Clinical Criteria Grid

NJ FamilyCare Dental Services Clinical Criteria Policy

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0120	PERIODIC ORAL EVALUATION	none	Twice during a rolling year (RY) without PA per servicing provider/group and a maximum of four times during a rolling year for Special Health Care Needs (SHCN) or ECC Members which may require prior authorization. Not within 6 months of D0150 per servicing provider/group.	Medical diagnosis or clinical presentation required for increased frequency; all documentation to be included in dental records.	Subsequent oral evaluation for patient of record.
D0140	LIMIT ORAL EVAL PROBLM FOCUS	none	Twice in a RY, per servicing provider/group more require PA with documentation of medical necessity (DMN).	Documentation of medical necessity (DMN) to be included in dental records.	For use in emergent/urgent situations.
D0145	ORAL EVALUATION PATIENT < 3yrs	Under 3 years of age	Twice during a rolling year (RY) without PA and a maximum of four times during a rolling year per servicing provider/group for Special Health Care Needs (SHCN) or ECC Members which may require prior authorization.	Medical diagnosis or clinical presentation required for increased frequency; all documentation to be included in dental records.	Oral evaluation and continual counselling of primary caregiver.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0150	COMPREHENSIVE ORAL EVALUATION	Age 3 and older	Once every three years per servicing provider/group unless medical necessity can be documented for additional service.	Medical diagnosis or clinical presentation required for increased frequency.	For new patient or 3 years post previous comprehensive oral evaluation by same provider.
D0160	EXTENSV ORAL EVAL PROB FOCUS	none	Twice per RY per servicing provider/group.	DMN; to develop a treatment plan for a specific problem; only radiographs and/or other non-evaluation diagnostic codes provided on same date of service (DOS).	DMN; May be used by general dentists for second opinion for same complaint, condition or diagnosis.
D0170	RE-EVAL,EST PT, PROBLEM FOCUS	none	Twice per RY	DMN; only additional services allowed on same DOS are radiographs (D0220, D0240, D0270, D0277 and D0330).	For follow-up of recent prior visit for same complaint, condition or diagnosis.
D0171	RE-EVAL POST-OP VISIT	none	Twice a RY per servicing provider/group; additional units require prior authorization.	DMN; only additional services allowed on same DOS are radiographs (D0220, D0270, D0277 and D0330).	For follow-up of recent prior oral surgical or periodontal surgery visit.
D0180	COMP PERIODONTAL EVALUATION	none	Once every three years unless medical necessity can be documented for more frequent service.	Recent full mouth perio charting and radiographs as needed for diagnosis; narrative and photos if bone loss not visible on x-rays.	Evidence of periodontal disease.
D0190	SCREENING OF A PATIENT	Under 19 years of age	Allowed once per RY to same member	Service must be provided in non-office setting.	No other services on same DOS.
D0210	INTRAORAL COMPLETE FILM SERIES	none	Complete series D0210 allowed once every three years per servicing provider/group unless medical necessity can be documented for additional service.	DMN; for additional service-documentation of extreme change in medical or dental condition.	Radiographic evaluation for diagnosis.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0220	INTRAORAL PERIAPICAL FIRST	none	AMN for diagnosis	Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition.	For diagnosing.
D0230	INTRAORAL PERIAPICAL EACH ADDITIONAL	none	AMN for diagnosis	Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition.	For diagnosing.
D0240	INTRAORAL OCCLUSAL FILM	none	2 per RY	DMN in dental records; image covers a larger area than a periapical view; based on image, not size of film.	For diagnosing. Differential diagnosis supports image.
D0250	EXTRA ORAL 2D PROJECT IMAGE	none	2 per RY	Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition; one per DOS.	For diagnosing.
D0251	EXTRA ORAL POSTERIOR IMAGE	none	AMN for diagnosis	Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition.	For diagnosing. For complete view of posterior teeth, both arches.
D0270	DENTAL BITEWING SINGLE IMAGE	none	AMN for diagnosis	Provider is to indicate diagnosis in dental records. Periapical films (D0220, D0230) and bitewings (D0270, D0272) may be taken as needed for diagnosing a condition.	For diagnosing.
D0272	DENTAL BITEWINGS TWO IMAGES	none	1 per RY, then AMN for diagnosis	When same DOS as D0330, consider as full mouth series.	For diagnosing.
D0273	BITEWINGS - THREE IMAGES	none	1 per RY, then AMN for diagnosis	When same DOS as D0330, consider as full mouth series.	For diagnosing.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0274	BITEWINGS FOUR IMAGES	none	1 per RY, then AMN for diagnosis	When same DOS as D0330, consider as full mouth series.	For diagnosing.
D0277	VERT BITEWINGS 7 TO 8 IMAGES	Age 21 and older	1 per RY, then AMN for diagnosis	When same DOS as D0330, consider as full mouth series; may be taken as needed for diagnosing condition.	For diagnosing.
D0310	DENTAL SIALOGRAPHY	none	AMN	Surgical narrative or dental records.	Salivary gland pathology diagnosis and treatment.
D0320	DENTAL TMJ ARTHROGRAM INCL INJECTION	none	AMN	Surgical narrative or dental records.	TMJD diagnosis and treatment.
D0321	OTHER TMJ IMAGES BY REPORT	none	AMN	DMN	TMJD diagnosis and treatment.
D0322	DENTAL TOMOGRAPHIC SURVEY	none	AMN-PA required	DMN; surgical narrative or dental records	Must demonstrate that tomographic survey improves treatment decisions and outcome/prognosis.
D0330	PANORAMIC IMAGE	none	D0330 allowed once every three years per servicing provider/group unless medical necessity can be documented for additional service. Is equivalent to full mouth series with 2, 3 or 4 BWs on same DOS.	Medical diagnosis, clinical presentation, orthodontic narrative. Additional service as needed to diagnose extensive oral surgery; interceptive or comprehensive orthodontic treatment; extreme change in medical or dental condition.	Diagnosis and treatment
D0340	2D CEPHALOMETRIC IMAGE	none	1 per RY per servicing provider/group.	DMN for use by OMFS; Orthodontists may take D0330 and D0340 as needed for diagnosing and must document rationale for this in dental records.	DMN for use by OMFS; case evaluation for interceptive or comprehensive orthodontics.
D0350	ORAL/FACIAL PHOTO IMAGES	none	Maximum 4 per RY	Documentation of medical necessity when radiographs cannot be provided for SHCN members or LTCF residents; orthodontic treatment included with orthodontic case rate.	Diagnosis and treatment

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0351	3D PHOTOGRAPHIC IMAGE	none	1 per RY per provider/group per DOS	DMN; differential diagnosis, medical and dental history associated with treatment request	For OMFS diagnosis.
D0364	CONE BEAM CT CAPTURE & INTERPRETATION LIMITED VIEW	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, assessment of cracked teeth when subgingival or furcational, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0365	CONE BEAM CT INTERPRETATION MANDIBLE	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0366	CONE BEAM CT INTERPRETATION MAXILLA	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0367	CONE BEAM CT INTERP BOTH JAW	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0368	CONE BEAM CT CAPTURE AND INTERPRETE TMJ	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated. May be included in TMJ case rate.	For TMJD Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0380	CONE BEAM CT IMAGE CAPTURE LIMITED	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, assessment of cracked teeth when subgingival or furcational, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0381	CONE BEAM CT CAPT MANDIBLE	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				included in TMJ case rate.
D0393	TREATMENT SIMULATION 3D IMAGE	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0394	DIGITAL SUBTRACTION- 2 OR MORE IMAGES	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0395	FUSION 2 OR MORE 3D IMAGES	none	AMN-PA required	PA to DMN with periapical view, narrative and service to be provided; for use in diagnosis and treatment planning based on medical necessity for complex cases: implant placement, complex endodontic procedures, large bony lesions, complex impactions, TMJ treatment where indicated.	Must demonstrate that CBCT improves treatment decisions and outcome/prognosis.
D0411	HBA1C IN OFFICE TESTING	none	Once per RY	Medical history positive for diabetes, clinical presentation.	For planned perio or OMFS service. Limited to teaching facilities to include residencies and hygiene schools. W/obesity, history of DM, poor glycemic control; referral to PCP.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0416	VIRAL CULTURE	none	AMN	Lab report, clinical rationale for test, biopsy and test requested/performed dental records; maximum 2 per DOS.	Diagnosis and treatment
D0417	COLLECTION & PREPARE SALIVA SAMPLE	none	AMN; Maximum 1 per DOS	Differential diagnosis, medical and dental history associated with treatment request	Diagnosis and treatment
D0470	DIAGNOSTIC CASTS	none	AMN	Reimbursement and approval of service cannot be limited to orthodontic cases but allowed based on medical necessity. Prior authorization may be required with documentation supporting the procedure. Service is included in payment for services that have a laboratory component.	Documentation of diagnosis (malocclusion, traumatic occlusal relationships), clinical presentation to include involved quadrants and purpose as noted in dental records.
D0472	GROSS EXAM, PREP & REPORT	none	AMN	Lab report, clinical rationale for test, biopsy and test requested/performed dental records; Maximum 8 per DOS.	Diagnosis and treatment
D0473	MICRO EXAM, PREP & REPORT	none	AMN	Lab report, clinical rationale for test, biopsy and test requested/performed dental records; Maximum 8 per DOS.	Diagnosis and treatment
D0474	MICRO EXAM OF SURGICAL MARGINS	none	AMN	Lab report, clinical rationale for test, biopsy and test requested/performed dental records; Maximum 8 per DOS.	Diagnosis and treatment
D0480	CYTOLOGY SMEAR PREP AND REPORT	none	AMN	Lab report, clinical rationale for test, biopsy and test requested/ performed dental records; Max. 4 per DOS.	Diagnosis and treatment

