Clinical Criteria Grid

NJ FamilyCare Dental Services Clinical Criteria Policy

NJ FamilyCare Dental Services Clinical Criteria Grid – 2023

Effective January 1, 2023

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. The findings are discussed with the patient 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 none May be considered up to 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; evaluation for oral cancer; 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D0210 INTRAORAL COMPREHENSIVE SERIES OF RADIOGRAPHIC IMAGES 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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
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, vertical root fractures, 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, vertical root fractures, large bony lesions, complex impactions, TMJ treatment where indicated. Not same DOS as D0364 Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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. Not same DOS as D0365. Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0382 CONE BEAM CT IMAGE CAPT 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. Not same DOS as D0366. Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0383 CONE BEAM CT BOTH JAWS 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. Not same DOS as D0367. Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0384 CONE BEAM CT IMAGE CAPTURE 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D0393 VIRTUAL TREATMENT SIMULATION 3D IMAGE VOLUME OR SURFACE SCAN 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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
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
D0606 MOLECULAR TESTING FOR A PUBLIC HEALTH RELATED PATHOGEN, INCLUDING CORONAVIRUS none AMN Medical history to include any symptoms of coronavirus infection. Limited to FQHCs. To confirm/rule out coronavirus infection.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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. Exfoliation is not imminent. D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. Deep fissures and grooves with no evidence of caries. D1353 and D1351 are allowed on unrestored surfaces of primary molars only on same DOS as OR/ASC visit.
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.
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. Exfoliation is not imminent. D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. For damaged sealant in the absence of caries Includes primary molars. D1353 and D1351 are allowed on unrestored surfaces of primary molars only on same DOS as OR/ASC visit.
D1354 APPLICATION OFCARIES 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 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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D1527 SPACE MAINTAINER-REMOVABLE-BILATERAL, MANDIBULA 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-MA 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 MAINTAINER-MAND 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.
D1553 RE-CEMENT or REBOND 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D1999 UNSPECIFIED PREVENTIVE PROCEDURE none BR. DMN; diagnosis, clinical presentation of provided service. Service not described by CDT code.
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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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. When replacing defective amalgams, indicated for restorative use in “certain high risk populations” as defined by the US Food and Drug Administration https://www.fda.gov/medical-devices/dental-amalgam-fillings/dental-amalgam-fillings-recommendations-graphics 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 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. When replacing defective amalgams, indicated for restorative use in “certain high risk populations” as defined by the US Food and Drug Administration https://www.fda.gov/medical-devices/dental-amalgam-fillings/dental-amalgam-fillings-recommendations-graphics 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 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. When replacing defective amalgams, indicated for restorative use in “certain high risk populations” as defined by the US Food and Drug Administration https://www.fda.gov/medical-devices/dental-amalgam-fillings/dental-amalgam-fillings-recommendations-graphics 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
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. When replacing defective amalgams, indicated for restorative use in “certain high risk populations” as defined by the US Food and Drug Administration https://www.fda.gov/medical-devices/dental-amalgam-fillings/dental-amalgam-fillings-recommendations-graphics 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
D2710 CROWN RESIN-BASED INDIRECT none There are no time limits on replacement or recementations 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 recementations 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
D2721 CROWN RESIN W/BASE METAL none There are no time limits on replacement or recementations 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 recementations 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 recementations 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 recementations 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
D2751 CROWN PORCELAIN FUSED BASE METAL none There are no time limits on replacement or recementations 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.
D2752 CROWN PORCELAIN W/NOBLE METAL none There are no time limits on replacement or recementations 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
D2790 CROWN FULL CAST HIGH NOBLE METAL none There are no time limits on replacement or recementations 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.
D2791 CROWN FULL CAST BASE METAL none There are no time limits on replacement or recementations 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
D2792 CROWN FULL CAST NOBLE METAL none There are no time limits on replacement or recementations 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.
D2910 RECEMENT INLAY ONLAY OR PART none There are no time limits on replacement or recementations 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D2915 RECEMENT CAST OR PREFABRICATED POST none There are no time limits on replacement or recementations 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.
D2920 RE-CEMENT OR RE-BOND CROWN none There are no time limits on replacement or recementations 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 recementations 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 recementations 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 recementations 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 recementations 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D2933 PREFABRICATED STAINLESS STEEL CROWN none There are no time limits on replacement or recementations 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.. 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..
D2934 PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN PRIMARY TOOTH Under age 9 unless There are no time limits on replacement or recementations when medical necessity can be documented. Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity. Primary anterior tooth cannot retain direct restoration. Exfoliation is not imminent.
