without bone loss; presence of inflammation; medical history.

D4355

FULL MOUTH DEBRIDEMENT

none

Once per 3 years. Allowed once per year for SHCN members and LTCF residents.

DMN; Code cannot be billed on same DOS with D0150, D0160 or D0180

or with prophylaxis – adult or child (D1110, D1120) or any other periodontal code unless service is provided in OR setting for SHCN

member.

Removal of heavy plaque and/or calculus deposits required to perform oral evaluation.

D4381

LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS

none

One placement per tooth per DOS per 12

month period; not same DOS

Narrative report, recent full mouth perio charting. May be provided on same DOS

Minimum 6mm probing depth; presence of bone loss. Patient must have completed

root planning, or periodontal surgical procedure in same

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

as D1110, D4346, or D4355.

as D4341, D4342 or D4910.

quadrant, and have documented regular recall visits.

D4910

PERIODONTAL MAINTENANCE

none

May be provided twice a RY and for members with SHCN additional visits can be considered in a RY with documentation of medical necessity. For periodontal maintenance on a 3 month cycle additional service will be considered as prophylaxis

Recent full mouth charting and radiographs, documentation of recent provision of other periodontal therapy, improved oral hygiene and periodontal prognosis with documented caries control.

Recent provision of periodontal therapy presence of bone loss.

D4999

UNSPECIFIED PERIODONTAL PROCEDURE

none

 

DMN; diagnosis, clinical presentation of provided service; BR.

Service not described by CDT code.

D5110

COMPLETE DENTURE MAXILLARY

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

Replacements: Documentation of physical changes, post denture insertion extractions or planned extractions, broken or lost dentures and other extenuating circumstances. Date of previous denture(s) not required.; includes adjustments for first six months post-insertion, relines and rebases not

covered 6 months post insertion.

Edentulous arch or planned full arch extraction

D5120

COMPLETE DENTURE MANDIBULAR

none

7.5 years; less if medical necessity can

be demonstrated;

Full mouth radiographs or photographs, charting of dentition,

planned surgical procedures.

Edentulous arch or planned full arch extraction.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.

Replacements: Documentation of physical changes, post denture insertion extractions or planned extractions, broken or lost dentures and other extenuating circumstances. Date of previous denture(s) not required.; includes adjustments for first six months post-insertion, relines and rebases not covered 6 months post

insertion.

 

D5130

IMMEDIATE DENTURE MAXILLARY

none

Once per lifetime

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

Adjustments, relines/rebases are included for the 1st 6 months post insertion.

Remaining teeth have poor to hopeless prognosis; extractions (to include teeth #s 05-12) performed on date of insertion.

D5140

IMMEDIATE DENTURE MANDIBULAR

none

Once per lifetime

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

Adjustments, relines/rebases are included for the 1st 6

months post insertion.

Remaining teeth have poor to hopeless prognosis; extractions (to include teeth #s 21-28) performed on date of insertion.

D5211

MAXILLARY PARTIAL DENTURE RESIN BASE

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed

through MCO of enrollment.

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than

7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5212

MANDIBULAR PARTIAL DENTURE RESIN BASE

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of

enrollment.

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than

7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided.

D5213

MAXILLARY PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASP ING MATERIALS, RESTS AND TEETH)

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed

through MCO of enrollment.

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than

7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided.

D5214

MANDIBULAR PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASP ING MATERIALS, RESTS AND TEETH)

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is

based on

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than

7.5 years old, documentation to support loss, inability to

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

service

 

repair or multiple planned

reimbursed

extractions will be provided.

through MCO of

 

enrollment.

 

D5225

MAXILLARY

none

7.5 years; less if

Full mouth radiographs

Additional retention

 

PARTIAL

 

medical

or photographs,

required; at least one

 

DENTURE

 

necessity can

charting of dentition,

missing anterior tooth; less

 

FLEXIBLE BASE

 

be

planned surgical

than 8 points of contact that

 

 

 

demonstrated;

procedures.

establish functional and

 

 

 

dentures

 

balanced occlusion; all

 

 

 

denied for

 

procedures to be provided

 

 

 

frequency are

 

before impressions;

 

 

 

denied with an

 

remaining teeth have good

 

 

 

administrative,

 

prognosis; adjustments,

 

 

 

not a clinical

 

relines, rebases included 6

 

 

 

edit. Frequency

 

mos. post insert. If denture is

 

 

 

for provision of

 

less than 7.5 years old,

 

 

 

denture is

 

documentation to support

 

 

 

based on

 

loss, inability to repair or

 

 

 

service

 

multiple planned extractions

 

 

 

reimbursed

 

will be provided.

 

 

 

through MCO of

 

 

 

 

 

enrollment.

 

 

D5226

MANDIBULAR

none

7.5 years; less if

Full mouth radiographs

Additional retention

 

PARTIAL

 

medical

or photographs,

required; at least one

 

DENTURE

 

necessity can

charting of dentition,

missing anterior tooth; less

 

FLEXIBLE BASE

 

be

planned surgical

than 8 points of contact that

 

 

 

demonstrated;

procedures.

establish functional and

 

 

 

dentures

 

balanced occlusion; all

 

 

 

denied for

 

procedures to be provided

 

 

 

frequency are

 

before impressions;

 

 

 

denied with an

 

remaining teeth have good

 

 

 

administrative,

 

prognosis; adjustments,

 

 

 

not a clinical

 

relines, rebases included 6

 

 

 

edit. Frequency

 

mos. post insert. If denture is

 

 

 

for provision of

 

less than 7.5 years old,

 

 

 

denture is

 

documentation to support

 

 

 

based on

 

loss, inability to repair or

 

 

 

service

 

multiple planned extractions

 

 

 

reimbursed

 

will be provided.

 

 

 

through MCO of

 

 

 

 

 

enrollment.

 

 

D5410

DENTURES

none

AMN; Service

Clinical presentation

Necessity to restore form,

 

ADJUST CMPLT

 

cannot have

supports service;

function and to relieve sore

 

MAXILLARY

 

frequency or

Needed repairs and

spots and over-extensions

 

 

 

time limits that

adjustments 6 months

causing tissue damage by

 

 

 

adversely affect

after insertion are

existing denture.

 

 

 

the member by

included in denture

 

 

 

 

impairing their

reimbursement to

 

 

 

 

ability to

provider of prosthesis

 

 

 

 

function.

regardless of the

 

 

 

 

 

number of visits; the

 

 

 

 

 

member cannot be

 

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

charged for these services.

 

D5411

DENTURES ADJUST COMPLETE MANDIBULAR

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture.

D5421

DENTURES ADJUST PARTIAL MAXILLARY

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture

D5422

DENTURES ADJUST PARTIAL MANDBLULAR

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be

charged for these services.

Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture.

D5511

REPAIR BROKEN COMPLETE

DENTURE BASE MANDIBULAR

none

AMN; Service cannot have

frequency or time limits that

Clinical presentation supports service;

Needed repairs and adjustments 6 months

To restore denture function and retention.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

adversely affect the member by impairing their ability to function.

after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

 

D5512

REPAIR BROKEN COMPLETE DENTURE BASE MAXILLARY

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore denture function and retention.

D5520

REPLACE DENTURE TEETH COMPLETE

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore function and occlusion.

D5611

REPAIR RESIN PARTIAL DENTURE BASE MANDIBULAR

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore denture function and retention.

D5612

REPAIR RESIN PARTIAL DENTURE BASE MAXILLARY

none

AMN; Service cannot have frequency or

time limits that adversely affect

Clinical presentation supports service; Needed repairs and

adjustments 6 months after insertion are

To restore denture function and retention.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

the member by impairing their ability to function.

included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

 

D5621

REPAIR CAST PARTIAL DENTURE FRAME MANDIBULAR

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore denture function and retention.

D5622

REPAIR CAST PARTIAL DENTURE FRAME MAXILLARY

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore denture function and retention.

D5630

REPAIR PARTIAL DENTURE CLASP

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore denture function and retention.

D5640

REPLACE PARTIAL DENTURE TEETH

none

AMN; Service cannot have frequency or time limits that adversely affect

the member by

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are

included in denture

To restore function and occlusion; replacement of denture tooth.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

impairing their ability to function.

reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

 

D5650

ADD TOOTH TO PARTIAL DENTURE

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore function and occlusion; replacement of a missing natural tooth.

D5660

ADD CLASP TO PARTIAL DENTURE

none

AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.

Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these

services.

To restore denture function and retention.

D5710

DENTURES REBASE COMPLETE MAXILLARY

none

Every 3 years

Narrative to DMN; photograph.

Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore

denture fit and retention.

D5711

DENTURES REBASE COMPLETE MANDIBULAR

none

Every 3 years

Narrative to DMN; photograph.

Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore

denture fit and retention.

D5720

DENTURES REBASE PARTIAL MAXILLARY

none

Every 3 years

Narrative to DMN; photograph.

Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore

denture fit and retention.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5721

DENTURES REBASE PARTIAL MANDIBULAR

none

Every 3 years

Narrative to DMN; photograph.

Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore

denture fit and retention.