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D0502	OTHER ORAL PATHOLOGY PROCEDURE	none	DMN	BR	Diagnosis and treatment
D0601	CARIES RISK ASSESS LOW RISK	Under 21 years of age	Once per RY	CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and D0150).	Diagnosis and treatment
D0602	CARIES RISK ASSESS MODERATE RISK	Under 21 years of age	Once per RY	CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and D0150).	Diagnosis and treatment
D0603	CARIES RISK ASSESS HIGH RISK	Under 21 years of age	Once per RY	CRA form in dental record; Service is provided on same date as oral evaluations (D0120, D0145, and D0150).	Diagnosis and treatment
D0999	UNSPECIFIED DIAGNOSTIC PROCEDURE	none		BR. DMN; diagnosis, clinical presentation of provided service.	Service not described by CDT code
D1110	DENTAL PROPHYLAXIS ADULT	Age 16 and older	Allowed twice during a RY and a maximum of four times during a RY per servicing provider/group for SHCN Members which may require prior authorization.	DMN for increased frequency. Prophylaxes will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code.	Evidence of plaque, stains, calculus on tooth structure of permanent or transitional dentition.
D1120	DENTAL PROPHYLAXIS CHILD	Under age 16	Allowed twice during a RY and a maximum of four times during a RY per servicing provider/group for SHCN or ECC Members which may require prior authorization.	DMN for increased frequency. Prophylaxes will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code.	Evidence of plaque, stains, calculus on tooth structure of primary or transitional dentition.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D1206	TOPICAL FLUORIDE VARNISH	none	Can be provided to members twice in a RY per servicing provider/group under 21 with moderate to high risk on CRA; SHCN and ECC members up to four times annually with documentation of medical necessity; LTCF residents with high caries incidence and/or root caries.	Will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code. DMN for increased frequency.	Applied same day as D1110 or D1120; not same DOS as D1208.To prevent caries.
D1208	TOPICAL APPLICATION OF FLUORIDE EXCLUDING VARNISH	none	Can be provided to members of all ages (children and adults) twice in a RY per servicing provider/group; considered for SHCN and ECC members every 3 months with consideration based on documentation of medical necessity.	Will not be reimbursed on same date of service (DOS) as D4346, D4341, D4342, D4355, D4910 or any periodontal surgical code. DMN for increased frequency.	Applied same day as D1110 or D1120; not same DOS as D1206. To prevent caries.
D1351	DENTAL SEALANT PER TOOTH	Under age 17	May be provided every 3 years for children through the age of 16. Age restriction does not apply to SHCN.	Diagnostic periapical or bitewing; provide documentation of medical necessity. Moderate to high CRA score; previous history of restorations and/or caries.	D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. Deep fissures and grooves with no evidence of caries.
D1352	PREVENTIVE RESIN REST, PERMENENT TOOTH	none	Once per tooth	Diagnostic periapical or bitewing; caries risk assessment.	Moderate to high caries risk; active cavitated pit or fissure lesion not extended into dentin; includes sealant on same tooth.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D1353	SEALANT REPAIR PER TOOTH	Under age 17	May be provided every 3 years for children through the age of 16. Age restriction does not apply to SHCN.	Diagnostic periapical or bitewing; provide documentation of medical necessity.	D1353 and D1351 are allowed on unrestored surfaces of permanent molars and bicuspids. For damaged sealant in the absence of caries Includes primary molars.
D1354	INTTERIM CARIES MED APPLICATION PER TOOTH	none	Twice per RY without PA	Medical history, clinical presentation	Primary and permanent teeth; ECC/rampant decay, SHCN members, root caries, LTCF residents.
D1510	SPACE MAINTAINER- FIXED- UNILATERAL PER QUADRANT	Under age 15	Once per quadrant without PA	Diagnostic periapicals or bitewings.	For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1516	SPACE MAINTAINER- FIXED BILATERAL, MAXILLARY	Under age 15	Once without PA	Diagnostic periapicals or bitewings	For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1517	SPACE MAINTAINER- FIXED-BILATERAL, MANDIBULAR	Under age 15	Once without PA	Diagnostic periapicals or bitewings	For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1526	SPACE MAINTAINER- REMOVABLE- BILATERAL, MAXILLARY	Under age 15	Once without PA	Diagnostic periapicals or bitewings	For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1527	SPACE MAINTAINER- REMOVABLE- BILATERAL, MANDIBULAR	Under age 15	Once without PA	Diagnostic periapicals or bitewings	For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1551	RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER- MAX	Under age 15	Once without PA	Diagnostic periapicals or bitewings	Dislodged appliance for premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1552	RE-CEMENT OR RE-BOND BILATERAL SPACE	Under age 15	Once without PA	Diagnostic periapicals or bitewings	Dislodged appliance for premature loss of primary tooth; permanent tooth not

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
	MAINTAINER- MAND				ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1553	RE-CEMENT or RE- BOND UNILATERAL SPACE MAINTAINER-PER QUAD	Under age 15	Once without PA	Diagnostic periapicals or bitewings	Dislodged appliance for premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1556	REMOVAL OF FIXED UNILATERAL SPACE MAINTAINER-PER QUAD	none	Once per space maintainer	Diagnostic periapicals or bitewings Not to same provider who placed appliance.	Treatment completed, appliance broken, causing problem.
D1557	REMOVAL OF FIXED BILATERAL SPACE MAINTAINER- MAX	none	Once per space maintainer	Diagnostic periapicals or bitewings Not to same provider who placed appliance.	Treatment completed, appliance broken, causing problem.
D1558	REMOVAL OF FIXED BILATERAL SPACE MAINTAINER- MAND	none	Once per space maintainer	Diagnostic periapicals or bitewings Not to same provider who placed appliance.	Treatment completed, appliance broken, causing problem.
D1575	DISTAL SHOE SPACE MAINT, FIXED- UNILATERAL-PER QUAD	Under age 11	Once without PA	Diagnostic periapicals or bitewings	For premature loss of primary tooth; permanent tooth not ready to erupt; congenitally missing teeth; to prevent tooth movement; includes adjustments.
D1999	UNSPECIFIED PREVENTIVE PROCEDURE	none		BR. DMN; diagnosis, clinical presentation of provided service.	Service not described by CDT code.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D2140	AMALGAM ONE SURFACE PERMANENT	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.
D2150	AMALGAM TWO SURFACES PERMANENT	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.
D2160	AMALGAM THREE SURFACES PERMANENT	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				with documentation for PA consideration.
D2161	AMALGAM 4 OR > SURFACES PERMANENT	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.
D2330	RESIN ONE SURFACE- ANTERIOR	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration may be limited to incisal, mesial, distal, facial or lingual surface. Extension to self-cleansing areas not additional surfaces.
D2331	RESIN TWO SURFACES- ANTERIOR	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration extends onto one third of facial/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				recurrent decay, submit with documentation for PA consideration.
D2332	RESIN THREE SURFACES- ANTERIOR	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration extends onto one third of facial/ lingual. Extension to self-cleansing areas not additional surfaces.
D2335	RESIN 4/> SURF OR W INCISAL ANGLE	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Restoration must include incisal angle or at least four of the five tooth surfaces. Extension to self-cleansing areas not additional surfaces.
D2390	ANT RESIN- BASED COMPSITE CROWN	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				due to trauma or recurrent decay, submit with documentation for PA consideration.
D2391	POST 1 SURFACE RESIN BASED COMPOSITE	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.
D2392	POST 2 SURFACE RESIN BASED COMPOSITE	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.
D2393	POST 3 SURFACE RESIN BASED COMPOSITE	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.
D2394	POST>=4 SURFACE RESIN BASED COMPOSITE	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	For caries/tooth fracture at least 50% bone support, no mobility. No primary teeth near exfoliation. Based on surfaces restored. Occlusal extends onto one third of buccal/ lingual. Extension to self-cleansing areas not additional surfaces.
D2542	DENTAL ONLAY METALLIC 2 SURFACE	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.	Restoration is lab fabricated, covers one or more cusp tips and adjoining occlusal surfaces, but not entire occlusal surface; reimbursable to dental schools and dental residency programs only.
D2543	DENTAL ONLAY METALLIC 3 SURFACE	none	There are no limits for replacement of restorations when medical necessity can be documented.	Dental records to include diagnostic radiographs, diagnosis and treatment with tooth number and surface(s). Replacement one year after placement will be reimbursed. Replacement within one year will not be reimbursed to same	Restoration is lab fabricated, covers one or more cusp tips and adjoining occlusal surfaces, but not entire occlusal surface; reimbursable to dental schools and dental residency programs only.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				provider and replaced at provider’s expense. If due to trauma or recurrent decay, submit with documentation for PA consideration.
D2710	CROWN RESIN- BASED INDIRECT	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.
D2720	CROWN RESIN W/HIGH NOBLE METAL	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				trauma or recurrent decay can be documented.
D2721	CROWN RESIN W/BASE METAL	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.
D2722	CROWN RESIN W/NOBLE METAL	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D2740	CROWN PORCELAIN/ CERAMIC	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.
D2750	CROWN PORCELAIN w/HIGH NOBLE METAL	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.
D2751	CROWN PORCELAIN FUSED BASE METAL	none	There are no time limits on replacement or	For single crowns, recent, diagnostic full mouth radiographs or	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			re-	panoramic image. If	cannot retain direct
			cementations	tooth has no occlusion,	restoration; is in occlusion,
			when medical	narrative documenting	or will be utilized as an
			necessity can	that there is an	abutment to a prosthesis;
			be	opposing denture or	Crown to root ratio at least
			documented.	tooth will be used as an	50%; bone support at least
				abutment to a fixed or	50%, without mobility or
				removable denture.	furcation involvement; RCT
				Documentation of caries	(if present) is clinically
				control. If required	acceptable. Not for esthetics.
				within a year of
				placement, these
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D2752	CROWN	none	There are no	For single crowns,	Tooth is fully erupted and
	PORCELAIN		time limits on	recent, diagnostic full	restorable, but lacks at least
	W/NOBLE METAL		replacement or	mouth radiographs or	50% tooth structure or
			re-	panoramic image. If	cannot retain direct
			cementations	tooth has no occlusion,	restoration; is in occlusion,
			when medical	narrative documenting	or will be utilized as an
			necessity can	that there is an	abutment to a prosthesis;
			be	opposing denture or	Crown to root ratio at least
			documented.	tooth will be used as an	50%; bone support at least
				abutment to a fixed or	50%, without mobility or
				removable denture.	furcation involvement; RCT
				Documentation of caries	(if present) is clinically
				control. If required	acceptable. Not for esthetics.
				within a year of
				placement, these
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D2790	CROWN FULL	none	There are no	For single crowns,	Tooth is fully erupted and
	CAST HIGH NOBLE		time limits on	recent, diagnostic full	restorable, but lacks at least
	METAL		replacement or	mouth radiographs or	50% tooth structure or
			re-	panoramic image. If	cannot retain direct
			cementations	tooth has no occlusion,	restoration; is in occlusion,
			when medical	narrative documenting	or will be utilized as an

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			necessity can	that there is an	abutment to a prosthesis;
			be	opposing denture or	Crown to root ratio at least
			documented.	tooth will be used as an	50%; bone support at least
				abutment to a fixed or	50%, without mobility or
				removable denture.	furcation involvement; RCT
				Documentation of caries	(if present) is clinically
				control. If required	acceptable. Not for esthetics.
				within a year of
				placement, these
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D2791	CROWN FULL	none	There are no	For single crowns,	Tooth is fully erupted and
	CAST BASE METAL		time limits on	recent, diagnostic full	restorable, but lacks at least
			replacement or	mouth radiographs or	50% tooth structure or
			re-	panoramic image. If	cannot retain direct
			cementations	tooth has no occlusion,	restoration; is in occlusion,
			when medical	narrative documenting	or will be utilized as an
			necessity can	that there is an	abutment to a prosthesis;
			be	opposing denture or	Crown to root ratio at least
			documented.	tooth will be used as an	50%; bone support at least
				abutment to a fixed or	50%, without mobility or
				removable denture.	furcation involvement; RCT
				Documentation of caries	(if present) is clinically
				control. If required	acceptable. Not for esthetics.
				within a year of
				placement, these
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D2792	CROWN FULL	none	There are no	For single crowns,	Tooth is fully erupted and
	CAST NOBLE		time limits on	recent, diagnostic full	restorable, but lacks at least
	METAL		replacement or	mouth radiographs or	50% tooth structure or
			re-	panoramic image. If	cannot retain direct
			cementations	tooth has no occlusion,	restoration; is in occlusion,
			when medical	narrative documenting	or will be utilized as an
			necessity can	that there is an	abutment to a prosthesis;
			be	opposing denture or	Crown to root ratio at least
			documented.	tooth will be used as an	50%; bone support at least

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				abutment to a fixed or	50%, without mobility or
				removable denture.	furcation involvement; RCT
				Documentation of caries	(if present) is clinically
				control. If required	acceptable. Not for esthetics.
				within a year of
				placement, these
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D2910	RECEMENT INLAY	none	There are no	For single crowns,	Restoration intact, absence
	ONLAY OR PART		time limits on	recent, diagnostic full	of decay or additional loss of
			replacement or	mouth radiographs or	tooth structure.
			re-	panoramic image. If
			cementations	tooth has no occlusion,
			when medical	narrative documenting
			necessity can	that there is an
			be	opposing denture or
			documented.	tooth will be used as an
				abutment to a fixed or
				removable denture.
				Documentation of caries
				control. If required
				within a year of
				placement, these
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D2915	RECEMENT CAST	none	There are no	For single crowns,	Restoration intact, absence
	OR		time limits on	recent, diagnostic full	of decay or additional loss of
	PREFABRICATED		replacement or	mouth radiographs or	tooth structure.
	POST		re-	panoramic image. If
			cementations	tooth has no occlusion,
			when medical	narrative documenting
			necessity can	that there is an
			be	opposing denture or
			documented.	tooth will be used as an
				abutment to a fixed or
				removable denture.
				Documentation of caries