D2940 PROTECTIVE RESTORATION none There are no time limits on replacement or recementations when medical necessity can be documented. Diagnostic radiographs; for tooth in occlusion or planned abutment; diagnosis and reason for treatment To relieve pain, promote healing or prevent further deterioration, preserve tooth and/or tissue form; for primary and permanent teeth.
D2941 INTERIM THERAPEUTIC RESTORATION PRIMARY DENTITION none There are no time limits on replacement or recementations when medical necessity can be documented. Diagnostic radiographs Adhesive restorative material placed to arrest caries in primary teeth; not a definitive restoration; for early childhood caries or provided in non-office setting. Exfoliation is not imminent.
D2950 CORE BUILDUP INCLUDING ANY PINS none There are no time limits on replacement or re-cementations when medical necessity can be documented. Not same day as D2952, D2954. Diagnostic radiographs Tooth meets criteria for full coverage restoration.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D2951 TOOTH PIN none There are no time limits on replacement or recementations 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 recementations 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 recementations 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 recementations 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D2957 EACH ADDTIONAL none There are no time limits on replacement or recementations 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.
D2971 ADDITIONAL PROCEDURE TO CUSTOMIZE CROWN TO FIT UNDER AN EXISTING RPD none There are no time limits on replacement or recementations 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 recementations 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 recementations 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D2981 INLAY REPAIR none There are no time limits on replacement or recementations 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 inlay is otherwise clinically acceptable.
D2982 ONLAY REPAIR none There are no time limits on replacement or recementations 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 recementations 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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 OF PERFORATION DEFECTS none Once per tooth BR. To include diagnostic image. To correct resorption or carious perforation, but not iatrogenic by same provider.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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/ RECALCIFICATION 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/ RECALC 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 included in reimbursement. Vital pulp, insufficient apical development.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D3353 APEXIFICATION/ RECALCIFICATION 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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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, 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D3425 APICOECTOMY MOLAR (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.
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 nonautogenous graft material. To repair perforation, resorption, fracture, removal of foreign material or seal accessory canals.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D3429 BONE GRAFT PERI RADICULAR EACH ADDL TOOTH none One treatment allowed per tooth BR; Provided w/D3427; includes nonautogenous 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.
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 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 adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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, PER SITE 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, NATURAL TEETH 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 defects involving restorable teeth in occlusion presence of bone loss.
D4267 GUIDED TISSUE REGENERATION, NATURAL TEETH 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 defects involving restorable teeth 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 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.
D4286 REMOVAL OF NON-RESORBABLE BARRIER AGE 18 and older Once per tooth Recent diagnostic images and periodontal charting. Used with other regenerative materials; 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
D4322 SPLINT – INTRA-CORONAL; NATURAL TEETH OR PROSTHETIC CROWNS none AMN Full mouth x-rays or photos and narrative if SHCN; perio charting to include level of bone support, presence of occlusal trauma and/or mobility; treatment plan: per tooth For interim stabilization of periodontally involved teeth; not for stabilization posttrauma (see D7270) presence of bone loss.
D4323 SPLINT – EXTRA-CORONAL; NATURAL TEETH OR PROSTHETIC CROWNS none AMN Full mouth x-rays or photos and narrative if SHCN; perio charting to include level of bone support, presence of occlusal trauma and/or mobility; treatment plan: per tooth For interim stabilization of periodontally involved teeth; not for stabilization posttrauma (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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D4355 FULL MOUTH DEBRIDEMENT TO ENABLE A COMPREHENSIVE PERIODONTAL EVALUATION none Once per 3 years. Allowed once per year for SHCN members and LTCF residents. DMN; Code cannot be billed on same DOS 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 as D1110, D4346, or D4355. Narrative report, recent full mouth perio charting. May be provided on same DOS as D4341, D4342 or D4910. Minimum 6mm probing depth; presence of bone loss. Patient must have completed root planning, or periodontal surgical procedure in same 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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; 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
D5225 MAXILLARY PARTIAL DENTURE FLEXIBLE 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. Additional retention required; 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 good prognosis; 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
D5226 MANDIBULAR PARTIAL DENTURE FLEXIBLE 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. Additional retention required; 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 good prognosis; 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.
D5410 DENTURES ADJUST CMPLT 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 adversely affect the member by impairing their ability to function. Clinical presentation supports service; Needed 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.