D5730

DENTURE RELNE COMPLETE MAXIL

CHAIRSIDE

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5731

DENTURE RELNE

COMPLETE MAND CHAIRSIDE

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5740

DENTURE RELINE

PARTIAL MAXIL CHAIRSIDE

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5741

DENTURE RELINE PARTIAL MAND

CHAIRSIDE

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5750

DENTURE RELINE COMPLETE MAX

LAB

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5751

DENTURE RELINE COMPLETE MAND

LAB

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5760

DENTURE RELINE PARTIAL MAXIL

LAB

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5761

DENTURE RELINE PARTIAL MAND

LAB

none

Once per RY

Documentation of ill- fitting denture.

Restore function and retention by resurfacing.

D5850

DENTURE TISSUE CONDITIONING MAXILLA

none

Once per RY

DMN; history of dentures includes adjustments to same provider for 6 months.

To heal soft tissue and ridge before definitive treatment; evidence of inflammation or tissue irritation.

D5851

DENTURE TISSUE CONDITIONING MANDBLE

none

Once per RY

DMN; history of dentures includes adjustments to same

provider for 6 months.

To heal soft tissue and ridge before definitive treatment; evidence of inflammation or

tissue irritation.

D5862

PRECISION ATTACHMENT

none

There are no time limits on replacement or re- cementations when medical necessity can

be documented.

Diagnostic full mouth images, treatment plan

Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement.

Documented caries control; RCT (if present) is clinically acceptable.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5863

OVERDENTURE COMPLETE MAXILLARY

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of

enrollment.

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

Planned extraction with natural roots retained for arch integrity.

Planned extractions with specific roots retained to limit future arch resorption and improve denture retention. Retained roots have at least 50% bone support

D5864

OVERDENTURE PARTIAL MAXILLARY

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

Planned extraction with natural roots retained for arch integrity.

At least one natural root or teeth retained for arch integrity and one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided.

Retained roots have at least 50% bone support

D5865

OVERDENTURE COMPLETE MANDIBULAR

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency

for provision of

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

Planned extraction with natural roots retained for arch integrity.

Planned extractions with specific roots retained to limit future arch resorption and improve denture retention. Retained roots have at least 50% bone support

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

denture is based on service reimbursed through MCO of

enrollment.

 

 

D5866

OVERDENTURE PARTIAL MANDIBULAR

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.

Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.

Planned extraction with natural roots retained for arch integrity.

At least one natural root or teeth retained for arch integrity and one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. Retained roots have at least

50% bone support

D5867

REPLACEMENT OF PRECISION ATTACHMENT

none

There are no time limits on replacement or re- cementations when medical necessity can

be documented.

Image of abutment, narrative.

Failed attachment; can be replacement of male and/or female component(s). Same periodontal criteria as for D2710; good prognosis for abutment and denture.

D5875

PROSTHESIS MODIFICATION

none

Once per lifetime of prosthesis

BR; dental records. For implant cases only.

For existing prosthesis following implant surgery.

D5899

UNSPECIFIED REMOVABLE PROSTHODONTIC

PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation of provided service.

Service not described by CDT code.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5911

FACIAL MOULAGE SECTIONAL

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5912

FACIAL MOULAGE COMPLETE

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5913

NASAL PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5914

AURICULAR PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all

providers involved in

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and

sequence.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Conforms to CDT descriptor.

D5915

ORBITAL PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5916

OCULAR PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5919

FACIAL PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5922

NASAL SEPTAL PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5923

OCULAR PROSTHESIS INTERIM

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5924

CRANIAL PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5925

FACIAL AUGMENTATION IMPLANT

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in

treating the case. May

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

 

D5926

REPLACEMENT NASAL PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5927

AURICULAR REPLACEMENT

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5928

ORBITAL REPLACEMENT

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5929

FACIAL REPLACEMENT

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5931

SURGICAL OBTURATOR

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5932

POSTSURGICAL OBTURATOR

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5933

REFITTING OF OBTURATOR

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in

treating the case. May

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

 

D5934

MANDIBULAR FLANGE PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5935

MANDIBULAR DENTURE PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5936

TEMPORARY OBTURATOR PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5937

TRISMUS APPLIANCE

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5951

FEEDING AID

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5952

PEDIATRIC SPEECH AID

Under age 19

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5953

ADULT SPEECH AID

Age 19 and older

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in

treating the case. May

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

 

D5954

PALATAL AUGMENTATION PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5955

PALATAL LIFT PROSTHESIS, DEFINITIVE

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5958

PALATAL LIFT PROSTHESIS INTERIM

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5959

PALATAL LIFT PROSTHESIS, MODIFACATION

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5960

MODIFY SPEECH AID PROSTHESIS

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5982

SURGICAL STENT

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5983

RADIATION APPLICATOR

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in

treating the case. May

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

 

D5984

RADIATION SHIELD

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5985

RADIATION CONE LOCATOR

none

AMN

BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or

CDT codes.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5986

FLUORIDE CARRIER

none

AMN

BR; dental records.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT

descriptor.

D5987

COMMISURE SPLINT

none

AMN

BR; dental records.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT

descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D5988

SURGICAL SPLINT

none

AMN

Treatment plan, narrative

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5991

VESICULO BULLOUS DISEASE MED CARRIER

none

AMN

Treatment plan, narrative

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5992

ADJUST MAXILLOFACIAL PROSTHETIC APPLIANCE

none

AMN

Treatment plan, narrative

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5993

MAINTAIN/CLEAN MAXILLOFACIAL PROSTHESIS

none

AMN

BR; indicate type of prosthesis and description of service provided/planned.

Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

Conforms to CDT descriptor.

D5999

UNSPECIFIED MAXILLOFACIAL PROSTHESIS

none

 

BR. DMN; diagnosis, clinical presentation of provided service;

Service not described by CDT code.

D6010

ENDOSTEAL IMPLANT

none

Maximum 4 per arch

Diagnostic radiographic images of implant sites as appropriate, number of and area where implants are to be placed, dental history to indicate date of denture fabrication, two years of difficulty with denture retention and provider’s attempts to improve or correct retention of denture are required.

Service is only considered with PA for

denture(s) for edentulous arch(es) and

Patient is unable to function with conventional complete denture due to lack of retention due to insufficient bone.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

complete implant

treatment plan.

 

D6011

SECOND STAGE IMPLANT SURGERY

none

Maximum 4 per arch

Recent diagnostic radiographic images of implants. Service is only considered with PA for denture(s) for

edentulous arch(es).

Implant body(ies) require surgical exposure to continue case.

D6055

IMPLANT CONNECTING BAR

none

Once per arch

BR. To include diagnostic radiographs of implants showing successful osteointegration, Service is only considered with PA for denture(s) for edentulous arch(es) or narrative describing modification to functional preexisting dentures. Paid as case

rate for entire arch.

Patient is unable to function with conventional complete denture due to lack of retention due to insufficient bone.

D6080

IMPLANT MAINTENANCE PROCEDURES

none

Twice per RY

BR; for debridement and evaluation of entire arch prostheses and its associated implants.

Prosthesis is removed and reinserted.

Evidence of plaque, stains, calculus on implant structure. Ensure occlusion and stability of prosthesis.

D6081

SCALE & DEBRIDE, SINGLE IMPLANT

none

Once every 3 years

Recent images of implants, narrative to document inflammation; not on same DOS as D1110, D4910 or D4346 D6101,

D6102, D6103.

For a single implant. Documentation of inflammation, medical history supports procedure.

D6090

REPAIR IMPLANT SUPPORTED PROSTHESIS

none

AMN There are no frequencies or time limits when DMN shows failure of material.

BR. Photograph, documentation of clinical findings and description of planned repair to include if it will be lab or in-office service.

If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense

unless accidental

For repair of implant supported prosthesis.

 

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

trauma or damage by patient can be documented.

Documentation that existing denture is serviceable and functional.

 

D6091

REPLACE SEMI/PRECISION ATTACH OF IMPLANT SUPPORTED PROSTHESIS

none

AMN There are no frequencies or time limits when DMN shows failure of material.

Photograph, clinical findings and description of planned repair to include if it will be lab or in-office service If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or damage by patient can be documented.

Documentation that existing denture is serviceable and functional.

Direct replacement of preexisting failed/defective semi-precision attachments; can be male and/or female component(s). Applies to replaceable male or female component of attachment.

D6092

RECEMENT ABUTMENT SUPPORTED CROWN

none

AMN There are no frequencies or time limits when DMN

shows failure of material.

For single implant crowns. Recent, diagnostic radiograph or panoramic image.

Recementation of undamaged implant crown. Associated denture must be functional.

D6095

REPAIR IMPLANT ABUTMENT

none

AMN There are no frequencies or time limits when DMN shows failure of

material.

BR. Photograph, narrative. Submit denture repair on same PA when applicable.

Repair of any part of implant abutment.

D6096

REMOVE BROKEN IMPLANT RETAIN

SCREW

none

Once per implant

BR. To include diagnostic radiographs

and narrative.

Failed implant screw.

D6100

REMOVAL OF IMPLANT

none

Once per implant

BR. To include diagnostic radiographs

and narrative.

Implant failure

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D6101

DEBRIDEMENT OF A PERIIMPLANT DEFECT

none

Once every 3 years; per implant

Diagnostic x-rays or photos and narrative to include oral hygiene status; occlusal trauma; mobility; Includes entry and closure. Not on same DOS as D6081.