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.
D2920	RE-CEMENT OR RE-BOND CROWN	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	For single crowns, recent, diagnostic full mouth radiographs or panoramic image. If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture. Documentation of caries control. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	Restoration intact, absence of decay or additional loss of tooth structure.
D2921	REATTACH TOOTH FRAGMENT	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Recent diagnostic photographs and radiographs, clinical findings and dental history associated with treatment request.	No pulpal involvement, for incisal edge or single cusp fracture. Tooth is fully erupted and restorable. Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D2929	PREFABRICATED PORCELAIN/ CERAMIC CROWN PRIMARY TOOTH	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity.	Primary tooth cannot retain direct restoration. Exfoliation is not imminent.
D2930	PREFABRICATED STAINLESS STEEL CROWN, PRIMARY TOOTH	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity.	Primary tooth cannot retain direct restoration. Exfoliation is not imminent.
D2931	PREFABRICATED STAINLESS STEEL CROWN, PERMANENT TOOTH	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. For permanent tooth
D2932	PREFABRICATED RESIN CROWN	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs. Allowed for SHCN members regardless of age or with demonstration of medical necessity for permanent or primary tooth.	Tooth cannot retain direct restoration. If for primary tooth, exfoliation is not imminent. Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable.
D2933	PREFABRICATED STAINLESS STEEL CROWN	none	There are no time limits on replacement or re-	Diagnostic radiographs. Allowed for SHCN members regardless of age or with	Primary tooth cannot retain direct restoration.. If for primary tooth, exfoliation is not imminent. Tooth is fully

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			cementations	demonstration of	erupted and restorable, but
			when medical	medical necessity.	lacks at least 50% tooth
			necessity can		structure or cannot retain
			be		direct restoration; is in
			documented.		occlusion, or will be utilized
					as an abutment to a
					prosthesis; Crown to root
					ratio at least 50%; bone
					support at least 50%,
					without mobility or furcation
					involvement; RCT (if present)
					is clinically acceptable. .
D2934	PREFABRICATED	Under	There are no	Diagnostic radiographs.	Primary anterior tooth
	ESTHETIC	age 9	time limits on	Allowed for SHCN	cannot retain direct
	COATED	unless	replacement or	members regardless of	restoration. Exfoliation is not
	STAINLESS STEEL	SHCN	re-	age or with	imminent.
	CROWN PRIMARY		cementations	demonstration of
	TOOTH		when medical	medical necessity.
			necessity can
			be
			documented.
D2940	PROTECTIVE	none	There are no	Diagnostic radiographs;	To relieve pain, promote
	RESTORATION		time limits on	for tooth in occlusion or	healing or prevent further
			replacement or	planned abutment;	deterioration, preserve tooth
			re-	diagnosis and reason for	and/or tissue form; for
			cementations	treatment	primary and permanent
			when medical		teeth.
			necessity can
			be
			documented.
D2941	INTERIM	none	There are no	Diagnostic radiographs	Adhesive restorative material
	THERAPEUTIC		time limits on		placed to arrest caries in
	RESTORATION		replacement or		primary teeth; not a
	PRIMARY		re-		definitive restoration; for
	DENTITION		cementations		early childhood caries or
			when medical		provided in non-office
			necessity can		setting. Exfoliation is not
			be		imminent.
			documented.
D2950	CORE BUILDUP	none	There are no	Diagnostic radiographs	Tooth meets criteria for full
	INCLUDING ANY		time limits on		coverage restoration.
	PINS		replacement or
			re-
			cementations
			when medical
			necessity can
			be
			documented.
			Not same day
			as D2952,
			D2954.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D2951	TOOTH PIN RETENTION	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs	Tooth to receive direct restoration 3 or more surfaces as definitive restoration.
D2952	CAST POST AND CORE IN ADDITION TO CROWN	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.	Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown.
D2953	EACH ADDTIONAL CAST POST	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.	Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown for molars only.
D2954	PREFABRICATED POST/CORE IN ADDITION TO CROWN	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.	Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not include crown; meets clinical criteria for a crown.
D2955	POST REMOVAL	none	AMN	Diagnostic radiographs demonstrating failed endo or restoration Is included in service and reimbursement for endodontic retreatment codes, but can be billed as separate rate when different provider is doing retreatment.	Failure of RCT requires post removal for retreatment. Post is not clinically acceptable.
D2957	EACH ADDTIONAL PREFABRICATED POST	none	There are no time limits on replacement or re- cementations when medical	Diagnostic radiographs of clinically acceptable post-op RCT not same day as D2952, D2954.	Evidence of clinically acceptable post-treatment view of RCT and restorable tooth; post should extend at least 1/2 (preferably 2/3) length of root; does not

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			necessity can be documented.		include crown; meets clinical criteria for a crown.
D2971	ADDITIONAL PROCEDURE TO CONSTRUCT NEW CROWN UNDER RPD	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	BR. Diagnostic radiographs, presence of removable partial denture (RPD).	Tooth will receive crown (to be billed separately) and serve as abutment to existing functional RPD. Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.
D2975	COPING	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic radiographs, planned full-coverage restoration.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics.
D2980	CROWN REPAIR	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	BR; diagnostic image.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing crown is otherwise clinically acceptable.
D2981	INLAY REPAIR	none	There are no time limits on replacement or re- cementations	BR; diagnostic image.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion,

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			when medical necessity can be documented.		or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing inlay is otherwise clinically acceptable.
D2982	ONLAY REPAIR	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	BR; diagnostic image.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing onlay is otherwise clinically acceptable.
D2983	VENEER REPAIR	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	BR; diagnostic image.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Not for esthetics. Existing veneer is otherwise clinically acceptable.
D2999	UNSPECIFIED RESTORATIVE PROCEDURE	none		BR. DMN; diagnosis, clinical presentation of provided service.	Service not described by CDT code.
D3220	THERAPUTIC PULPOTOMY	none	Once per tooth	Emergency procedure	For pain relief; primary or permanent tooth; not first stage of RCT or for apexogenesis. Tooth is restorable.
D3221	GROSS PULPAL DEBRIDEMENT	none	Once per tooth	Emergency procedure not same DOS as RCT performed in one visit.	For pain relief; primary or permanent tooth; not first stage of RCT or for

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
					apexogenesis. Tooth is restorable.
D3222	PART PULPOTOMY FOR APEXOGENESIS	To age 19	Once per tooth	Diagnostic radiographs	Restorable permanent tooth with incomplete root formation; open apex.
D3230	PULPAL THERAPY ANTERIOR PRIM ARY TOOTH	none	Once per tooth	Diagnostic radiographs	Restorable tooth, good prognosis; space preservation.
D3240	PULPAL THERAPY POSTERIOR PRI MARY TOOTH	none	Once per tooth	Diagnostic radiographs	Restorable tooth, good prognosis; space preservation.
D3310	ENDO THERAPY ANTERIOR TOOTH	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP.
D3320	ENDO THERAPY PREMOLAR TOOTH	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D3330	ENDO THERAPY MOLAR TOOTH	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Tooth is restorable, in occlusion or will be utilized as an abutment to a prosthesis; crown/root ratio of at least 50%; without mobility. Also includes clinical criteria for D2710. Exposed pulp or carious involved pulp, pulpal necrosis, PAP.
D3331	NON SURGICAL TREATMENT ROOT CANAL OBSTRUCTION	none	Once per tooth	BR. To include diagnostic image.	Tooth is restorable, canal(s) blocked by calcification or foreign body for at least 50% of length. Pulpal exposure or caries.
D3332	INCOMPLETE ENDODONTIC TREATMENT	none	Once per tooth	BR. To include diagnostic image.	Tooth found to be unrestorable during the course of RCT.
D3333	INTERNAL ROOT REPAIR	none	Once per tooth	BR. To include diagnostic image.	To correct resorption or carious perforation; not iatrogenic.
D3346	RETREAT ROOT CANAL ANTERIOR	none	Once per tooth	Not benefited to same provider of D3310 within 36 months; there is no timeframe for consideration of an endodontic retreatment.	Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or otherwise symptomatic.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D3347	RETREAT ROOT CANAL PREMOLAR	none	Once per tooth	Not benefited to same provider of D3320 within 36 months; there is no timeframe for consideration of an endodontic retreatment.	Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or otherwise symptomatic.
D3348	RETREAT ROOT CANAL MOLAR	none	Once per tooth	Not benefited to same provider of D3330 within 36 months; there is no timeframe for consideration of an endodontic retreatment.	Tooth is restorable; canal fill appears to be shorter than 2mm from apex or significantly beyond apex; fill appears to be incomplete or poor condensation, periapical pathology; tooth is sensitive to pressure or otherwise symptomatic.
D3351	APEXIFICATION/R ECALCIFICATION INITIAL	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Vital pulp, insufficient apical development.
D3352	APEXIFICATION/R ECALC INTERIM MEDICATION REPLACEMENT	none	Once per tooth includes all visits	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs	Vital pulp, insufficient apical development.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				included in reimbursement.
D3353	APEXIFICATION/R ECALCIFICATION FINAL	none	Once per tooth	BR. To include diagnostic image.	Vital pulp, insufficient apical development
D3355	PULPAL REGENERATION INITIAL	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Permanent tooth; necrotic pulp, insufficient apical development.
D3356	PULPAL REGENERATION INTERIM	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Permanent tooth; necrotic pulp, insufficient apical development.
D3357	PULPAL REGENERATION COMPLETE	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images,	Permanent tooth; necrotic pulp, insufficient apical development.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.
D3410	APICOECTOMY- ANTERIOR	none	Once per tooth	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement. there is no timeframe for consideration of service.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic.
D3421	APICOECTOMY PREMOLAR (FIRST ROOT)	none	One treatment per initial root treated; all subsequent roots to be considered as D3426.	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic.
D3425	APICOECTOMY MOLAR (FIRST ROOT)	none	One treatment per initial root treated; all subsequent roots to be	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion,