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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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 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 the member by impairing their ability to function. Clinical presentation supports service; Needed 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.
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 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 none AMN; Service cannot have Clinical presentation supports service; To restore denture function and retention.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
FRAME MAXILLARY frequency or time limits that adversely affect the member by impairing their ability to function. Needed 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.
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 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 impairing their ability to function. Clinical presentation supports service; Needed 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 denture tooth.
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 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 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
D5725 REBASE HYBRID PROSTHESIS none Every 2 years Narrative to DMN; photograph. Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing implant supported denture; restore denture fit and retention.
D5730 DENTURE RELNE COMPLETE MAXIL CHAIRSIDE none Once per RY Documentation of illfitting denture. Restore function and retention by resurfacing.
D5731 DENTURE RELNE COMPLETE MAND CHAIRSIDE none Once per RY Documentation of illfitting denture. Restore function and retention by resurfacing.
D5740 DENTURE RELINE none Once per RY Documentation of illfitting denture. Restore function and retention by resurfacing.
D5741 DENTURE RELINE PARTIAL MAND CHAIRSIDE none Once per RY Documentation of illfitting denture. Restore function and retention by resurfacing.
D5750 DENTURE RELINE COMPLETE MAX LAB none Once per RY Documentation of illfitting denture. Restore function and retention by resurfacing.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D5751 DENTURE RELINE COMPLETE MAND LAB none Once per RY Documentation of illfitting denture. Restore function and retention by resurfacing.
D5760 PARTIAL MAXIL LAB DENTURE RELINE PARTIAL MAXIL LAB none Once per RY Documentation of illfitting denture. Restore function and retention by resurfacing.
D5761 DENTURE RELINE PARTIAL MAND LAB none Once per RY Documentation of illfitting 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 recementations when medical necessity can be documented. Diagnostic full mouth images, treatment plan. Each pair of components reported as one attachment. 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.
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
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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
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
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D5867 REPLACEMENT OF PRECISION ATTACHMENT, PER ATTACHMENT none There are no time limits on replacement or recementations 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
D5926 REPLACEMENT NASAL PROSTHESI 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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 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
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 Age 19 and older AID 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 complete implant treatment plan. Patient is unable to function with conventional complete denture due to lack of retention due to insufficient bone.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 trauma or damage by patient can be documented. Documentation that existing denture is serviceable and functional. For repair of implant supported prosthesis.
D6091 REPLACEMENT OF REPLACEABLE PART OF SEMI-PRECISION R PRECISION ATTACHMENT OF IMPLANT/ ABUTMENT SUPPORTED PROSTHESIS, PER ATTACHMEN 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; a pair of components constitutes one attachment.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 SURGICAL REMOVAL OF IMPLANT BODY none Once per implant To include diagnostic radiographs and narrative. Implant failure
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D6105 REMOVAL OF IMPLANT BODY none Once per implant Diagnostic x-rays or photos and narrative Failed implant requiring removal without bone removal or flap.
D6106 GUIDED TISSUE REGENERATION, RESORBABLE BARRIER none Once per implant Recent diagnostic images. 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 periimplant defects involving restorable implant in occlusion presence of bone loss.
D6107 GUIDED TISSUE REGENERATION – NON-RESORBABLE BARRIE none Once per implant 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. 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 periimplant defects involving restorable implant in occlusion presence of bone loss.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D6111 IMPLANT/ABUT REMOVEABLE DENTURE FOR EDENTULOUS ARCH 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. BR. To include diagnostic radiographs. Include all associated implant services on same PA. Inability to function with conventional complete mandibular denture due to ridge resorption and lack of retention for at least 2 years
D6191 SEMI-PRECISION ABUTMENT PLACEMENT none Initial placement or replacement. Once per implant body; maximum 4 per arch Diagnostic radiographs of implants showing successful osteointegration, photograph, clinical findings and description of planned repair if applicable. Service is only considered for complete denture(s). Patient is unable to function with conventional complete denture due to lack of retention and insufficient bone. Include reason for replacement if applicable.
D6192 SEMI-PRECISION ATTACHMENT PLACEMENT none Initial placement or replacement. Once per implant body; maximum 4 per arch Diagnostic radiographs of implants showing successful osteointegration, photograph, clinical findings and description of planned repair to include denture modification if applicable. Service is only considered for complete denture(s). Patient is unable to function with conventional complete denture due to lack of retention and insufficient bone. Include reason for replacement if applicable.
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 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
D6240 PONTIC PORCELAIN 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 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.