For debridement and correction of peri-implant defect(s).

D6102

DEBRIDEMENT & CONTOURING OF A PERI-IMPLANT DEFECT

none

Once every 3 years; per implant

Diagnostic x-rays or photos and narrative to include oral hygiene status; occlusal trauma; mobility; Includes entry and closure. Not on same DOS as D6081.

For debridement and correction of peri-implant osseous defect(s).

D6103

BONE GRAFT REPAIR PERIMPLANT

none

Once every 3 years; per implant

Diagnostic x-rays or photos and narrative; to include oral hygiene status; occlusal trauma; mobility. Does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own code on same PA. Not on same DOS

as D6081.

For regeneration of bone loss associated with peri-implant osseous defect(s), to correct a deformity or defect.

D6110

IMPLANT/ABUT REMOVEABLE DENTURE FOR EDENTULOUS ARCH-MAXILLARY

none

7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of

enrollment.

BR. To include diagnostic radiographs. Include all associated implant services on same PA.

Inability to function with conventional complete maxillary denture due to ridge resorption and lack of retention for at least 2 years.

D6111

IMPLANT/ABUT

REMOVEABLE

none

7.5 years; less if

medical

BR. To include

diagnostic radiographs.

Inability to function with

conventional complete

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

DENTURE FOR

 

necessity can

Include all associated

mandibular denture due to

EDENTULOUS

be

implant services on

ridge resorption and lack of

ARCH

demonstrated;

same PA.

retention for at least 2 years

MANDIBULAR

dentures

 

 

 

denied for

 

 

 

frequency are

 

 

 

denied with an

 

 

 

administrative,

 

 

 

not a clinical

 

 

 

edit. Frequency

 

 

 

for provision of

 

 

 

denture is

 

 

 

based on

 

 

 

service

 

 

 

reimbursed

 

 

 

through MCO of

 

 

 

enrollment.

 

 

D6191

SEMI-PRECISION

none

Initial

Diagnostic radiographs

Patient is unable to function

 

ABUTMENT

 

placement or

of implants showing

with conventional complete

 

PLACEMENT

 

replacement.

Once per

successful

osteointegration,

denture due to lack of

retention and insufficient

 

 

 

implant body;

photograph, clinical

bone. Include reason for

 

 

 

maximum 4 per

findings and description

replacement if applicable.

 

 

 

arch

of planned repair if

 

 

 

 

 

applicable. Service is

 

 

 

 

 

only considered for

 

 

 

 

 

complete denture(s).

 

D6192

SEMI-PRECISION

none

Initial

Diagnostic radiographs

Patient is unable to function

 

ATTACHMENT

 

placement or

of implants showing

with conventional complete

 

PLACEMENT

 

replacement.

Once per

successful

osteointegration,

denture due to lack of

retention and insufficient

 

 

 

implant body;

photograph, clinical

bone. Include reason for

 

 

 

maximum 4 per

findings and description

replacement if applicable.

 

 

 

arch

of planned repair to

 

 

 

 

 

include denture

 

 

 

 

 

modification if

 

 

 

 

 

applicable. Service is

 

 

 

 

 

only considered for

 

 

 

 

 

complete denture(s).

 

D6199

UNSPECIFIED IMPLANT PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation, description of service to be provided.

Service not described by CDT code.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D6210

HIGH NOBLE METAL PONTIC

none

Replacement criteria based on N.J.A.C.

10:56 -2.13

Prosthodontic treatment (a) and (b).

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6211

PONTIC BASE METAL CAST

none

Replacement criteria based on N.J.A.C.

10:56 -2.13

Prosthodontic treatment (a) and (b).

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent

decay can be documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6212

PONTIC NOBLE METAL

CAST

none

Replacement criteria based on N.J.A.C.

10:56 -2.13

Prosthodontic treatment (a) and (b).

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of

involved teeth) or full

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

periapical series with

who cannot function with

bitewings; narrative of

removable appliance.

medical necessity if

Removable prosthesis will be

Member is SHCN. If

considered when not a direct

required within a year

replacement and criteria for

of placement, these

removable prosthesis are

services will generally

met.

not be reimbursed to

 

the same

 

provider/group. They

 

are replaced at

 

provider’s expense

 

unless accidental

 

trauma or recurrent

 

decay can be

 

documented.

 

D6240

PONTIC

none

Replacement

Recent, diagnostic full

As initial replacement of:

 

PORCELAIN HIGH

 

criteria based

mouth radiographic

single anterior tooth for

 

NOBLE

 

on N.J.A.C.

images: panoramic

members under the age of

 

 

 

10:56 -2.13

image with bitewings

21, direct replacement of

 

 

 

Prosthodontic

(may also require

preexisting failed/defective

 

 

 

treatment (a)

periapical view of

bridgework; SHCN Members

 

 

 

and (b).

involved teeth) or full

who cannot function with

 

 

 

 

periapical series with

removable appliance.

 

 

 

 

bitewings; narrative of

Removable prosthesis will be

 

 

 

 

medical necessity if

considered when not a direct

 

 

 

 

Member is SHCN. If

replacement and criteria for

 

 

 

 

required within a year

removable prosthesis are

 

 

 

 

of placement, these

met.

 

 

 

 

services will generally

 

 

 

 

 

not be reimbursed to

 

 

 

 

 

the same

 

 

 

 

 

provider/group. They

 

 

 

 

 

are replaced at

 

 

 

 

 

provider’s expense

 

 

 

 

 

unless accidental

 

 

 

 

 

trauma or recurrent

 

 

 

 

 

decay can be

 

 

 

 

 

documented.

 

D6241

PONTIC

none

Replacement

Recent, diagnostic full

As initial replacement of:

 

PORCELAIN BASE

 

criteria based

mouth radiographic

single anterior tooth for

 

METAL

 

on N.J.A.C.

images: panoramic

members under the age of

 

 

 

10:56 -2.13

image with bitewings

21, direct replacement of

 

 

 

Prosthodontic

(may also require

preexisting failed/defective

 

 

 

treatment (a)

periapical view of

bridgework; SHCN Members

 

 

 

and (b).

involved teeth) or full

who cannot function with

 

 

 

 

periapical series with

removable appliance.

 

 

 

 

bitewings; narrative of

Removable prosthesis will be

 

 

 

 

medical necessity if

considered when not a direct

 

 

 

 

Member is SHCN. If

replacement and criteria for

 

 

 

 

required within a year

removable prosthesis are

 

 

 

 

of placement, these

met.

 

 

 

 

services will generally

 

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

 

D6242

PONTIC PORCELAIN NOBLE METAL

none

Replacement criteria based on N.J.A.C.

10:56 -2.13

Prosthodontic treatment (a) and (b).

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6250

PONTIC RESIN W/HIGH NOBLE

none

Replacement criteria based on N.J.A.C.

10:56 -2.13

Prosthodontic treatment (a) and (b).

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental

trauma or recurrent

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

decay can be documented.

 

D6251

PONTIC RESIN BASE METAL

none

Replacement criteria based on N.J.A.C.

10:56 -2.13

Prosthodontic treatment (a) and (b).

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6252

PONTIC RESIN W/NOBLE METAL

none

Replacement criteria based on N.J.A.C.

10:56 -2.13

Prosthodontic treatment (a) and (b).

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent

decay can be documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6545

RETAINER CAST METAL

none

Service is associated with

need to provide/replace

Recent, diagnostic full mouth radiographic

images: panoramic image with bitewings

As initial replacement of: single anterior tooth for

members under the age of 21, direct replacement of

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

(may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6720

RETAINER CROWN RESIN W HI NBLE

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent

decay can be documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6721

RETAINER CROWN RESIN W/BASE METAL

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of

material or

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if

Member is SHCN. If

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct

replacement and criteria for

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

removable prosthesis are met.

D6722

RETAINER CROWN RESIN W/NOBLE METAL

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent

decay can be documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6750

RETAINER CROWN PORCELAIN HIGH NOBLE METAL

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They

are replaced at

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

material or carious lesion.

provider’s expense unless accidental trauma or recurrent decay can be

documented.

 

D6751

RETAINER CROWN PORCELAIN BASE METAL

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent

decay can be documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6752

RETAINER CROWN PORCELAIN NOBLE METAL

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D6790

RETAINER CROWN FULL HIGH NOBLE METAL

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6791

RETAINER CROWN FULL BASE METAL CAST

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent

decay can be documented.

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance.

Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

D6792

RETAINER CROWN FULLNOBLE METAL CAST

none

Service is associated with need to provide/replace fixed prosthetic. There are no

frequencies or

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of

involved teeth) or full

As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

time limits

periapical series with

who cannot function with

when DMN

bitewings; narrative of

removable appliance.

shows failure of

medical necessity if

Removable prosthesis will be

material or

Member is SHCN. If

considered when not a direct

carious lesion.

required within a year

replacement and criteria for

There are no

of placement, these

removable prosthesis are

frequencies or

services will generally

met.

time limits

not be reimbursed to

 

when DMN

the same

 

shows failure of

provider/group. They

 

material or

are replaced at

 

carious lesion.

provider’s expense

 

 

unless accidental

 

 

trauma or recurrent

 

 

decay can be

 

 

documented.