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			considered as D3426.	Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic.
D3426	APICOECTOMY EACH ADDITIONAL ROOT	none	One treatment per additional tooth root(s)	Pre-treatment and when already provided, post treatment radiographic images showing apex of tooth. Retreatment and all other endodontic services require radiographic image of completed initial endodontic treatment and current images, diagnosis and reason for treatment if it is not evident on films. All treatment radiographs included in reimbursement.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic.
D3428	BONE GRAFT PERI RADICULAR PER TOOTH	none	One treatment allowed per tooth	BR; Provided w/D3427; includes non- autogenous graft material.	To repair perforation, resorption, fracture, removal of foreign material or seal accessory canals.
D3429	BONE GRAFT PERI RADICULAR EACH ADDL TOOTH	none	One treatment allowed per tooth	BR; Provided w/D3427; includes non- autogenous graft material.	To repair perforation, resorption, fracture, removal of foreign material or seal accessory canals.
D3430	RETROGRADE FILLING –PER ROOT	none	One treatment per tooth root	Provided w/ D3410, D3421, D3425, D3426.	To repair perforation, resorption, fracture, removal of foreign material or seal accessory canals.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D3450	ROOT AMPUTATION	none	Once per root	Restorative treatment plan, full mouth radiographs.	Presence of root fracture, caries or resorption; bone support and crown: root ratio both at least 50%; remaining root(s) functional and restorable with good long term prognosis.
D3471	SURGICAL REPAIR OF ROOT RESORPTION - ANTERIOR	none	One treatment allowed per tooth	Restorative treatment plan, full mouth radiographs. Surgery on root of anterior tooth; does not include restoration.	Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term prognosis.
D3472	SURGICAL REPAIR OF ROOT RESORPTION - PREMOLAR	none	One treatment allowed per tooth	Restorative treatment plan, full mouth radiographs. Surgery on root of premolar tooth; does not include restoration.	Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term prognosis.
D3473	SURGICAL REPAIR OF ROOT RESORPTION - MOLAR	none	One treatment allowed per tooth	Restorative treatment plan, full mouth radiographs. Surgery on root of molar tooth; does not include restoration.	Radiographic evidence of root resorption; both bone support and crown to root ratio at least 50%; tooth is restorable and will be in function with good long term prognosis.
D3501	SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION - ANTERIOR	none	One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS.	BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs.	History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor.
D3502	SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION – PREMOLAR	none	One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS.	BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs.	History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D3503	SURGICAL EXPOSURE OF ROOT SURFACE WITHOUT APICOECTOMY OR REPAIR OF ROOT RESORPTION – MOLAR	none	One treatment allowed per tooth. No other services (excepting diagnostic) to be performed on same DOS.	BR Clinical findings, differential diagnosis, restorative treatment plan, recent radiograph of involved tooth, full mouth radiographs.	History of pain or discomfort which could not be diagnosed from clinical evaluation or radiographic images; exploratory procedure. Conforms to CDT descriptor.
D3910	SURGICAL ISOLATION- TOOTH W/ RUBBER DAM	none	Once per tooth	BR. To include diagnostic image.	Insufficient supra-osseous tooth structure to retain rubber dam clamp.
D3920	TOOTH SPLITTING	none	Once per tooth	Diagnostic full mouth radiographs; does not include RCT.	Hemisection; tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic tooth is restorable and required for occlusal function or as an abutment.
D3950	CANAL PREP/ FITTING OF DOWEL	none	Once per tooth	Diagnostic periapical, restorative treatment plan; not to same provider as D2952, D2953, D2954, D2957.	Tooth is fully erupted and restorable, but lacks at least 50% tooth structure or cannot retain direct restoration; is in occlusion, or will be utilized as an abutment to a prosthesis; Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement; RCT (if present) is clinically acceptable. Restorable tooth; calcification prevents

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
					adequate fill to apex; failed retreatment; accessory canals; marked over extension of fill material preventing healing; tooth is sensitive to pressure or otherwise symptomatic.
D3999	UNSPECIFIED ENDODONTIC PROCEDURE	none		BR. DMN; diagnosis, clinical presentation of provided service.	Service not described by CDT code.
D4210	GINGIVECTOMY/ PLASTY 4 OR MORE TEETH	none	Periodontal surgical procedures will be allowed every 3 years.	Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member.	Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.
D4211	GINGIVECTOMY/ PLASTY 1 TO 3 TEETH	none	Periodontal surgical procedures will be allowed every 3 years.	Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member.	Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.
D4212	GINGIVECTOMY/ PLASTY ACCESS FOR RESTORATION	none	Periodontal surgical procedures will be allowed every 3 years.	Diagnostic periapical or bitewing radiograph, restorative treatment plan.	To allow visualize & access for placement of restoration.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D4240	GINGIVAL FLAP PROCEDURE W/ ROOT PLANING 4 OR MORE TEETH	Age 18 and older	Periodontal surgical procedures will be allowed every 3 years.	Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member, there is no requirement for prior scaling and root planning.	Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable without recent history of scaling and root planning.
D4241	GINGIVAL FLAP W/ ROOT PLANING 1 -3 TEETH	Age 18 and older	Periodontal surgical procedures will be allowed every 3 years.	Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member, there is no requirement for prior scaling and root planning.	Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.
D4245	APICALLY POSITIONED FLAP	Age 18 and older	Once per tooth	Full mouth x-rays or photos, perio charting, oral hygiene status.	To preserve keratinized gingiva surrounding natural teeth or implant(s).
D4249	CLINICAL CROWN LENGTHENING HARD TISSUE	Age 18 and older	Once per tooth	Diagnostic periapical or bitewing radiograph, restorative treatment plan	To restore clinically acceptable crown root ratio or to create proper biologic width for crown margin; tooth has good long term

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
					prognosis and periodontium is healthy; RCT if present is clinically acceptable.
D4260	OSSEOUS SURGERY 4 OR MORE TEETH	Age 18 and older	Periodontal surgical procedures will be allowed every 3 years.	Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. Periodontal surgical procedures will be allowed every 3 years.	Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.
D4261	OSSEOUS SURGERY 1 TO 3 TEETH	Age 18 and older	Periodontal surgical procedures will be allowed every 3 years.	Based on number of involved restorable teeth in quadrant. Full mouth x-rays or photos and narrative if SHCN member; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting OR cases. Units reimbursable per DOS will be limited to 2 quadrants unless services are provided in an operating room or for a developmentally disabled or SHCN member. Periodontal surgical procedures will be allowed every 3 years.	Recent history of scaling and root planning or periodontal maintenance; documentation of bone loss and pocket depth exceeding 5 mm.; documentation of caries control; documentation of drug induced gingival hyperplasia, where applicable.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D4263	BONE REPLACE GRAFT FIRST SITE IN QUAD	Age 18 and older	Once per tooth (each tooth = 1 site)	Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own codes.	For regeneration of bone lost through periodontal disease to correct a deformity or defect; not for edentulous spaces or extraction sites. For retained natural tooth, presence of bone loss.
D4264	BONE REPLACE GRAFT EACH ADDITIONAL SITE IN A QUADRANT	Age 18 and older	Once per tooth	Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases Not with implant cases. Performed with one or more bone replacement grafts; number of sites to be documented	For regeneration of bone lost through periodontal disease to correct a deformity or defect; not for edentulous spaces or extraction sites. For retained natural tooth, presence of bone loss.
D4265	BIOLOGIC MATERIALS TO AID SOFT TISSUE/ OSSEOUS REGENERATION	Age 18 and older	Once per tooth	Recent diagnostic images and periodontal charting. Used alone or with other regenerative materials such as bone and barrier membranes; does not include surgical entry and closure, debridement, osseous contouring or placement of graft related materials and or membranes. Other procedures provided on same DOS to be reported with own codes.	For the correction of periodontal defects involving restorable teeth in occlusion, presence of bone loss.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D4266	GUIDED TISSUE REGENERATION RESORBABLE	Age 18 and older	Once per tooth (each tooth = 1 site)	Recent diagnostic images and periodontal charting. Does not include surgical entry and closure, wound debridement, osseous contouring or placement of barrier membranes or graft materials; other procedures provided on same DOS reported using their own codes	For correction of periodontal and peri-implant defects involving restorable teeth or implant in occlusion presence of bone loss.
D4267	GUIDED TISSUE REGENERATION NONRESORBABLE	Age 18 and older	Once per tooth (each tooth = 1 site)	Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own codes.	For correction of periodontal and peri-implant defects involving restorable teeth or implant in occlusion presence of bone loss.
D4268	SURGICAL REVISION PROCEDURE, PER TOOTH	Age 18 and older	Once per tooth	Full mouth x-rays or photos and narrative if SHCN; perio charting; case type; oral hygiene status; occlusal trauma; mobility; at least four weeks after scaling, excepting SHCN OR cases. Not with implant cases; does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own codes.	To refine results of previous surgical procedure; presence of bone loss, may modify irregular contours of soft or hard tissue; muccoperiosteal flap to access alveolar bone; flap(s) replaced or repositioned and sutured.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D4270	PEDICLE SOFT TISSUE GRAFT PROCEDURE	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	Adjacent gingiva is used to replace absent alveolar mucosa as marginal tissue; for root coverage or correct gingival defects on prominent teeth.
D4273	AUTO TISSUE GRAFT FIRST TOOTH	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site.
D4274	MESIAL/DISTAL WEDGE PROCEDURE	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	To reduce pocket depth in edentulous area adjacent to erupted tooth.
D4275	NON-AUTOGEOUS GRAFT FIRST TOOTH	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	For correction of gingival defects of tooth (including recession), implant or dental ridge; eliminate pull of frena and muscle attachments; no donor site.
D4276	CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	For advanced gingival recession, utilizes combined tissue grafting procedures.
D4277	SOFT TISSUE GRAFT FIRSTTOOTH	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site.
D4278	SOFT TISSUE GRAFT ADDITIONAL TOOTH	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site.
D4283	AUTO TISSUE GRAFT ADDITIONAL TOOTH	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	For correction of gingival defects of tooth, implant or dental ridge; utilizes donor site.
D4285	NON-AUTO GRAFT ADDITIONAL TOOTH	Age 18 and older	Once per tooth	Recent perio charting, diagnostic radiographs and/or photographs, narrative.	For correction of gingival defects of tooth (including recession), implant or dental ridge; eliminate pull of frena and muscle attachments; no donor site; same graft site, used in conjunction with D4275.
D4320	PROVISIONAL SPLINTING INTRACORONAL	none	AMN	Full mouth x-rays or photos and narrative if SHCN; perio charting to include presence of occlusal trauma and/or mobility; treatment plan: per tooth	For interim stabilization of periodontally involved teeth; not for stabilization post- trauma (see D7270) presence of bone loss.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D4321	PROVISIONAL SPLINTING EXTRACORONAL	none	AMN	Full mouth x-rays or photos and narrative if SHCN; perio charting to include presence of occlusal trauma and/or mobility; treatment plan: per tooth	For interim stabilization of periodontally involved teeth; not for stabilization post- trauma (see D7270) presence of bone loss.
D4341	PERIODONTAL SCALING & ROOT PLANING 4 OR MORE TEETH	Age 18 and older unless SHCN	Allowed every 3 years; can be considered once a year with DMN for SHCN members	Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate radiographs.	Documentation of pocket depth, presence of bone loss inflammation, medical history or mobility supports procedure; pocket depths of 5mm. or greater.
D4342	PERIODONTAL SCALING 1-3 TEETH	Age 18 and older unless SHCN	Allowed every 3 years; can be considered once a year with DMN for SHCN members.	Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate radiographs	Documentation of pocket depth, presence of bone loss inflammation, medical history or mobility supports procedure; pocket depths of 5mm. or greater.
D4346	SCALING W/GINGIVAL INFLAMATION	Age 10 and older (unless SHCN)	Once per RY; up to four times per RY for SHCN with documentation of medical necessity.	Recent full mouth perio charting and radiographs; narrative and photos if bone loss not visible on x-rays or for SHCN Member, LTCF resident or member who cannot tolerate radiographs; not allowed within 6 months of D4341, D4342, D4355, D4210, D4211, D4910.	Pocket depths of 4mm. or greater without bone loss; presence of inflammation; medical history.
D4355	FULL MOUTH DEBRIDEMENT	none	Once per 3 years. Allowed once per year for SHCN members and LTCF residents.	DMN; Code cannot be billed on same DOS with D0150, D0160 or D0180 or with prophylaxis – adult or child (D1110, D1120) or any other periodontal code unless service is provided in OR setting for SHCN member.	Removal of heavy plaque and/or calculus deposits required to perform oral evaluation.
D4381	LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS	none	One placement per tooth per DOS per 12 month period; not same DOS	Narrative report, recent full mouth perio charting. May be provided on same DOS	Minimum 6mm probing depth; presence of bone loss. Patient must have completed root planning, or periodontal surgical procedure in same