D6241 PONTIC PORCELAIN 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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
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 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
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 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
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 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
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 CAS 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 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
D6920 DENTAL CONNECTOR BAR 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 BR. To include diagnostic radiographs. Device attached to abutment crown or coping to stabilize removable overdenture prosthesis.
D6930 RECEMENT/BOND FIXED PARTIAL DENTURE none No frequency or time limits. 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. Recement functional and undamaged fixed partial denture; includes all retainers/abutments.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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. A pair of components constitutes one attachment.
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 dentist doing the exactions should retain the request for extractions or document this in the dental records. Conforms to CDT descriptor.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 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 COMPLETELY 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. Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Conforms to CDT descriptor.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 PLACEMENT OF TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE] REQUIRING FLAP 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
D7293 PLACEMENT OF TEMPORARY ANCHORAGE DEVICE REQUIRING FLAP 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
D7294 PLACEMENT OF TEMPORARY ANCHORAGE DEVICE WITHOUT FLAP 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
D7298 REMOVAL OF TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE, REQUIRING FLAP Under age 21 Once per area BR; Treatment plan, recent diagnostic radiographs and photographs. D7292 in history. Based on completion of treatment or defective or damaged anchorage device.
D7299 REMOVAL OF TEMPORARY ANCHORAGE DEVICE, REQUIRING FLAP Under age 21 Once per area BR; Treatment plan, recent diagnostic radiographs and photographs. D7293 in history. Based on completion of treatment or defective or damaged anchorage device.
D7300 REMOVAL OF TEMPORARY ANCHORAGE DEVICE, WITHOUT FLAP Under age 21 Once per area BR; Treatment plan, recent diagnostic radiographs and photographs. D7294 in history. Based on completion of treatment or defective or damaged anchorage device.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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
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 none Once per area Dental records, full mouth radiographs or intraoral images. Overgrowth of mandibular hard tissue. Conforms to CDT descriptor.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
D7509 MARSUPIALIZATION OF ODONTOGENIC CYST none Once per area BR; Dental records, full mouth radiographs or intraoral images. Surgical decompression of large cystic lesion. 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
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 nonsurgical reduction Conforms to CDT descriptor.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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, nonsurgical 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 SIMPLE 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
D7856 TMJ CUTTING OF A MUSCLE none AMN BR, dental records For therapeutic purposes; separate procedure. Conforms to CDT descriptor.
D7858 TMJ 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
D7946 RECONSTRUCTION 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 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
D7956 GUIDED TISSUE REGENERATION, EDENTULOUS AREA – RESORBABLE BARRIER, PER SITE none Once per site Recent diagnostic images. Used with other regenerative materials; does not include surgical entry and closure, debridement, osseous contouring or placement of graft related materials. Other procedures provided on same DOS to be reported with own codes. For the correction of extensive bony defects: ridge augmentation, sinus lift procedures for placement of implants to support maxillary denture and after tooth extraction where defect compromises integrity of arch.
D7957 GUIDED TISSUE REGENERATION, EDENTULOUS AREA – NON-RESORBABLE BARRIER, PER SITE none Once per site Recent diagnostic images. Used with other regenerative materials; does not include surgical entry and closure, debridement, osseous contouring or placement of graft related materials. Other procedures provided on same DOS to be reported with own codes. For the correction of extensive bony defects: ridge augmentation, sinus lift procedures for placement of implants to support maxillary denture and after tooth extraction where defect compromises integrity of arch.
D7961 BUCCAL/LABIAL FRENECTOMY (FRENULEC-TOMY) none AMN DMN. Narrative describing importance to success of prosthetic or orthodontic treatment. Intraoral image when available. Aberrant muscle attachments which hinder oral function, development or treatment. Separate procedure. Conforms to CDT descriptor
D7962 LINGUAL FRENECTOMY (FRENULECTOMY) none AMN PA required. If referred by PCP, narrative of medical necessity required when requested for purposes of lactation or speech. Narrative describing importance to success of prosthetic or orthodontic treatment. Intraoral image when available. Aberrant muscle attachments which hinder oral function, development or treatment. Separate procedure. Conforms to CDT descriptor.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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 PLACEMENT OF CRANIOFACIAL IMPLANT - EXTRAORAL none AMN BR; dental records. 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. To aid in retention of an auricular, nasal or orbital prosthesis. Conforms to CDT descriptor.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D7994 SURGICAL PLACEMENT – ZYGOMATIC IMPLANT none AMN BR; dental records. 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. To provide support and attachment of a maxillary dental prosthesis. Conforms to CDT descriptor.