 

D6920

DENTAL

none

Service is

BR. To include

Device attached to abutment

 

CONNECTOR BAR

 

associated with

diagnostic radiographs.

crown or coping to stabilize

 

 

 

need to

 

removable overdenture

 

 

 

provide/replace

 

prosthesis.

 

 

 

fixed prosthetic.

 

 

 

 

 

There are no

 

 

 

 

 

frequencies or

 

 

 

 

 

time limits

 

 

 

 

 

when DMN

 

 

 

 

 

shows failure of

 

 

 

 

 

material or

 

 

 

 

 

carious lesion.

 

 

 

 

 

There are no

 

 

 

 

 

frequencies or

 

 

 

 

 

time limits

 

 

 

 

 

when DMN

 

 

 

 

 

shows failure of

 

 

 

 

 

material or

 

 

 

 

 

carious lesion.

 

 

D6930

RECEMENT/BOND

none

No frequency or

Recent, diagnostic full

Recement functional and

 

FIXED PARTIAL

 

time limits.

mouth radiographic

undamaged fixed partial

 

DENTURE

 

 

images: panoramic

denture; includes all

 

 

 

 

image with bitewings

retainers/abutments.

 

 

 

 

(may also require

 

 

 

 

 

periapical view of

 

 

 

 

 

involved teeth) or full

 

 

 

 

 

periapical series with

 

 

 

 

 

bitewings; narrative of

 

 

 

 

 

medical necessity if

 

 

 

 

 

Member is SHCN. If

 

 

 

 

 

required within a year

 

 

 

 

 

of placement, these

 

 

 

 

 

services will generally

 

 

 

 

 

not be reimbursed to

 

 

 

 

 

the same

 

 

 

 

 

provider/group. They

 

 

 

 

 

are replaced at

 

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

provider’s expense unless accidental trauma or recurrent decay can be

documented.

 

D6940

STRESS BREAKER

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or

carious lesion

BR. To include diagnostic radiographs.

Used to decrease occlusal forces on abutment teeth.

D6950

PRECISION ATTACHEMENT

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion.

Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be

documented.

Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement.

Documented caries control; RCT (if present) is clinically acceptable. Separate from prosthesis.

D6980

FIXED PARTIAL DENTURE REPAIR

none

Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or

carious lesion

BR. To include diagnostic radiographs.

Repair of functional fixed partial denture.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D6985

PEDIATRIC PARTIAL DENTURE FIXED

Under age 21

PA required

Diagnostic views of upper anterior region.

Premature loss or extraction of maxillary

incisor(s) or when eruption of permanent teeth is not imminent. May be required for proper function and/or

enunciation.

D6999

UNSPECIFIED FIXED PROSTHODONTIC

PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation, description of service to

be provided.

Service not described by CDT code.

D7111

EXTRACTION CORONAL REMNANTS

none

Once per tooth

Diagnostic radiographs

Primary tooth remnants

D7140

EXTRACT ERUPTED TOOTH/EXPOSED ROOT

none

Once per tooth

Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered

Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental

records.

Unrestorable tooth with or without pulpal involvement.

D7210

REM OVAL ERUPTED TOOTH

W/ MUCOPERIOSTEA L FLAP

none

Once per tooth

Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered

Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding

are allowed and the

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

dentist doing the exactions should retain the request for extractions or document this in the dental

records.

 

D7220

IMPACTED TOOTH REMOVALE SOFT TISSUE

none

Once per tooth

Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered

Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document

this in the dental records.

Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation.

Conforms to CDT descriptor.

D7230

IMPACTED TOOTH REMOVAL PARTIAL BONY

none

Once per tooth

Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered

Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental

records.

Part of crown covered by bone; requires mucoperiosteal flap elevation.

Conforms to CDT descriptor.

D7240

IMPACTED TOOTH REMOVAL

none

Once per tooth

Diagnostic radiographs

Extraction of teeth that are restorable,

Most or all of crown covered by bone; requires

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

COMPLETELY BONY

 

 

asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered

Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental

records.

mucoperiosteal flap elevation and bone removal. Conforms to CDT descriptor.

D7241

IMPACTED TOOTH REMOVAL BONY IMPACTION W/UNUSUAL COMPLICATIONS

none

Once per tooth

BR. Diagnostic radiographs

Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered

Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental

records.

Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position.

Conforms to CDT descriptor.

D7250

TOOTH ROOT REMOVAL

none

Once per tooth

Diagnostic radiographs

Includes cutting of soft tissue and bone, removal of tooth structure and closure.

Conforms to CDT descriptor.

D7251

CORONECTOMY

none

Once per tooth

Diagnostic radiographs

Intentional partial removal of impacted tooth performed when neurovascular complication likely with complete removal.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7260

ORAL ANTRAL FISTULA CLOSURE

none

AMN

Diagnostic radiographs, dental records.

To provide primary closure between maxillary sinus and oral cavity.

Conforms to CDT descriptor.

D7261

PRIMARY CLOSURE SINUS PERFORATION

none

AMN

Diagnostic radiographs, dental records; same DOS as surgery in upper posterior region

To repair sinus perforation. Conforms to CDT descriptor.

D7270

TOOTH REIMPLANTATION AND STABILIZATION

None

Once per tooth

Diagnostic radiographs, dental records; post dental/facial trauma includes splinting and/or stabilization not for periodontal splinting (see D4320, D4321: full mouth x-rays or photos and narrative if SHCN; perio charting to include presence of occlusal trauma and/or mobility, treatment plan (per

tooth.).

Restorable tooth which had been in occlusion.

Conforms to CDT descriptor.

D7280

EXPOSURE OF UNERUPTED TOOTH

Under age 21

Once per tooth

Diagnostic radiographs, dental records, narrative, treatment plan; approved PA for associated orthodontic

service(s).

To aid in eruption of permanent teeth into functional position.

D7282

MOBILIZE ERUPTED/MALPO SITIONED TOOTH

Under age 21

Once per tooth

Diagnostic radiographs, dental records, narrative, treatment plan, approved PA for associated orthodontic

services.

To aid in eruption of permanent tooth.

D7283

PLACE DEVICE FOR IMPACTED TOOTH ERRUPTION

Under age 21

Once per tooth

Diagnostic radiographs, dental records, narrative, treatment plan, approved PA for associated orthodontic

services.

To aid in eruption of permanent tooth.

D7285

BIOPSY OF ORAL TISSUE HARD

none

No limits

Lab report, progress notes, area of mouth pathology report.

Per site

Abnormal radiographic finding. Conforms to CDT descriptor.

D7286

BIOPSY OF ORAL TISSUE SOFT

none

No limits

Lab report, progress notes, area of mouth pathology report.

Abnormal appearance of soft tissue; for diagnosis and treatment.

Conforms to CDT descriptor.

D7287

EXFOLIATIVE CYTOLOG COLLECTION

none

No limits

Lab report, progress notes, area of mouth pathology report.

Abnormal appearance of soft tissue; for diagnosis and treatment.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7288

BRUSH BIOPSY

none

No limits

Lab report, progress notes, area of mouth pathology report.

Abnormal appearance of soft tissue; for diagnosis and treatment.

Conforms to CDT descriptor.

D7290

REPOSITIONING OF TEETH

Under age 21

Once per tooth

BR; Treatment plan, full mouth radiographs/panoramic image, narrative.

Submitted on same PA with any associated grafting procedures.

Malposed tooth that is restorable has adequate bone support and is in occlusion; with ongoing orthodontic treatment or approved PA for orthodontic services.

Conforms to CDT descriptor.

D7291

TRANSSEPTAL FIBEROTOMY

Under age 21

Once per area

BR; Treatment plan, recent diagnostic radiographs and photographs.

To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services.

Conforms to CDT descriptor.

D7292

SCREW RETAINED PLATE

Under age 21

Once per area

BR; Treatment plan, recent diagnostic radiographs and photographs. Includes placement and removal.

To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services.

Conforms to CDT descriptor

D7293

TEMPORARY ANCHORAGE DEVICE W/ FLAP

Under age 21

Once per area

BR; Treatment plan, recent diagnostic radiographs and photographs. Includes placement and removal.

To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services.

Conforms to CDT descriptor

D7294

TEMPORARY ANCHORAGE DEVICE W/O FLAP

Under age 21

Once per area

BR; Treatment plan, recent diagnostic radiographs and photographs Includes placement and removal.

To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services.

Conforms to CDT descriptor

D7295

BONE HARVEST, AUTO GRAFT PROCEDURE

none

AMN

BR; Treatment plan, full mouth radiographs/panoramic image, narrative.

Include on same PA with other autogenous graft placement procedures which do not include

harvesting of bone.

DMN

Bone defect.

D7310

ALVEOPLASTY W/EXTRACTION 4 OR MORE TEETH

none

 

Once per quadrant

Treatment plan, full mouth radiographs/panoramic image, narrative; Four or more teeth per

quadrant.

Preprosthetic surgery or before radiation therapy or transplant surgery.

Recontouring of bone in area of extractions.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7311

ALVEOLOPLASTY W/EXTRACT 1-3 TEETH

none

Once per quadrant

Treatment plan, full mouth radiographs/panoramic image, narrative; One to three teeth per

quadrant.