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			as D1110, D4346, or D4355.	as D4341, D4342 or D4910.	quadrant, and have documented regular recall visits.
D4910	PERIODONTAL MAINTENANCE	none	May be provided twice a RY and for members with SHCN additional visits can be considered in a RY with documentation of medical necessity. For periodontal maintenance on a 3 month cycle additional service will be considered as prophylaxis	Recent full mouth charting and radiographs, documentation of recent provision of other periodontal therapy, improved oral hygiene and periodontal prognosis with documented caries control.	Recent provision of periodontal therapy presence of bone loss.
D4999	UNSPECIFIED PERIODONTAL PROCEDURE	none		DMN; diagnosis, clinical presentation of provided service; BR.	Service not described by CDT code.
D5110	COMPLETE DENTURE MAXILLARY	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Replacements: Documentation of physical changes, post denture insertion extractions or planned extractions, broken or lost dentures and other extenuating circumstances. Date of previous denture(s) not required.; includes adjustments for first six months post-insertion, relines and rebases not covered 6 months post insertion.	Edentulous arch or planned full arch extraction
D5120	COMPLETE DENTURE MANDIBULAR	none	7.5 years; less if medical necessity can be demonstrated;	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.	Edentulous arch or planned full arch extraction.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Replacements: Documentation of physical changes, post denture insertion extractions or planned extractions, broken or lost dentures and other extenuating circumstances. Date of previous denture(s) not required.; includes adjustments for first six months post-insertion, relines and rebases not covered 6 months post insertion.
D5130	IMMEDIATE DENTURE MAXILLARY	none	Once per lifetime	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Adjustments, relines/rebases are included for the 1st 6 months post insertion.	Remaining teeth have poor to hopeless prognosis; extractions (to include teeth #s 05-12) performed on date of insertion.
D5140	IMMEDIATE DENTURE MANDIBULAR	none	Once per lifetime	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Adjustments, relines/rebases are included for the 1st 6 months post insertion.	Remaining teeth have poor to hopeless prognosis; extractions (to include teeth #s 21-28) performed on date of insertion.
D5211	MAXILLARY PARTIAL DENTURE RESIN BASE	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.	At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5212	MANDIBULAR PARTIAL DENTURE RESIN BASE	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.	At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided.
D5213	MAXILLARY PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASP ING MATERIALS, RESTS AND TEETH)	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.	At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided.
D5214	MANDIBULAR PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING RETENTIVE/CLASP ING MATERIALS, RESTS AND TEETH)	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures.	At least one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			service		repair or multiple planned
			reimbursed		extractions will be provided.
			through MCO of
			enrollment.
D5225	MAXILLARY	none	7.5 years; less if	Full mouth radiographs	Additional retention
	PARTIAL		medical	or photographs,	required; at least one
	DENTURE		necessity can	charting of dentition,	missing anterior tooth; less
	FLEXIBLE BASE		be	planned surgical	than 8 points of contact that
			demonstrated;	procedures.	establish functional and
			dentures		balanced occlusion; all
			denied for		procedures to be provided
			frequency are		before impressions;
			denied with an		remaining teeth have good
			administrative,		prognosis; adjustments,
			not a clinical		relines, rebases included 6
			edit. Frequency		mos. post insert. If denture is
			for provision of		less than 7.5 years old,
			denture is		documentation to support
			based on		loss, inability to repair or
			service		multiple planned extractions
			reimbursed		will be provided.
			through MCO of
			enrollment.
D5226	MANDIBULAR	none	7.5 years; less if	Full mouth radiographs	Additional retention
	PARTIAL		medical	or photographs,	required; at least one
	DENTURE		necessity can	charting of dentition,	missing anterior tooth; less
	FLEXIBLE BASE		be	planned surgical	than 8 points of contact that
			demonstrated;	procedures.	establish functional and
			dentures		balanced occlusion; all
			denied for		procedures to be provided
			frequency are		before impressions;
			denied with an		remaining teeth have good
			administrative,		prognosis; adjustments,
			not a clinical		relines, rebases included 6
			edit. Frequency		mos. post insert. If denture is
			for provision of		less than 7.5 years old,
			denture is		documentation to support
			based on		loss, inability to repair or
			service		multiple planned extractions
			reimbursed		will be provided.
			through MCO of
			enrollment.
D5410	DENTURES	none	AMN; Service	Clinical presentation	Necessity to restore form,
	ADJUST CMPLT		cannot have	supports service;	function and to relieve sore
	MAXILLARY		frequency or	Needed repairs and	spots and over-extensions
			time limits that	adjustments 6 months	causing tissue damage by
			adversely affect	after insertion are	existing denture.
			the member by	included in denture
			impairing their	reimbursement to
			ability to	provider of prosthesis
			function.	regardless of the
				number of visits; the
				member cannot be

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				charged for these services.
D5411	DENTURES ADJUST COMPLETE MANDIBULAR	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture.
D5421	DENTURES ADJUST PARTIAL MAXILLARY	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture
D5422	DENTURES ADJUST PARTIAL MANDBLULAR	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture.
D5511	REPAIR BROKEN COMPLETE DENTURE BASE MANDIBULAR	none	AMN; Service cannot have frequency or time limits that	Clinical presentation supports service; Needed repairs and adjustments 6 months	To restore denture function and retention.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			adversely affect the member by impairing their ability to function.	after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.
D5512	REPAIR BROKEN COMPLETE DENTURE BASE MAXILLARY	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore denture function and retention.
D5520	REPLACE DENTURE TEETH COMPLETE	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore function and occlusion.
D5611	REPAIR RESIN PARTIAL DENTURE BASE MANDIBULAR	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore denture function and retention.
D5612	REPAIR RESIN PARTIAL DENTURE BASE MAXILLARY	none	AMN; Service cannot have frequency or time limits that adversely affect	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are	To restore denture function and retention.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			the member by impairing their ability to function.	included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.
D5621	REPAIR CAST PARTIAL DENTURE FRAME MANDIBULAR	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore denture function and retention.
D5622	REPAIR CAST PARTIAL DENTURE FRAME MAXILLARY	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore denture function and retention.
D5630	REPAIR PARTIAL DENTURE CLASP	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore denture function and retention.
D5640	REPLACE PARTIAL DENTURE TEETH	none	AMN; Service cannot have frequency or time limits that adversely affect the member by	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture	To restore function and occlusion; replacement of denture tooth.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			impairing their ability to function.	reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.
D5650	ADD TOOTH TO PARTIAL DENTURE	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore function and occlusion; replacement of a missing natural tooth.
D5660	ADD CLASP TO PARTIAL DENTURE	none	AMN; Service cannot have frequency or time limits that adversely affect the member by impairing their ability to function.	Clinical presentation supports service; Needed repairs and adjustments 6 months after insertion are included in denture reimbursement to provider of prosthesis regardless of the number of visits; the member cannot be charged for these services.	To restore denture function and retention.
D5710	DENTURES REBASE COMPLETE MAXILLARY	none	Every 3 years	Narrative to DMN; photograph.	Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention.
D5711	DENTURES REBASE COMPLETE MANDIBULAR	none	Every 3 years	Narrative to DMN; photograph.	Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention.
D5720	DENTURES REBASE PARTIAL MAXILLARY	none	Every 3 years	Narrative to DMN; photograph.	Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5721	DENTURES REBASE PARTIAL MANDIBULAR	none	Every 3 years	Narrative to DMN; photograph.	Necessity to restore form, function and to relieve sore spots and over-extensions causing tissue damage by existing denture; restore denture fit and retention.
D5730	DENTURE RELNE COMPLETE MAXIL CHAIRSIDE	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5731	DENTURE RELNE COMPLETE MAND CHAIRSIDE	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5740	DENTURE RELINE PARTIAL MAXIL CHAIRSIDE	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5741	DENTURE RELINE PARTIAL MAND CHAIRSIDE	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5750	DENTURE RELINE COMPLETE MAX LAB	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5751	DENTURE RELINE COMPLETE MAND LAB	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5760	DENTURE RELINE PARTIAL MAXIL LAB	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5761	DENTURE RELINE PARTIAL MAND LAB	none	Once per RY	Documentation of ill- fitting denture.	Restore function and retention by resurfacing.
D5850	DENTURE TISSUE CONDITIONING MAXILLA	none	Once per RY	DMN; history of dentures includes adjustments to same provider for 6 months.	To heal soft tissue and ridge before definitive treatment; evidence of inflammation or tissue irritation.
D5851	DENTURE TISSUE CONDITIONING MANDBLE	none	Once per RY	DMN; history of dentures includes adjustments to same provider for 6 months.	To heal soft tissue and ridge before definitive treatment; evidence of inflammation or tissue irritation.
D5862	PRECISION ATTACHMENT	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Diagnostic full mouth images, treatment plan	Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement. Documented caries control; RCT (if present) is clinically acceptable.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5863	OVERDENTURE COMPLETE MAXILLARY	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity.	Planned extractions with specific roots retained to limit future arch resorption and improve denture retention. Retained roots have at least 50% bone support
D5864	OVERDENTURE PARTIAL MAXILLARY	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity.	At least one natural root or teeth retained for arch integrity and one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. Retained roots have at least 50% bone support
D5865	OVERDENTURE COMPLETE MANDIBULAR	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity.	Planned extractions with specific roots retained to limit future arch resorption and improve denture retention. Retained roots have at least 50% bone support