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.
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, xrays 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 primary dentition. Utilizes any therapeutic modality (to include palatal expansion) with a limited objective or scale of treatment. The objective may be limited by: not involving the entire dentition, not attempting to address the full scope of the existing or developing orthodontic problem, mitigating an aspect of a greater malocclusion, a decision to defer or forego comprehensive treatment. 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 transitional dentition. Utilizes any therapeutic modality (to include palatal expansion) with a limited objective or scale of treatment. The objective may be limited by: not involving the entire dentition, not attempting to address the full scope of the existing or developing orthodontic problem, mitigating an aspect of a greater malocclusion, a decision to defer or forego comprehensive treatment. 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, xrays 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 adult dentition. Utilizes any therapeutic modality (to include palatal expansion) with a limited objective or scale of treatment. The objective may be limited by: not involving the entire dentition, not attempting to address the full scope of the existing or developing orthodontic problem, mitigating an aspect of a greater malocclusion, a decision to defer or forego comprehensive treatment. 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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 dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis. Include documentation of extenuating conditions. Handicapping malocclusion to treat late mixed and permanent dentition. Scoring based on HLD or extenuating circumstance which meets medical necessity requirement.
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 PREORTHODON-TIC 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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; 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.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
D8999 UNSPECIFIED ORTHODONTIC PROCEDURE Up to age 21 BR. DMN; diagnosis, clinical presentation of provided service. Service not described by CDT code.
D9110 PALLIATIVE TREATMENT OF DENTAL PAIN – PER VISIT 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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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.
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).
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
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
D9613 INFILTRATION OF SUSTAINED RELEASE THERAPUTIC DRUG, PER QUADRANT none AMN Narrative, dental records. For long acting pain control at surgical site after oral surgical procedure. Must be submitted with surgical procedures provided on same DOS. Not employed as local anesthesia. May be covered under medical benefit. Confirms to CDT descriptor.
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.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D9930 TREATMENT OF COMPLICATIONS POST SURGICAL none AMN Narrative, dental records. Recent complex surgical procedure by same provider or group.
D9941 FABRICATION OF ATHLETIC MOUTHGUARD Ages 12 through 18 Once per 12 months Narrative in dental record documenting need for appliance. To prevent or mitigate injury to teeth and dental/oral hard and soft tissue due to trauma during contact sports activities.
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 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.
D9947 CUSTOM SLEEP APNEA APPLIANCE FABRICATION AND PLACEMENT none AMN Comprehensive dental exam to include periodontal charting, panoramic radiograph/full mouth radiographic series bidirectional referral (dentist/pulmonologist), sleep study (with interpretation), documented failure of CPAP, all required dental work must be completed prior to impression for OSA appliance, providers are required to provide adjustments, relines and repairs for the first 12 months after insertion at no additional cost to the plan or member. Case rate; may be covered under medical plan. Includes adjustment and follow-up visits six months post insertion.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D9948 ADJUSTMENT OF CUSTOM SLEEP APNEA APPLIANCE none AMN Dental records to document prior placement of sleep apnea appliance and to DMN for procedure. Not reimbursable to provider of placement if within six months of insertion.
D9949 REPAIR OF CUSTOM SLEEP APNEA APPLIANCE none AMN Dental records to document prior placement of sleep apnea appliance and to DMN for procedure. Not reimbursable to provider of placement if within one year of insertion.
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
D9952 COMPLETE OCCLUSAL ADJUSTMENT none Once Narrative, dental records. Diagnostic casts should be available upon request. For permanent teeth; not same DOS with a restorative, endodontic or prosthetic service; may require several appointments; includes all visits. In conjunction with extensive restorative treatment, periodontics, orthognathic surgery dysfunctional occlusion or past jaw trauma. Not in conjunction with orthodontics. Conforms to CDT descriptor
D9953 RELINE CUSTOM SLEEP APNEA DEVIC none Once per RY Documentation of illfitting sleep apnea device. Not reimbursed to provider of placement within one year of device placement. Restore function and retention by resurfacing.
CDT SHORT - DESCRIPTION AGE LIMITS FREQUENCY LIMITS DOCUMENTATION/ REQUIREMENTS CLINICAL CRITERIA
D9971 ODONTOPLASTY PER TOOTH none Once per tooth Narrative, dental records. For permanent teeth; not same DOS with a restorative, endodontic or prosthetic procedure. Enamel projections irregular tooth morphology.
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).
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