Preprosthetic surgery or before radiation therapy or transplant surgery.

Recontouring of bone in area of extractions.

D7320

ALVEOLOPLASTY W/O EXTRACTION 4 OR MORE TEETH

none

AMN

Treatment plan, full mouth radiographs/panoramic image, narrative; Four

or more teeth per quadrant.

Pre prosthetic surgery or before radiation therapy or transplant surgery.

Recontouring of bone i

D7321

ALVEOLOPLASTY NOT W/EXTRACTS 1-3 TEETH

none

AMN

Treatment plan, full mouth radiographs/panoramic image, narrative; One to

three teeth per quadrant.

Preprosthetic surgery or before radiation therapy or transplant surgery.

Recontouring of bone

D7340

VESTIBULOPLASTY RIDGE EXTENSION

none

AMN

Treatment plan, full mouth radiographs/panoramic

image, narrative.

Second epithelization; preprosthetic surgery. To increase ridge height.

D7350

VESTIBULOPLASTY EXTENION W/ GRAFTS

none

AMN

Treatment plan, full mouth radiographs/panoramic image, narrative includes soft tissue grafts, muscle reattachments, revision of soft tissue attachment, management/removal

of excessive soft tissue.

Preprosthetic surgery To increase ridge height.

D7410

EXCISION BENIGN LESION UP TO

1.25 CM

none

AMN

Pathology report, radiographs, dental records

Removal of abnormal soft tissue lesion or tissue overgrowth.

D7411

EXCISION BENIGN LESION > 1.25 C

none

AMN

Pathology report, radiographs, dental

records

Removal of abnormal soft tissue lesion or tissue

overgrowth.

D7412

EXCISION BENIGN LESION

COMPLICATED

none

AMN

Pathology report, radiographs, dental

records

Removal of abnormal soft tissue lesion or tissue

overgrowth.

D7413

EXCISION MALIG LESION<= 1.25C

none

AMN

Pathology report, radiographs, dental

records

Removal of cancerous soft tissue lesion.

D7414

EXCISION MALIG LESION>1.25 CM

none

AMN

Pathology report, radiographs, dental

records

Removal of cancerous soft tissue lesion.

D7415

EXCISION MALIG

LESION COMPLICATED

none

AMN

Pathology report,

radiographs, dental record

Removal of cancerous soft tissue lesion.

Conforms to CDT descriptor.

 

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7440

MALIG TUMOR EXCISION TO

1.25CM

none

AMN

Pathology report, radiographs, dental

records

Removal of cancerous soft tissue lesion.

Conforms to CDT descriptor.

D7441

MALIG TUMOR > 1.25CM

none

AMN

Pathology report, radiographs, dental

records

Removal of cancerous soft tissue lesion.

Conforms to CDT descriptor.

D7450

REMOVE ODONTOGENIC CYST TO 1.25CM

none

AMN

Pathology report, radiographs, dental records; any extractions on same DOS

considered separately.

Removal of cyst

Conforms to CDT descriptor.

D7451

REMOVE ODONTOGENIC CYST >1.25CM

none

AMN

Pathology report, radiographs, dental records; any extractions on same DOS

considered separately.

Removal of cyst

Conforms to CDT descriptor.

D7460

REMOVE NON- ODONTOGENIC CYST TO 1.25 CM

none

AMN

Pathology report, radiographs, dental record; any extractions on same DOS

considered separately.

Removal of cyst

Conforms to CDT descriptor.

D7461

REMOVE NON- ODONTOGENIC CYST >1.25 CM

none

AMN

Pathology report, radiographs, dental records; any extractions on same DOS

considered separately.

Removal of cyst

Conforms to CDT descriptor.

D7465

LESION

DESTRUCTION

none

AMN

Dental records

Removal of abnormal tissue.

Conforms to CDT descriptor.

D7471

REMOVE EXOSTOSIS ANY SITE

none

Once per area

Dental records, full mouth radiographs or intraoral images.

Overgrowth of hard tissue. Conforms to CDT descriptor.

D7472

REMOVAL OF TORUS

PALATINUS

none

Once per area

Dental records, full mouth radiographs or

intraoral images.

Overgrowth of palatal hard tissue.

Conforms to CDT descriptor.

D7473

REMOVE TORUS MANDIBULARIS

none

Once per area

Dental records, full

mouth radiographs or intraoral images.

Overgrowth of mandibular hard tissue.

Conforms to CDT descriptor.

D7485

SURG REDUCT OSSEOUS

TUBEROSITY

none

Once per area

Dental records, full mouth radiographs or

intraoral images.

Need to reshape tuberosity for denture construction

D7490

MAXILLA OR MANDIBLR RESECTION

none

Once per area

Lab report, radiographs, dental records.

Removal of lesion in mandible

Conforms to CDT descriptor.

D7510

I&D ABSCESS INTRORAL SOFT

TISSUE

none

AMN

Dental records

Abscess

Conforms to CDT descriptor.

D7511

I&D ABSCESS INTRAORAL SOFT

TISSUE, COMPLICATED

none

AMN

BR, dental records.

Abscess

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7520

I&D ABSCESS,

EXTRAORAL

none

AMN

Dental records

Abscess

Conforms to CDT descriptor.

D7521

I&D ABSCESS, EXTRAORAL,

COMPLICATED

none

AMN

BR, dental records.

Abscess

D7530

REMOVAL FOREIGN BODY

SKIN/ALVEOLAR TISSUE

None

AMN

Dental records.

Foreign body

Conforms to CDT descriptor.

D7540

REMOVAL OF FOREIGN BODY

REACTION

none

AMN

Dental records

Foreign body

Conforms to CDT descriptor.

D7550

REMOVAL OF NON-VITAL BONE

none

Once per area

Dental records

Sequestrectomy; for removal of necrotic, sloughed-off bone due to infection or reduced blood supply.

Conforms to CDT descriptor.

D7560

MAXILLARY SINUSOTOMY

none

AMN

Dental records, diagnostic radiograph of area.

Presence of tooth fragment or foreign body.

Conforms to CDT descriptor.

D7610

MAXILLA OPEN REDUCTION SIMPLE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Maxillary fracture requiring surgical reduction

Conforms to CDT descriptor.

D7620

CLOSED REDUCTION SIMPLE MAXILLA FRACTURE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Maxillary fracture with non- surgical reduction

Conforms to CDT descriptor.

D7630

OPEN REDUCTION SIMPLE MANDIBLE FRACTURE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and

removal of appliance to same provider.

Mandibular fracture requiring surgical reduction Conforms to CDT descriptor.

D7640

CLOSED REDUCTION SIMPLE MANDIBLE FRACTURE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Mandibular fracture, non- surgical reduction

Conforms to CDT descriptor.

D7650

OPEN REDUCTION SIMPLE MALAR/ZYGOMA FRACTURE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Unilateral surgical reduction Conforms to CDT descriptor.

D7660

CLOSED

REDUCTION

none

AMN

Dental records,

diagnostic radiograph of

Unilateral non-surgical

reduction

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

SIMPLE MALAR/ZYGOMA FRACTURE

 

 

area where applicable; includes placement and removal of appliance to

same provider.

Conforms to CDT descriptor.

D7670

CLOSED REDUCTION SLPINT ALVEOLUS

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and

removal of appliance to same provider.

One site non-surgical reduction

Conforms to CDT descriptor.

D7671

ALVEOLUS OPEN REDUCTION

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Surgical reduction

Conforms to CDT descriptor.

D7680

REDUCTION COMPLEX FACIAL BONES FRACTURE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Surgical reduction

Conforms to CDT descriptor.

D7710

MAXILLA-OPEN REDUCTION

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and

removal of appliance to same provider.

Maxillary fracture requiring surgical reduction.

Conforms to CDT descriptor.

D7720

MAXILLA-CLOSED REDUCTION

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Maxillary fracture requiring non-surgical reduction.

Conforms to CDT descriptor.

D7730

MANDIBLE-OPEN REDUCTION

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and

removal of appliance to same provider.

Mandibular fracture requiring surgical reduction. Conforms to CDT descriptor.

D7740

MANDIBLE- CLOSED REDUCTION

none

AMN

Dental records; diagnostic radiograph of area where applicable; includes placement and

removal of appliance to same provider.

Mandibular fracture requiring non-surgical reduction.

Conforms to CDT descriptor.

D7750

OPEN REDUCTION MALAR/ZYGOMA FRACTURE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Unilateral. Requires surgical reduction.

 

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7760

CLOSED REDUCTION MALAR/ZYGOMA FRACTURE

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Unilateral Non-surgical reduction

Conforms to CDT descriptor.

D7770

ALVEOLUS-OPEN REDUCTION STABILIZE TEETH

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and

removal of appliance to same provider.

Surgical reduction

Conforms to CDT descriptor.

D7771

ALVEOLUS - CLOSED REDUCTION STABILIZE TEETH

none

AMN

Dental records, diagnostic radiograph of area where applicable; includes placement and

removal of appliance to same provider.

Non-surgical reduction Conforms to CDT descriptor.

D7780

REDUCT COMPND FACIAL BONE FRACTURE

none

AMN

Dental records; diagnostic radiograph of area where applicable; includes placement and removal of appliance to

same provider.