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			denture is based on service reimbursed through MCO of enrollment.
D5866	OVERDENTURE PARTIAL MANDIBULAR	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	Full mouth radiographs or photographs, charting of dentition, planned surgical procedures. Planned extraction with natural roots retained for arch integrity.	At least one natural root or teeth retained for arch integrity and one missing anterior tooth; less than 8 points of contact that establish functional and balanced occlusion; all procedures to be provided before impressions; remaining teeth have at least fair prognosis; design allows for addition of teeth; adjustments, relines, rebases included 6 mos. post insert. If denture is less than 7.5 years old, documentation to support loss, inability to repair or multiple planned extractions will be provided. Retained roots have at least 50% bone support
D5867	REPLACEMENT OF PRECISION ATTACHMENT	none	There are no time limits on replacement or re- cementations when medical necessity can be documented.	Image of abutment, narrative.	Failed attachment; can be replacement of male and/or female component(s). Same periodontal criteria as for D2710; good prognosis for abutment and denture.
D5875	PROSTHESIS MODIFICATION	none	Once per lifetime of prosthesis	BR; dental records. For implant cases only.	For existing prosthesis following implant surgery.
D5899	UNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE	none		BR. DMN; diagnosis, clinical presentation of provided service.	Service not described by CDT code.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5911	FACIAL MOULAGE SECTIONAL	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5912	FACIAL MOULAGE COMPLETE	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5913	NASAL PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5914	AURICULAR PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Conforms to CDT descriptor.
D5915	ORBITAL PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5916	OCULAR PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5919	FACIAL PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5922	NASAL SEPTAL PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5923	OCULAR PROSTHESIS INTERIM	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5924	CRANIAL PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5925	FACIAL AUGMENTATION IMPLANT	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.
D5926	REPLACEMENT NASAL PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5927	AURICULAR REPLACEMENT	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5928	ORBITAL REPLACEMENT	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5929	FACIAL REPLACEMENT	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5931	SURGICAL OBTURATOR	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5932	POSTSURGICAL OBTURATOR	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5933	REFITTING OF OBTURATOR	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.
D5934	MANDIBULAR FLANGE PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5935	MANDIBULAR DENTURE PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5936	TEMPORARY OBTURATOR PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5937	TRISMUS APPLIANCE	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5951	FEEDING AID	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5952	PEDIATRIC SPEECH AID	Under age 19	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5953	ADULT SPEECH AID	Age 19 and older	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.
D5954	PALATAL AUGMENTATION PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5955	PALATAL LIFT PROSTHESIS, DEFINITIVE	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5958	PALATAL LIFT PROSTHESIS INTERIM	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5959	PALATAL LIFT PROSTHESIS, MODIFACATION	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5960	MODIFY SPEECH AID PROSTHESIS	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5982	SURGICAL STENT	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5983	RADIATION APPLICATOR	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.
D5984	RADIATION SHIELD	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5985	RADIATION CONE LOCATOR	none	AMN	BR-Recent radiographic and photographic images, medical diagnosis and complete treatment plan to include that of all providers involved in treating the case. May be paid under medical benefit; indicate that these services are provided by physicians or OMFS and include if provider uses CPT or CDT codes.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5986	FLUORIDE CARRIER	none	AMN	BR; dental records.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5987	COMMISURE SPLINT	none	AMN	BR; dental records.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D5988	SURGICAL SPLINT	none	AMN	Treatment plan, narrative	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5991	VESICULO BULLOUS DISEASE MED CARRIER	none	AMN	Treatment plan, narrative	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5992	ADJUST MAXILLOFACIAL PROSTHETIC APPLIANCE	none	AMN	Treatment plan, narrative	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5993	MAINTAIN/CLEAN MAXILLOFACIAL PROSTHESIS	none	AMN	BR; indicate type of prosthesis and description of service provided/planned.	Medical diagnosis and clinical description of case supports provision of service. Must document if medical team is treating case and include treatment plan and sequence. Conforms to CDT descriptor.
D5999	UNSPECIFIED MAXILLOFACIAL PROSTHESIS	none		BR. DMN; diagnosis, clinical presentation of provided service;	Service not described by CDT code.
D6010	ENDOSTEAL IMPLANT	none	Maximum 4 per arch	Diagnostic radiographic images of implant sites as appropriate, number of and area where implants are to be placed, dental history to indicate date of denture fabrication, two years of difficulty with denture retention and provider’s attempts to improve or correct retention of denture are required. Service is only considered with PA for denture(s) for edentulous arch(es) and	Patient is unable to function with conventional complete denture due to lack of retention due to insufficient bone.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				complete implant treatment plan.
D6011	SECOND STAGE IMPLANT SURGERY	none	Maximum 4 per arch	Recent diagnostic radiographic images of implants. Service is only considered with PA for denture(s) for edentulous arch(es).	Implant body(ies) require surgical exposure to continue case.
D6055	IMPLANT CONNECTING BAR	none	Once per arch	BR. To include diagnostic radiographs of implants showing successful osteointegration, Service is only considered with PA for denture(s) for edentulous arch(es) or narrative describing modification to functional preexisting dentures. Paid as case rate for entire arch.	Patient is unable to function with conventional complete denture due to lack of retention due to insufficient bone.
D6080	IMPLANT MAINTENANCE PROCEDURES	none	Twice per RY	BR; for debridement and evaluation of entire arch prostheses and its associated implants. Prosthesis is removed and reinserted.	Evidence of plaque, stains, calculus on implant structure. Ensure occlusion and stability of prosthesis.
D6081	SCALE & DEBRIDE, SINGLE IMPLANT	none	Once every 3 years	Recent images of implants, narrative to document inflammation; not on same DOS as D1110, D4910 or D4346 D6101, D6102, D6103.	For a single implant. Documentation of inflammation, medical history supports procedure.
D6090	REPAIR IMPLANT SUPPORTED PROSTHESIS	none	AMN There are no frequencies or time limits when DMN shows failure of material.	BR. Photograph, documentation of clinical findings and description of planned repair to include if it will be lab or in-office service. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental	For repair of implant supported prosthesis.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				trauma or damage by patient can be documented. Documentation that existing denture is serviceable and functional.
D6091	REPLACE SEMI/PRECISION ATTACH OF IMPLANT SUPPORTED PROSTHESIS	none	AMN There are no frequencies or time limits when DMN shows failure of material.	Photograph, clinical findings and description of planned repair to include if it will be lab or in-office service If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or damage by patient can be documented. Documentation that existing denture is serviceable and functional.	Direct replacement of preexisting failed/defective semi-precision attachments; can be male and/or female component(s). Applies to replaceable male or female component of attachment.
D6092	RECEMENT ABUTMENT SUPPORTED CROWN	none	AMN There are no frequencies or time limits when DMN shows failure of material.	For single implant crowns. Recent, diagnostic radiograph or panoramic image.	Recementation of undamaged implant crown. Associated denture must be functional.
D6095	REPAIR IMPLANT ABUTMENT	none	AMN There are no frequencies or time limits when DMN shows failure of material.	BR. Photograph, narrative. Submit denture repair on same PA when applicable.	Repair of any part of implant abutment.
D6096	REMOVE BROKEN IMPLANT RETAIN SCREW	none	Once per implant	BR. To include diagnostic radiographs and narrative.	Failed implant screw.
D6100	REMOVAL OF IMPLANT	none	Once per implant	BR. To include diagnostic radiographs and narrative.	Implant failure

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D6101	DEBRIDEMENT OF A PERIIMPLANT DEFECT	none	Once every 3 years; per implant	Diagnostic x-rays or photos and narrative to include oral hygiene status; occlusal trauma; mobility; Includes entry and closure. Not on same DOS as D6081.	For debridement and correction of peri-implant defect(s).
D6102	DEBRIDEMENT & CONTOURING OF A PERI-IMPLANT DEFECT	none	Once every 3 years; per implant	Diagnostic x-rays or photos and narrative to include oral hygiene status; occlusal trauma; mobility; Includes entry and closure. Not on same DOS as D6081.	For debridement and correction of peri-implant osseous defect(s).
D6103	BONE GRAFT REPAIR PERIMPLANT	none	Once every 3 years; per implant	Diagnostic x-rays or photos and narrative; to include oral hygiene status; occlusal trauma; mobility. Does not include entry and closure, wound debridement, osseous contouring, biologic materials or barrier membranes. Other procedures on same DOS documented by their own code on same PA. Not on same DOS as D6081.	For regeneration of bone loss associated with peri-implant osseous defect(s), to correct a deformity or defect.
D6110	IMPLANT/ABUT REMOVEABLE DENTURE FOR EDENTULOUS ARCH-MAXILLARY	none	7.5 years; less if medical necessity can be demonstrated; dentures denied for frequency are denied with an administrative, not a clinical edit. Frequency for provision of denture is based on service reimbursed through MCO of enrollment.	BR. To include diagnostic radiographs. Include all associated implant services on same PA.	Inability to function with conventional complete maxillary denture due to ridge resorption and lack of retention for at least 2 years.
D6111	IMPLANT/ABUT REMOVEABLE	none	7.5 years; less if medical	BR. To include diagnostic radiographs.	Inability to function with conventional complete

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
	DENTURE FOR		necessity can	Include all associated	mandibular denture due to
	EDENTULOUS		be	implant services on	ridge resorption and lack of
	ARCH		demonstrated;	same PA.	retention for at least 2 years
	MANDIBULAR		dentures
			denied for
			frequency are
			denied with an
			administrative,
			not a clinical
			edit. Frequency
			for provision of
			denture is
			based on
			service
			reimbursed
			through MCO of
			enrollment.
D6191	SEMI-PRECISION	none	Initial	Diagnostic radiographs	Patient is unable to function
	ABUTMENT		placement or	of implants showing	with conventional complete
	PLACEMENT		replacement. Once per	successful osteointegration,	denture due to lack of retention and insufficient
			implant body;	photograph, clinical	bone. Include reason for
			maximum 4 per	findings and description	replacement if applicable.
			arch	of planned repair if
				applicable. Service is
				only considered for
				complete denture(s).
D6192	SEMI-PRECISION	none	Initial	Diagnostic radiographs	Patient is unable to function
	ATTACHMENT		placement or	of implants showing	with conventional complete
	PLACEMENT		replacement. Once per	successful osteointegration,	denture due to lack of retention and insufficient
			implant body;	photograph, clinical	bone. Include reason for
			maximum 4 per	findings and description	replacement if applicable.
			arch	of planned repair to
				include denture
				modification if
				applicable. Service is
				only considered for
				complete denture(s).
D6199	UNSPECIFIED IMPLANT PROCEDURE	none		BR. DMN; diagnosis, clinical presentation, description of service to be provided.	Service not described by CDT code.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D6210	HIGH NOBLE METAL PONTIC	none	Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b).	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6211	PONTIC BASE METAL CAST	none	Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b).	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6212	PONTIC NOBLE METAL CAST	none	Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b).	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				periapical series with	who cannot function with
				bitewings; narrative of	removable appliance.
				medical necessity if	Removable prosthesis will be
				Member is SHCN. If	considered when not a direct
				required within a year	replacement and criteria for
				of placement, these	removable prosthesis are
				services will generally	met.
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D6240	PONTIC	none	Replacement	Recent, diagnostic full	As initial replacement of:
	PORCELAIN HIGH		criteria based	mouth radiographic	single anterior tooth for
	NOBLE		on N.J.A.C.	images: panoramic	members under the age of
			10:56 -2.13	image with bitewings	21, direct replacement of
			Prosthodontic	(may also require	preexisting failed/defective
			treatment (a)	periapical view of	bridgework; SHCN Members
			and (b).	involved teeth) or full	who cannot function with
				periapical series with	removable appliance.
				bitewings; narrative of	Removable prosthesis will be
				medical necessity if	considered when not a direct
				Member is SHCN. If	replacement and criteria for
				required within a year	removable prosthesis are
				of placement, these	met.
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at
				provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D6241	PONTIC	none	Replacement	Recent, diagnostic full	As initial replacement of:
	PORCELAIN BASE		criteria based	mouth radiographic	single anterior tooth for
	METAL		on N.J.A.C.	images: panoramic	members under the age of
			10:56 -2.13	image with bitewings	21, direct replacement of
			Prosthodontic	(may also require	preexisting failed/defective
			treatment (a)	periapical view of	bridgework; SHCN Members
			and (b).	involved teeth) or full	who cannot function with
				periapical series with	removable appliance.
				bitewings; narrative of	Removable prosthesis will be
				medical necessity if	considered when not a direct
				Member is SHCN. If	replacement and criteria for
				required within a year	removable prosthesis are
				of placement, these	met.
				services will generally

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.
D6242	PONTIC PORCELAIN NOBLE METAL	none	Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b).	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6250	PONTIC RESIN W/HIGH NOBLE	none	Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b).	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				decay can be documented.
D6251	PONTIC RESIN BASE METAL	none	Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b).	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6252	PONTIC RESIN W/NOBLE METAL	none	Replacement criteria based on N.J.A.C. 10:56 -2.13 Prosthodontic treatment (a) and (b).	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6545	RETAINER CAST METAL	none	Service is associated with need to provide/replace	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	(may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6720	RETAINER CROWN RESIN W HI NBLE	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6721	RETAINER CROWN RESIN W/BASE METAL	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	removable prosthesis are met.
D6722	RETAINER CROWN RESIN W/NOBLE METAL	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6750	RETAINER CROWN PORCELAIN HIGH NOBLE METAL	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			material or carious lesion.	provider’s expense unless accidental trauma or recurrent decay can be documented.
D6751	RETAINER CROWN PORCELAIN BASE METAL	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6752	RETAINER CROWN PORCELAIN NOBLE METAL	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D6790	RETAINER CROWN FULL HIGH NOBLE METAL	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6791	RETAINER CROWN FULL BASE METAL CAST	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members who cannot function with removable appliance. Removable prosthesis will be considered when not a direct replacement and criteria for removable prosthesis are met.
D6792	RETAINER CROWN FULLNOBLE METAL CAST	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full	As initial replacement of: single anterior tooth for members under the age of 21, direct replacement of preexisting failed/defective bridgework; SHCN Members

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
			time limits	periapical series with	who cannot function with
			when DMN	bitewings; narrative of	removable appliance.
			shows failure of	medical necessity if	Removable prosthesis will be
			material or	Member is SHCN. If	considered when not a direct
			carious lesion.	required within a year	replacement and criteria for
			There are no	of placement, these	removable prosthesis are
			frequencies or	services will generally	met.
			time limits	not be reimbursed to
			when DMN	the same
			shows failure of	provider/group. They
			material or	are replaced at
			carious lesion.	provider’s expense
				unless accidental
				trauma or recurrent
				decay can be
				documented.
D6920	DENTAL	none	Service is	BR. To include	Device attached to abutment
	CONNECTOR BAR		associated with	diagnostic radiographs.	crown or coping to stabilize
			need to		removable overdenture
			provide/replace		prosthesis.
			fixed prosthetic.
			There are no
			frequencies or
			time limits
			when DMN
			shows failure of
			material or
			carious lesion.
			There are no
			frequencies or
			time limits
			when DMN
			shows failure of
			material or
			carious lesion.
D6930	RECEMENT/BOND	none	No frequency or	Recent, diagnostic full	Recement functional and
	FIXED PARTIAL		time limits.	mouth radiographic	undamaged fixed partial
	DENTURE			images: panoramic	denture; includes all
				image with bitewings	retainers/abutments.
				(may also require
				periapical view of
				involved teeth) or full
				periapical series with
				bitewings; narrative of
				medical necessity if
				Member is SHCN. If
				required within a year
				of placement, these
				services will generally
				not be reimbursed to
				the same
				provider/group. They
				are replaced at