Surgical reduction

Conforms to CDT descriptor.

D7810

TMJ OPEN REDUCTION- DISLOCATION

none

AMN

Dental records, clinical presentation.

Surgical reduction

Conforms to CDT descriptor.

D7820

CLOSED REDUCTION OF DISLOCATION

none

AMN

Dental records, clinical presentation; only billed with radiographs and anesthesia codes on

same DOS.

Non-surgical reduction Conforms to CDT descriptor.

D7830

TMJ MANUPULATION UNDER ANESTHESIA

none

AMN

Dental records, clinical presentation; only with IV sedation or GA and radiographs on same

DOS.

Reduction of dislocation with general or intravenous anesthesia.

Conforms to CDT descriptor.

D7840

CONDYLECTOMY REMOVAL OF TMJ CONDYLE

none

Once per side

Dental records, clinical presentation, diagnostic image.

Unilateral

Separate procedure. Conforms to CDT descriptor.

D7850

TMJ SURGICAL DISECTOMY

none

Once per side

Dental records, clinical presentation, diagnostic

image

Unilateral

With or without implant. Conforms to CDT descriptor.

D7852

TMJ REPAIR OF JOINT DISC

none

Once per side

Dental records, clinical presentation, diagnostic image.

Unilateral

Reposition and/or sculpting of disc.

Conforms to CDT descriptor.

D7854

SYNOVECTOMY

none

Once per side

Dental records, clinical presentation, diagnostic image.

Unilateral

Removal of all or part of membrane.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7856

TMJ CUTTING OF A MUSCLE

none

AMN

BR, dental records

For therapeutic purposes; separate procedure.

Conforms to CDT descriptor.

D7858

TMJ RECONSTRUCTIO

N

none

Once per side

Dental records, clinical presentation, diagnostic

image.

Reconstruction of hard and/or soft tissues

Conforms to CDT descriptor.

D7860

ARTHROTOMY

none

Once per side

Dental records, clinical presentation, diagnostic

image.

Conforms to CDT descriptor.

D7865

ARTHROPLASTY

none

Once per side

Dental records, clinical presentation, diagnostic

image.

Separate procedure Conforms to CDT descriptor.

D7870

ARTHROCENTISIS

none

AMN

Dental records, clinical presentation, diagnostic image.

Unilateral

Fluid removal from joint space.

Conforms to CDT descriptor.

D7871

LYSIS + LAVAGE W/ CATHETERS

none

AMN

Dental records, clinical presentation, diagnostic

image.

Non-arthroscopic; treatment of joint space.

Conforms to CDT descriptor.

D7872

TMJ DIAGNOSTIC ARTHROSCOPY

none

AMN

Dental records, clinical

presentation, diagnostic image.

With or without biopsy Conforms to CDT descriptor.

D7873

TMJ ARTHROSCOPY

LYSIS ADHESIONS

none

AMN

Dental records, clinical presentation, diagnostic

image.

Arthroscopic treatment of joint space

Conforms to CDT descriptor.

D7874

TMJ ARTHROSCOPY

DISC REPOSITION

none

AMN

Dental records, clinical presentation, diagnostic

image

Disc reposition and stabilization

Conforms to CDT descriptor.

D7875

TMJ ARTHROSCOPY

SYNOVECTOMY

none

AMN

Dental records, clinical presentation, diagnostic

image.

Partial or complete Conforms to CDT descriptor.

D7876

TMJ ARTHROSCOPY

DISCECTOMY

none

Once per area

BR, dental records.

For disc removal and to remodel attachment.

Conforms to CDT descriptor.

D7877

TMJ

ARTHROSCOPY DEBRIDEMENT

none

AMN

Dental records, clinical

presentation, diagnostic image.

Remove pathologic tissues Conforms to CDT descriptor.

D7880

OCCLUSAL ORTHOTIC APPLIANCE

none

AMN

BR; includes placement and adjustments to same provider for first 6 months.

May be Included in case rate for TMJ.

D7881

OCCLUSAL ORTHOTIC DEVICE ADJUST

none

AMN

BR, dental records.

Reimbursed to other than original provider or 6 months after placement.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7899

TMJ UNSPECIFIED THERAPY

none

AMN

BR-panoramic image, narrative describing clinical findings (to include measurements), dental records and TMJ images if available; treatment plan which includes expected time of treatment. Not for bruxism; paid as case rate.

Documentation supports presence of TMJ pain and /or decreased function.

D7910

SUTURE RECENT

WOUND TO 5 CM

none

AMN

Dental records

Conforms to CDT descriptor.

D7911

SUTURE WOUND

TO 5 CM

none

AMN

Dental records

Conforms to CDT descriptor.

D7912

SUTURE COMPLICATED

WOUND >5 CM

none

AMN

Dental records, photo of site.

Conforms to CDT descriptor.

D7920

DENTAL SKIN GRAFT

none

AMN

BR; dental records, photo of site.

Conforms to CDT descriptor.

D7940

OSTEOPLASTY FOR ORTHOGNATHIC DEFORMATIES

none

Once per area

BR; diagnostic images, dental records, treatment plan; can be uni-lateral or bi-lateral.

Congenital, developmental, traumatic or surgical deformity.

Conforms to CDT descriptor.

D7941

OSTEOTOMY MANDIBULAR RAMI

none

Once per area

BR; diagnostic images, dental records; treatment plan; can be uni-lateral or bi-lateral BR; Diagnostic images, progress notes, treatment plan; can be

uni-lateral or bi-lateral.

Conforms to CDT descriptor.

D7943

OSTEOTOMY W/GRAFT

none

Once per area

BR; diagnostic images, dental records; treatment plan; can be uni-lateral or bi-lateral

Includes obtaining graft.

Conforms to CDT descriptor.

D7944

OSTEOTOMY SEGMENTED

none

Once per area

Range of tooth numbers within segment; diagnostic images, dental records, treatment plan.

Conforms to CDT descriptor.

D7945

OSTEOTOMY BODY MANDIBLE

none

Once per area

BR; diagnostic images, dental records, treatment plan; can be

uni-lateral or bi-lateral.

Sectioning of lower jaw; includes entire procedure and follow-up care.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7946

RECONSTRUCTIO N MAXILLA TOTAL LE FORTE I

none

Once per area

Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21),

operative notes.

Sectioning of upper jaw; includes all procedures and follow-up care.

Conforms to CDT descriptor.

D7947

RECONSTRUCT MAXILLA SEGMENT

LE FORTE I

none

Once per area

Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery

(under age 21), operative notes.

BR ; reduced reimbursement when used for surgically assisted palatal expansion Conforms to CDT descriptor.

D7948

LE FORTE II or LE FORTE III

NO BONE GRAFT

none

Once per area

Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery

(under age 21), operative notes.

Sectioning of upper jaw; includes all procedures and follow-up care.

Conforms to CDT descriptor.

D7949

LE FORTE II OR LE FORTE III W/BONE GRAFT

none

Once per area

Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21),

operative notes.

Sectioning of upper jaw; includes all procedures and follow-up care.

Conforms to CDT descriptor.

D7950

MAXILLA OR MANDIBLE GRAFT

none

AMN

Full mouth radiographic images, approved restorative/prosthetic treatment plan.

Preprosthetic surgery to increase ridge height of Maxilla or Mandible; repair of trauma or post-cancer surgery.

Conforms to CDT descriptor.

D7951

SINUS AUGMENTATION W/ BONE OR BONE SUBSTS. LATERAL

APPROACH

none

Once per area; total limit is two procedures

Full mouth radiographic images, approved restorative/prosthetic treatment plan.

Unilateral.

Conforms to CDT descriptor.

D7952

SINUS AUGMENTATION VERTICAL

APPROACH

none

Once per area

Full mouth radiographic images, approved restorative/prosthetic

treatment plan.

Unilateral

Conforms to CDT descriptor.

D7955

REPAIR MAXILLOFACIAL SOFT/HARD TISSUE DEFECTS

none

AMN

Diagnostic imaging of area, dental records.

For facial reconstruction, trauma or congenital defects not a preprosthetic procedure.

Conforms to CDT descriptor.

D7961

BUCCAL/LABIAL FRENECTOMY (FRENULECTOM Y)

none

AMN

DMN. Narrative describing importance to success of prosthetic or orthodontic

Aberrant muscle attachments which hinder oral function, development or treatment.

Separate procedure.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

treatment. Intraoral image when available.

Conforms to CDT descriptor.

D7962

LINGUAL FRENECTOMY (FRENULECTOM Y)

none

AMN

PA required. If referred by PCP, narrative of medical necessity required when requested for purposes

of lactation or speech.

Aberrant muscle attachments which hinder oral function, development or treatment.

Separate procedure. Conforms to CDT descriptor.

 

 

 

 

Narrative describing

 

 

 

 

 

importance to success

 

 

 

 

 

of prosthetic or

 

 

 

 

 

orthodontic treatment.

 

 

 

 

 

Intraoral image when

 

 

 

 

 

available.

 

D7963

FRENULOPLASTY

none

AMN

Dental records, intraoral image.

Aberrant muscle attachments which hinder oral function, development or treatment.

Conforms to CDT descriptor.

D7970

EXCISION HYPERPLASTIC

TISSUE

none

AMN; per arch

Dental records, intraoral image.

Pre prosthetic surgery Conforms to CDT descriptor.

D7971

EXCISION PERCORONAL GINGIVA

none

AMN for permanent teeth

Dental records, intraoral image; with other oral surgical procedure.

To remove tissue surrounding partially erupted teeth; not as periodontal therapy.

Conforms to CDT descriptor.

D7972

SURGICAL REDUCTION FIBROUS TUBEROSITY

none

Once per area limit two per DOS

Dental records, intraoral image.

Pre prosthetic surgery Conforms to CDT descriptor.

D7979

NON-SURGICAL SIALOLITHOTOMY

none

AMN

BR, dental records.

Medical history, clinical presentation of glandular obstruction.

Conforms to CDT descriptor.

D7980

SURGICAL SIALOLITHOTOMY

none

AMN

Dental records.

Salivary gland/duct stone present. Conforms to CDT

descriptor.

D7981

EXCISION OF SALIVARY GLAND

none

Once per gland

BR; dental records.

Pathology due to tumor, infection or blockage.

Conforms to CDT descriptor.

D7982

SIALODOCHO- PLASTY

none

AMN

Dental records

Salivary gland duct defect. Conforms to CDT descriptor.

D7983

CLOSURE OF SALIVARY FISTULA

none

AMN

Dental records

Repair of pathological opening into oral cavity.

Conforms to CDT descriptor.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D7990

EMERGENCY TRACHEOTOMY

none

AMN

Dental records; may be paid under medical

benefit.

Blocked airway; respiratory distress

Conforms to CDT descriptor.

D7991

CORONOIDEC- TOMY

none

Once per side

Dental records, diagnostic radiograph/image of area.

Pathology resulting in need for removal of coronoid process.

Conforms to CDT descriptor.

D7993

SURGICAL

none

AMN

BR; dental records.

To aid in retention of an

 

PLACEMENT OF

 

 

May be paid under

auricular, nasal or orbital

 

CRANIOFACIAL IMPLANT - EXTRAORAL

 

 

medical benefit;

indicate that these

services are provided by physicians or OMFS and

prosthesis. Conforms to CDT

descriptor.

 

 

 

 

include if provider uses

 

 

 

 

 

CPT or CDT codes.

 

D7994

SURGICAL

none

AMN

BR; dental records.

To provide support and

 

PLACEMENT –

 

 

May be paid under

attachment of a maxillary

 

ZYGOMATIC IMPLANT

 

 

medical benefit;

indicate that these services are provided by

dental prosthesis. Conforms

to CDT descriptor.

 

 

 

 

physicians or OMFS and

 

 

 

 

 

include if provider uses

 

 

 

 

 

CPT or CDT codes.

 

D7995

SYNTHETIC GRAFT FACIAL BONES

none

AMN

BR; for congenital defects and/or trauma; includes allogenic

material.

Loss of bone or bone defect. Conforms to CDT descriptor.

D7996

IMPLANT MANDIBLE AUGMENTATION

none

AMN

BR, dental records.

Loss of mandibular bone width or height, Excludes alveolar ridge

Conforms to CDT descriptor.

D7997

APPLIANCE REMOVAL

none

Not to provider originally treating fracture(s)

Panoramic image, narrative, dental records.

Fracture of jaw(s); includes removal of arch bar; appliance non-functional, treatment complete.

Conforms to CDT descriptor.

D7999

UNSPECIFIED ORAL SURGERY PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation of provided service.

Service not described by CDT code.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D8010

LIMITED ORTHO TX PRIMARY DENTITION

From age 4 up

to age 9

Orthodontic treatment (D8010-D8080)

Based on DMN.

Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment

plan is required.

To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan.

Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate.

D8020

LIMITED ORTHO TX TRANSITIONAL DENTITION

From age 6 up to age 15

Orthodontic treatment (D8010-D8080)

Based on DMN.

Narrative of clinical dings; treatment plan; estimated treatment time; diagnostic photos, x-rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment

plan is required.

To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan.

Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate.

D8030

LIMITED ORTHO TX ADOLESCENT DENTITION

From age 8 up to age 21

Orthodontic treatment (D8010-D8080)

Based on DMN.

Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment

plan is required.

To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan.

Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate.

D8040

LIMITED ORTHO TX ADULT DENTITION

From age 8 up to age 21

Orthodontic treatment (D8010-D8080)

Based on DMN.

Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of

completed dental

To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan.

Reimbursement includes placement and removal of appliance(s) by same

provider. Refer to MCO

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment

plan is required.

Provider Manual. Paid as case rate.

D8050

INTERCEP ORTHO TX PRIMARY DENTITION

From age 4 up

to age 9

Orthodontic treatment (D8010-D8080)

Based on DMN.

Classification of malocclusion, diagnostic radiographic images and photographs, diagnostic study or digital study models, cephalometric image, attestation from PCD re: preventive and dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis.

May include localized tooth movement to include redirecting tooth eruption, correcting dental cross bite or recovery of space. When part of a comprehensive case, submit complete treatment plan.

D8060

INTERCEP ORTHO TX TRANSITIONAL DENTITION

From age 6 up to age 21

Orthodontic treatment (D8010-D8080)

Based on DMN.

Classification of malocclusion, diagnostic radiographic images and photographs, diagnostic study or digital study models, cephalometric image, attestation from PCD re: preventive and dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis.

May include localized tooth movement to include redirecting tooth eruption, correcting dental cross bite or recovery of space. When part of a comprehensive case, submit complete treatment plan. Localized tooth movement to redirect tooth movement, redirect tooth eruption regain space or correct cross bite. For treatment of anterior ectopic eruption when it does not meet criteria for anterior

cross bite.

D8080

COMPREHENSIVE ORTHO TX ADOLESCENT DENTITION

From age 8 up to age 21

Orthodontic treatment (D8010-D8080)

Based on DMN.

Classification of malocclusion, diagnostic radiographic images and photograph to show full view of millimeter ruler in position to show measurement, diagnostic study or digital study models, cephalometric image, completed current NJ HLD, attestation from

PCD re: preventive and

Handicapping malocclusion to treat late mixed and permanent dentition.

Scoring based on HLD or extenuating circumstance which meets medical necessity requirement.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

 

 

 

 

dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis. Include documentation of extenuating

conditions.

 

D8210

ORTHODONTIC REMOVEABLE APPLIANCE TX

Up to age 21

Maximum 2 per date of service

Clinical findings; treatment plan; estimated treatment time with prognosis; diagnostic photos and/or models; adjustments included to

provider of placement.

Documentation of harmful habit including but not limited to thumb sucking and tongue thrust.

D8220

FIXED APPLIANCE THERAPY HABIT

Up to age 21

Once without PA

Clinical findings; treatment plan; estimated treatment time with prognosis; diagnostic photos and/or models; adjustments included to

provider of placement.

Documentation of harmful habit including but not limited to thumb sucking and tongue thrust.

D8660

PREORTHODONTI C TX VISIT

Up to age 21

Once per year; service linked to provider

Clinical findings, diagnostic materials (current NJ HLD) required for interceptive and comprehensive

treatment.

Evaluate with documentation of findings associated with orthodontic conditions.

D8670

PERIODIC ORTHODONTIC TX VISIT

Up to age 21

24 months of active treatment are expected to be adequate to complete most cases (up to 36 months).

12 visits included on PA for D8080; PA for additional 12 visits to include treatment notes; PCD attestation; pre-and current panoramic image and/or photos; documentation of any compliance problems; initial approval if started in different NJFC program.

Case in comprehensive treatment.

D8680

ORTHODONTIC RETENTION

Up to age 21

AMN

Documents completion of D8080 by provider initiating or treating case.

Treatment outcomes demonstrate completion or termination of orthodontic treatment.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D8681

REMOVABLE RETAINER ADJUSTMENT

Up to age 21

Once per day of service

Narrative including Member compliance; dental records. Not to provider of original

placement.

Patient in retention.

D8695

REMOVE FIXED ORTHO APPLIANCE (FOR REASONS OTHER THAN CASE COMPLETION)

none

DMN, AMN

BR; Non-compliance with ortho treatment, dental records, provider attestation for request; release from treatment form from parent/member to agree to removal of appliances. Includes fee for removal and retainer(s) if provided by provider of

placement.

DMN; treatment is not progressing.

D8696

REPAIR OF ORTHODONTIC APPLIANCE-

MAXILLARY

Up to age 21

AMN

Clinical findings

For functional appliance and palatal expanders, not brackets (standard fixed

ortho appliance).

D8697

REPAIR OF ORTHODONTIC APPLIANCE-

MANDIBULAR

Up to age 21

AMN

Clinical findings

For functional appliance and palatal expanders, not brackets (standard fixed

ortho appliance).

D8698

RE-CEMENT OR RE-BOND FIXED RETAINER-

MAXILLARY

Up to age 21

AMN

Clinical findings

Patient in retention; may be included in case rate.

Dislodged retainer that is undamaged.

D8699

RE-CEMENT OR RE-BOND FIXED RETAINER-

MANDIBULAR

Up to age 21

AMN

Clinical findings

Patient in retention; may be included in case rate.

Dislodged retainer that is undamaged.