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				provider’s expense unless accidental trauma or recurrent decay can be documented.
D6940	STRESS BREAKER	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion	BR. To include diagnostic radiographs.	Used to decrease occlusal forces on abutment teeth.
D6950	PRECISION ATTACHEMENT	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion.	Recent, diagnostic full mouth radiographic images: panoramic image with bitewings (may also require periapical view of involved teeth) or full periapical series with bitewings; narrative of medical necessity if Member is SHCN. If required within a year of placement, these services will generally not be reimbursed to the same provider/group. They are replaced at provider’s expense unless accidental trauma or recurrent decay can be documented.	Crown to root ratio at least 50%; bone support at least 50%, without mobility or furcation involvement. Documented caries control; RCT (if present) is clinically acceptable. Separate from prosthesis.
D6980	FIXED PARTIAL DENTURE REPAIR	none	Service is associated with need to provide/replace fixed prosthetic. There are no frequencies or time limits when DMN shows failure of material or carious lesion	BR. To include diagnostic radiographs.	Repair of functional fixed partial denture.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D6985	PEDIATRIC PARTIAL DENTURE FIXED	Under age 21	PA required	Diagnostic views of upper anterior region.	Premature loss or extraction of maxillary incisor(s) or when eruption of permanent teeth is not imminent. May be required for proper function and/or enunciation.
D6999	UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE	none		BR. DMN; diagnosis, clinical presentation, description of service to be provided.	Service not described by CDT code.
D7111	EXTRACTION CORONAL REMNANTS	none	Once per tooth	Diagnostic radiographs	Primary tooth remnants
D7140	EXTRACT ERUPTED TOOTH/EXPOSED ROOT	none	Once per tooth	Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records.	Unrestorable tooth with or without pulpal involvement.
D7210	REM OVAL ERUPTED TOOTH W/ MUCOPERIOSTEA L FLAP	none	Once per tooth	Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the	Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				dentist doing the exactions should retain the request for extractions or document this in the dental records.
D7220	IMPACTED TOOTH REMOVALE SOFT TISSUE	none	Once per tooth	Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records.	Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation. Conforms to CDT descriptor.
D7230	IMPACTED TOOTH REMOVAL PARTIAL BONY	none	Once per tooth	Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records.	Part of crown covered by bone; requires mucoperiosteal flap elevation. Conforms to CDT descriptor.
D7240	IMPACTED TOOTH REMOVAL	none	Once per tooth	Diagnostic radiographs Extraction of teeth that are restorable,	Most or all of crown covered by bone; requires

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
	COMPLETELY BONY			asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records.	mucoperiosteal flap elevation and bone removal. Conforms to CDT descriptor.
D7241	IMPACTED TOOTH REMOVAL BONY IMPACTION W/UNUSUAL COMPLICATIONS	none	Once per tooth	BR. Diagnostic radiographs Extraction of teeth that are restorable, asymptomatic, not causing tissue damage or are not being removed to prevent a future condition will not be covered Extraction of restorable teeth at the request of an orthodontist as part of an orthodontic treatment plan or for treatment of crowding are allowed and the dentist doing the exactions should retain the request for extractions or document this in the dental records.	Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position. Conforms to CDT descriptor.
D7250	TOOTH ROOT REMOVAL	none	Once per tooth	Diagnostic radiographs	Includes cutting of soft tissue and bone, removal of tooth structure and closure. Conforms to CDT descriptor.
D7251	CORONECTOMY	none	Once per tooth	Diagnostic radiographs	Intentional partial removal of impacted tooth performed when neurovascular complication likely with complete removal. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7260	ORAL ANTRAL FISTULA CLOSURE	none	AMN	Diagnostic radiographs, dental records.	To provide primary closure between maxillary sinus and oral cavity. Conforms to CDT descriptor.
D7261	PRIMARY CLOSURE SINUS PERFORATION	none	AMN	Diagnostic radiographs, dental records; same DOS as surgery in upper posterior region	To repair sinus perforation. Conforms to CDT descriptor.
D7270	TOOTH REIMPLANTATION AND STABILIZATION	None	Once per tooth	Diagnostic radiographs, dental records; post dental/facial trauma includes splinting and/or stabilization not for periodontal splinting (see D4320, D4321: full mouth x-rays or photos and narrative if SHCN; perio charting to include presence of occlusal trauma and/or mobility, treatment plan (per tooth.).	Restorable tooth which had been in occlusion. Conforms to CDT descriptor.
D7280	EXPOSURE OF UNERUPTED TOOTH	Under age 21	Once per tooth	Diagnostic radiographs, dental records, narrative, treatment plan; approved PA for associated orthodontic service(s).	To aid in eruption of permanent teeth into functional position.
D7282	MOBILIZE ERUPTED/MALPO SITIONED TOOTH	Under age 21	Once per tooth	Diagnostic radiographs, dental records, narrative, treatment plan, approved PA for associated orthodontic services.	To aid in eruption of permanent tooth.
D7283	PLACE DEVICE FOR IMPACTED TOOTH ERRUPTION	Under age 21	Once per tooth	Diagnostic radiographs, dental records, narrative, treatment plan, approved PA for associated orthodontic services.	To aid in eruption of permanent tooth.
D7285	BIOPSY OF ORAL TISSUE HARD	none	No limits	Lab report, progress notes, area of mouth pathology report.	Per site Abnormal radiographic finding. Conforms to CDT descriptor.
D7286	BIOPSY OF ORAL TISSUE SOFT	none	No limits	Lab report, progress notes, area of mouth pathology report.	Abnormal appearance of soft tissue; for diagnosis and treatment. Conforms to CDT descriptor.
D7287	EXFOLIATIVE CYTOLOG COLLECTION	none	No limits	Lab report, progress notes, area of mouth pathology report.	Abnormal appearance of soft tissue; for diagnosis and treatment. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7288	BRUSH BIOPSY	none	No limits	Lab report, progress notes, area of mouth pathology report.	Abnormal appearance of soft tissue; for diagnosis and treatment. Conforms to CDT descriptor.
D7290	REPOSITIONING OF TEETH	Under age 21	Once per tooth	BR; Treatment plan, full mouth radiographs/panoramic image, narrative. Submitted on same PA with any associated grafting procedures.	Malposed tooth that is restorable has adequate bone support and is in occlusion; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor.
D7291	TRANSSEPTAL FIBEROTOMY	Under age 21	Once per area	BR; Treatment plan, recent diagnostic radiographs and photographs.	To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor.
D7292	SCREW RETAINED PLATE	Under age 21	Once per area	BR; Treatment plan, recent diagnostic radiographs and photographs. Includes placement and removal.	To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor
D7293	TEMPORARY ANCHORAGE DEVICE W/ FLAP	Under age 21	Once per area	BR; Treatment plan, recent diagnostic radiographs and photographs. Includes placement and removal.	To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor
D7294	TEMPORARY ANCHORAGE DEVICE W/O FLAP	Under age 21	Once per area	BR; Treatment plan, recent diagnostic radiographs and photographs Includes placement and removal.	To facilitate tooth movement of permanent tooth; with ongoing orthodontic treatment or approved PA for orthodontic services. Conforms to CDT descriptor
D7295	BONE HARVEST, AUTO GRAFT PROCEDURE	none	AMN	BR; Treatment plan, full mouth radiographs/panoramic image, narrative. Include on same PA with other autogenous graft placement procedures which do not include harvesting of bone.	DMN Bone defect.
D7310	ALVEOPLASTY W/EXTRACTION 4 OR MORE TEETH	none	Once per quadrant	Treatment plan, full mouth radiographs/panoramic image, narrative; Four or more teeth per quadrant.	Preprosthetic surgery or before radiation therapy or transplant surgery. Recontouring of bone in area of extractions.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7311	ALVEOLOPLASTY W/EXTRACT 1-3 TEETH	none	Once per quadrant	Treatment plan, full mouth radiographs/panoramic image, narrative; One to three teeth per quadrant.	Preprosthetic surgery or before radiation therapy or transplant surgery. Recontouring of bone in area of extractions.
D7320	ALVEOLOPLASTY W/O EXTRACTION 4 OR MORE TEETH	none	AMN	Treatment plan, full mouth radiographs/panoramic image, narrative; Four or more teeth per quadrant.	Pre prosthetic surgery or before radiation therapy or transplant surgery. Recontouring of bone i
D7321	ALVEOLOPLASTY NOT W/EXTRACTS 1-3 TEETH	none	AMN	Treatment plan, full mouth radiographs/panoramic image, narrative; One to three teeth per quadrant.	Preprosthetic surgery or before radiation therapy or transplant surgery. Recontouring of bone
D7340	VESTIBULOPLASTY RIDGE EXTENSION	none	AMN	Treatment plan, full mouth radiographs/panoramic image, narrative.	Second epithelization; preprosthetic surgery. To increase ridge height.
D7350	VESTIBULOPLASTY EXTENION W/ GRAFTS	none	AMN	Treatment plan, full mouth radiographs/panoramic image, narrative includes soft tissue grafts, muscle reattachments, revision of soft tissue attachment, management/removal of excessive soft tissue.	Preprosthetic surgery To increase ridge height.
D7410	EXCISION BENIGN LESION UP TO 1.25 CM	none	AMN	Pathology report, radiographs, dental records	Removal of abnormal soft tissue lesion or tissue overgrowth.
D7411	EXCISION BENIGN LESION > 1.25 C	none	AMN	Pathology report, radiographs, dental records	Removal of abnormal soft tissue lesion or tissue overgrowth.
D7412	EXCISION BENIGN LESION COMPLICATED	none	AMN	Pathology report, radiographs, dental records	Removal of abnormal soft tissue lesion or tissue overgrowth.
D7413	EXCISION MALIG LESION<= 1.25C	none	AMN	Pathology report, radiographs, dental records	Removal of cancerous soft tissue lesion.
D7414	EXCISION MALIG LESION>1.25 CM	none	AMN	Pathology report, radiographs, dental records	Removal of cancerous soft tissue lesion.
D7415	EXCISION MALIG LESION COMPLICATED	none	AMN	Pathology report, radiographs, dental record	Removal of cancerous soft tissue lesion. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7440	MALIG TUMOR EXCISION TO 1.25CM	none	AMN	Pathology report, radiographs, dental records	Removal of cancerous soft tissue lesion. Conforms to CDT descriptor.
D7441	MALIG TUMOR > 1.25CM	none	AMN	Pathology report, radiographs, dental records	Removal of cancerous soft tissue lesion. Conforms to CDT descriptor.
D7450	REMOVE ODONTOGENIC CYST TO 1.25CM	none	AMN	Pathology report, radiographs, dental records; any extractions on same DOS considered separately.	Removal of cyst Conforms to CDT descriptor.
D7451	REMOVE ODONTOGENIC CYST >1.25CM	none	AMN	Pathology report, radiographs, dental records; any extractions on same DOS considered separately.	Removal of cyst Conforms to CDT descriptor.
D7460	REMOVE NON- ODONTOGENIC CYST TO 1.25 CM	none	AMN	Pathology report, radiographs, dental record; any extractions on same DOS considered separately.	Removal of cyst Conforms to CDT descriptor.
D7461	REMOVE NON- ODONTOGENIC CYST >1.25 CM	none	AMN	Pathology report, radiographs, dental records; any extractions on same DOS considered separately.	Removal of cyst Conforms to CDT descriptor.
D7465	LESION DESTRUCTION	none	AMN	Dental records	Removal of abnormal tissue. Conforms to CDT descriptor.
D7471	REMOVE EXOSTOSIS ANY SITE	none	Once per area	Dental records, full mouth radiographs or intraoral images.	Overgrowth of hard tissue. Conforms to CDT descriptor.
D7472	REMOVAL OF TORUS PALATINUS	none	Once per area	Dental records, full mouth radiographs or intraoral images.	Overgrowth of palatal hard tissue. Conforms to CDT descriptor.
D7473	REMOVE TORUS MANDIBULARIS	none	Once per area	Dental records, full mouth radiographs or intraoral images.	Overgrowth of mandibular hard tissue. Conforms to CDT descriptor.
D7485	SURG REDUCT OSSEOUS TUBEROSITY	none	Once per area	Dental records, full mouth radiographs or intraoral images.	Need to reshape tuberosity for denture construction
D7490	MAXILLA OR MANDIBLR RESECTION	none	Once per area	Lab report, radiographs, dental records.	Removal of lesion in mandible Conforms to CDT descriptor.
D7510	I&D ABSCESS INTRORAL SOFT TISSUE	none	AMN	Dental records	Abscess Conforms to CDT descriptor.
D7511	I&D ABSCESS INTRAORAL SOFT TISSUE, COMPLICATED	none	AMN	BR, dental records.	Abscess Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7520	I&D ABSCESS, EXTRAORAL	none	AMN	Dental records	Abscess Conforms to CDT descriptor.
D7521	I&D ABSCESS, EXTRAORAL, COMPLICATED	none	AMN	BR, dental records.	Abscess
D7530	REMOVAL FOREIGN BODY SKIN/ALVEOLAR TISSUE	None	AMN	Dental records.	Foreign body Conforms to CDT descriptor.
D7540	REMOVAL OF FOREIGN BODY REACTION	none	AMN	Dental records	Foreign body Conforms to CDT descriptor.
D7550	REMOVAL OF NON-VITAL BONE	none	Once per area	Dental records	Sequestrectomy; for removal of necrotic, sloughed-off bone due to infection or reduced blood supply. Conforms to CDT descriptor.
D7560	MAXILLARY SINUSOTOMY	none	AMN	Dental records, diagnostic radiograph of area.	Presence of tooth fragment or foreign body. Conforms to CDT descriptor.
D7610	MAXILLA OPEN REDUCTION SIMPLE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Maxillary fracture requiring surgical reduction Conforms to CDT descriptor.
D7620	CLOSED REDUCTION SIMPLE MAXILLA FRACTURE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Maxillary fracture with non- surgical reduction Conforms to CDT descriptor.
D7630	OPEN REDUCTION SIMPLE MANDIBLE FRACTURE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Mandibular fracture requiring surgical reduction Conforms to CDT descriptor.
D7640	CLOSED REDUCTION SIMPLE MANDIBLE FRACTURE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Mandibular fracture, non- surgical reduction Conforms to CDT descriptor.
D7650	OPEN REDUCTION SIMPLE MALAR/ZYGOMA FRACTURE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Unilateral surgical reduction Conforms to CDT descriptor.
D7660	CLOSED REDUCTION	none	AMN	Dental records, diagnostic radiograph of	Unilateral non-surgical reduction