D8701

REPAIR OF FIXED RETAINER, INCLUDES

REATTACHMENT- MAXILLARY

Up to age 21

AMN

Narrative including Member compliance; dental records.

For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance).

D8702

REPAIR OF FIXED RETAINER, INCLUDES REATTACHMENT-

MANDIBULAR

Up to age 21

AMN

Narrative including Member compliance; dental records.

For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance).

D8703

REPLACEMENT OF LOST OR BROKEN RETAINER-

MAXILLARY

Up to age 21

AMN

Narrative including Member compliance; dental records.

Replacement of lost or broken retainer based on medical necessity.

D8704

REPLACEMENT OF LOST OR BROKEN

RETAINER- MANDIBULAR

Up to age 21

AMN

Narrative including Member compliance; dental records

Replacement of lost or broken retainer based on medical necessity.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D8999

UNSPECIFIED ORTHODONTIC PROCEDURE

Up to age 21

 

BR. DMN; diagnosis, clinical presentation of provided service.

Service not described by CDT code.

D9110

TREATMENT DENTAL PAIN MINOR PROCEDURE

none

Once per date of service; per tooth or per site

DMN

Emergency, limited treatment for pain.

D9210

DENTAL ANESTHESIA W/O SURGERY

none

Twice per year per provider with PA; not with dental procedure

Narrative, radiographs and/or photos not with D9211, D9212.

For diagnostic purposes only

D9211

REGIONAL BLOCK ANESTHESIA

none

Twice per year per provider with PA; not with dental

procedure

Narrative, radiographs and/or photos not with D9210, D9212.

For diagnostic purposes only

D9212

TRIGEMINAL BLOCK ANESTHESIA

none

Twice per year per provider with PA; not

with dental procedure

Narrative, radiographs and/or photos not with D9210, D9211.

For diagnostic purposes only

D9222

DEEP SEDATION GENERAL ANESTHESIA 1st 15 MINUTES

none

AMN

Dental records, radiographs, anesthesia record; Not with D9230

In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental

services; situational anxiety.

D9223

DEEP SEDATION GENERAL ANESTHESIA EACH SUBSEQUENT 15 MINUTES

none

AMN

Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239,

D9248.

In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety.

D9230

ANALGESIA (NITROUS OXIDE)

none

AMN

Dental records, clinical presentation; One unit per DOS; not with

D9222, D9223, D9239, D9243.

Situational anxiety during dental treatment.

D9239

IV MODERATE SEDATION, 1st 15 MINUTES

none

AMN

Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239,

D9248.

In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety.

D9243

IV MODERATE SEDATION EACH SUBSEQUENT 15 MINUTES

none

AMN

Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239,

D9248.

In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety.

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D9248

NON-IV CONSCIOUS SEDATION

none

Four times per RY

Dental records, clinical presentation; not with D9222, D9223, D9239,

D9243; may be billed with D9230.

Situational anxiety during dental treatment.

D9310

CONSULTATION

none

AMN

Dental records, clinical presentation; not with D9420. Only to be billed with diagnostic services on same DOS.

DMN; Used for: consultation by specialist with referral from general dentist or physician; or, general dentist consultation with referral from physician; or orthodontic evaluation when treatment is not imminent Cannot be used for 2nd opinion between general dentists. (For non-specialty dental second opinions D0140, D0160 may be used

as appropriate).

D9311

CONSULT W/MEDICAL HEALTH CARE PROFFESSIONAL

none

Two per RY

Medical history, clinical presentation; to licensed clinicians only.

Presence of appropriate medical diagnosis Conforms to CDT descriptor

D9410

DENTAL HOUSE CALL

none

Once per LTC facility per DOS; billed on one claim

Limited to visits at a LTC facility, institution, or homebound; in addition to services rendered

Patient in LTC facility, institution or home bound.

D9420

HOSPITAL/ASC CALL

none

AMN

Hospital call requiring dental evaluation Once per date of service; only when services rendered outside of office/clinic; not with D9310.

Scheduled visit in the OR of a hospital or ASC when medical necessity or age of patient

requires this place of service

Patient meets criteria for receiving dental services in a hospital OR or ASC; patient confined to hospital. (Refer to DMAHS Newsletter Vol. 22, No. 18).

D9430

OFFICE VISIT DURING HOURS OBSERVATION

none

No other services on same DOS; not for suture

removal

Post OMFS surgical case evaluation; no other services performed.

Recently received OMFS procedure from same provider/group.

D9610

THERAPEUTIC PARENTERAL DRUG SINGLE ADMIN

none

AMN

Narrative, dental records; not with D9222, D9223, D9239, D9243.

Not for sedatives, anesthetic or reversal agents.

Appropriate diagnosis; Conforms to CDT descriptor

D9612

THERAPUTIC PARENTERAL

DRUGS 2 OR > ADMIN

none

AMN

Narrative, dental records; not with

D9222, D9223, D9239, D9243.

Not for sedatives, anesthetic or reversal agents.

Appropriate diagnosis; Conforms to CDT descriptor

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D9630

DRUGS/MEDS DISPENSED FOR HOME USE

none

AMN

BR. To include name of product, strength and dosage administered.

Oral antibiotics, analgesics, topical fluoride; not for written prescriptions.

D9910

APPLICATION DESENSITIZING MEDICAMENT

Age 16 and older

Once per 12 months

Per visit; narrative, dental records.

For root/tooth sensitivity, sensitive dentin.

D9911

APPLICATION DESENSITIZING

RESIN

Age 16 and

older

Once per 12 months

Per tooth; narrative, dental records; not with

D9910.

Application of adhesive resin to sensitive dentin for

root/tooth sensitivity.

D9920

BEHAVIOR MANAGEMENT

none

AMN

Clinical presentation and documentation of medical necessity; One unit = 15 minutes; 2 units per DOS allowed. Not on same DOS as: D9222, D9223, D9239, D9243, D9248 or D9420.

DMN to include inability to cooperate with dental treatment due to behavioral health condition, intellectual, developmental or other disability, members with SHCN, children and individuals with situational anxiety.

D9930

TREATMENT OF COMPLICATIONS

POST SURGICAL

none

AMN

Narrative, dental records.

Recent complex surgical procedure by same provider

or group.

D9943

OCCLUSAL GUARD ADJUSTMENT

none

AMN

Narrative, dental records. Paid to provider who did not place occlusal guard.

DMN

Sore/high spots, areas of roughness.

D9944

OCCLUSAL GUARD-HARD APPLIANCE, FULL ARCH

Age 18 and older

Once per 24 months

Narrative, dental records.

For bruxism or other occlusal factors; not for TMJ; includes all adjustments; paid as case rate. Does not include athletic mouth guards (D9941) which are presently

not covered services.

D9945

OCCLUSAL GUARD-SOFT APPLIANCE, FULL ARCH

Age 18 and older

Once per 24 months

Narrative, dental records; FMX demonstrate occlusal wear.

For bruxism or other occlusal factors; not for TMJ; includes all adjustments; paid as case rate. Does not include athletic mouth guards (D9941) which are presently

not covered services.

D9951

LIMITED OCCLUSAL ADJUSTMENT

none

AMN

Per visit; narrative, dental records. For permanent teeth; not same DOS with a restorative, endodontic or prosthetic service

Occlusal equilibration to create more harmonious tooth contact.

Conforms to CDT descriptor

CDT

SHORT - DESCRIPTION

AGE LIMITS

FREQUENCY LIMITS

DOCUMENTATION/ REQUIREMENTS

CLINICAL CRITERIA

D9952

COMPLETE OCCLUSAL ADJUSTMENT

none

Once

Narrative, dental

records. Diagnostic casts should be

In conjunction with extensive restorative treatment, periodontics, orthognathic surgery dysfunctional occlusion or past jaw trauma. Not in conjunction with orthodontics.

Conforms to CDT descriptor

 

 

 

 

available upon request.

 

 

 

 

For permanent teeth;

 

 

 

 

not same DOS with a

 

 

 

 

restorative, endodontic

 

 

 

 

or prosthetic service;

 

 

 

 

may require several

 

 

 

 

appointments; includes

 

 

 

 

all visits.

D9971

ODONTOPLASTY

none

Once per

Narrative, dental

Enamel projections irregular

 

1-2 TEETH

 

location

records. For permanent

tooth morphology.

 

 

 

 

teeth; completed in one

 

 

 

 

 

visit; not same DOS with

 

 

 

 

 

a restorative,

 

 

 

 

 

endodontic or

 

 

 

 

 

prosthetic procedure.

 

D9974

INTERNAL BLEACHING PER TOOTH

none

Once per permanent tooth

Narrative, radiographs and/or photos.

Discolored anterior tooth, previous endodontics

D9999

UNSPECIFIED ADJUNCTIVE PROCEDURE

none

 

BR. DMN; diagnosis, clinical presentation of provided service.

For service not described by CDT code. Code may be used by MCO (in addition to dental services) when dental services are provided in the OR of a hospital or in an ASC. When the code is used for this service, the clinical criteria for D9420 must be met.

Medical necessity or age of patient requires in-patient or out-patient

dental services be rendered at a hospital or ASC (Refer to DMAHS Newsletter Vol. 22, No. 18).

END

GRID