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
	SIMPLE MALAR/ZYGOMA FRACTURE			area where applicable; includes placement and removal of appliance to same provider.	Conforms to CDT descriptor.
D7670	CLOSED REDUCTION SLPINT ALVEOLUS	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	One site non-surgical reduction Conforms to CDT descriptor.
D7671	ALVEOLUS OPEN REDUCTION	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Surgical reduction Conforms to CDT descriptor.
D7680	REDUCTION COMPLEX FACIAL BONES FRACTURE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Surgical reduction Conforms to CDT descriptor.
D7710	MAXILLA-OPEN REDUCTION	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Maxillary fracture requiring surgical reduction. Conforms to CDT descriptor.
D7720	MAXILLA-CLOSED REDUCTION	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Maxillary fracture requiring non-surgical reduction. Conforms to CDT descriptor.
D7730	MANDIBLE-OPEN REDUCTION	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Mandibular fracture requiring surgical reduction. Conforms to CDT descriptor.
D7740	MANDIBLE- CLOSED REDUCTION	none	AMN	Dental records; diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Mandibular fracture requiring non-surgical reduction. Conforms to CDT descriptor.
D7750	OPEN REDUCTION MALAR/ZYGOMA FRACTURE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Unilateral. Requires surgical reduction. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7760	CLOSED REDUCTION MALAR/ZYGOMA FRACTURE	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Unilateral Non-surgical reduction Conforms to CDT descriptor.
D7770	ALVEOLUS-OPEN REDUCTION STABILIZE TEETH	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Surgical reduction Conforms to CDT descriptor.
D7771	ALVEOLUS - CLOSED REDUCTION STABILIZE TEETH	none	AMN	Dental records, diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Non-surgical reduction Conforms to CDT descriptor.
D7780	REDUCT COMPND FACIAL BONE FRACTURE	none	AMN	Dental records; diagnostic radiograph of area where applicable; includes placement and removal of appliance to same provider.	Surgical reduction Conforms to CDT descriptor.
D7810	TMJ OPEN REDUCTION- DISLOCATION	none	AMN	Dental records, clinical presentation.	Surgical reduction Conforms to CDT descriptor.
D7820	CLOSED REDUCTION OF DISLOCATION	none	AMN	Dental records, clinical presentation; only billed with radiographs and anesthesia codes on same DOS.	Non-surgical reduction Conforms to CDT descriptor.
D7830	TMJ MANUPULATION UNDER ANESTHESIA	none	AMN	Dental records, clinical presentation; only with IV sedation or GA and radiographs on same DOS.	Reduction of dislocation with general or intravenous anesthesia. Conforms to CDT descriptor.
D7840	CONDYLECTOMY REMOVAL OF TMJ CONDYLE	none	Once per side	Dental records, clinical presentation, diagnostic image.	Unilateral Separate procedure. Conforms to CDT descriptor.
D7850	TMJ SURGICAL DISECTOMY	none	Once per side	Dental records, clinical presentation, diagnostic image	Unilateral With or without implant. Conforms to CDT descriptor.
D7852	TMJ REPAIR OF JOINT DISC	none	Once per side	Dental records, clinical presentation, diagnostic image.	Unilateral Reposition and/or sculpting of disc. Conforms to CDT descriptor.
D7854	SYNOVECTOMY	none	Once per side	Dental records, clinical presentation, diagnostic image.	Unilateral Removal of all or part of membrane. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7856	TMJ CUTTING OF A MUSCLE	none	AMN	BR, dental records	For therapeutic purposes; separate procedure. Conforms to CDT descriptor.
D7858	TMJ RECONSTRUCTIO N	none	Once per side	Dental records, clinical presentation, diagnostic image.	Reconstruction of hard and/or soft tissues Conforms to CDT descriptor.
D7860	ARTHROTOMY	none	Once per side	Dental records, clinical presentation, diagnostic image.	Conforms to CDT descriptor.
D7865	ARTHROPLASTY	none	Once per side	Dental records, clinical presentation, diagnostic image.	Separate procedure Conforms to CDT descriptor.
D7870	ARTHROCENTISIS	none	AMN	Dental records, clinical presentation, diagnostic image.	Unilateral Fluid removal from joint space. Conforms to CDT descriptor.
D7871	LYSIS + LAVAGE W/ CATHETERS	none	AMN	Dental records, clinical presentation, diagnostic image.	Non-arthroscopic; treatment of joint space. Conforms to CDT descriptor.
D7872	TMJ DIAGNOSTIC ARTHROSCOPY	none	AMN	Dental records, clinical presentation, diagnostic image.	With or without biopsy Conforms to CDT descriptor.
D7873	TMJ ARTHROSCOPY LYSIS ADHESIONS	none	AMN	Dental records, clinical presentation, diagnostic image.	Arthroscopic treatment of joint space Conforms to CDT descriptor.
D7874	TMJ ARTHROSCOPY DISC REPOSITION	none	AMN	Dental records, clinical presentation, diagnostic image	Disc reposition and stabilization Conforms to CDT descriptor.
D7875	TMJ ARTHROSCOPY SYNOVECTOMY	none	AMN	Dental records, clinical presentation, diagnostic image.	Partial or complete Conforms to CDT descriptor.
D7876	TMJ ARTHROSCOPY DISCECTOMY	none	Once per area	BR, dental records.	For disc removal and to remodel attachment. Conforms to CDT descriptor.
D7877	TMJ ARTHROSCOPY DEBRIDEMENT	none	AMN	Dental records, clinical presentation, diagnostic image.	Remove pathologic tissues Conforms to CDT descriptor.
D7880	OCCLUSAL ORTHOTIC APPLIANCE	none	AMN	BR; includes placement and adjustments to same provider for first 6 months.	May be Included in case rate for TMJ.
D7881	OCCLUSAL ORTHOTIC DEVICE ADJUST	none	AMN	BR, dental records.	Reimbursed to other than original provider or 6 months after placement.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7899	TMJ UNSPECIFIED THERAPY	none	AMN	BR-panoramic image, narrative describing clinical findings (to include measurements), dental records and TMJ images if available; treatment plan which includes expected time of treatment. Not for bruxism; paid as case rate.	Documentation supports presence of TMJ pain and /or decreased function.
D7910	SUTURE RECENT WOUND TO 5 CM	none	AMN	Dental records	Conforms to CDT descriptor.
D7911	SUTURE WOUND TO 5 CM	none	AMN	Dental records	Conforms to CDT descriptor.
D7912	SUTURE COMPLICATED WOUND >5 CM	none	AMN	Dental records, photo of site.	Conforms to CDT descriptor.
D7920	DENTAL SKIN GRAFT	none	AMN	BR; dental records, photo of site.	Conforms to CDT descriptor.
D7940	OSTEOPLASTY FOR ORTHOGNATHIC DEFORMATIES	none	Once per area	BR; diagnostic images, dental records, treatment plan; can be uni-lateral or bi-lateral.	Congenital, developmental, traumatic or surgical deformity. Conforms to CDT descriptor.
D7941	OSTEOTOMY MANDIBULAR RAMI	none	Once per area	BR; diagnostic images, dental records; treatment plan; can be uni-lateral or bi-lateral BR; Diagnostic images, progress notes, treatment plan; can be uni-lateral or bi-lateral.	Conforms to CDT descriptor.
D7943	OSTEOTOMY W/GRAFT	none	Once per area	BR; diagnostic images, dental records; treatment plan; can be uni-lateral or bi-lateral Includes obtaining graft.	Conforms to CDT descriptor.
D7944	OSTEOTOMY SEGMENTED	none	Once per area	Range of tooth numbers within segment; diagnostic images, dental records, treatment plan.	Conforms to CDT descriptor.
D7945	OSTEOTOMY BODY MANDIBLE	none	Once per area	BR; diagnostic images, dental records, treatment plan; can be uni-lateral or bi-lateral.	Sectioning of lower jaw; includes entire procedure and follow-up care. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7946	RECONSTRUCTIO N MAXILLA TOTAL LE FORTE I	none	Once per area	Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes.	Sectioning of upper jaw; includes all procedures and follow-up care. Conforms to CDT descriptor.
D7947	RECONSTRUCT MAXILLA SEGMENT LE FORTE I	none	Once per area	Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes.	BR ; reduced reimbursement when used for surgically assisted palatal expansion Conforms to CDT descriptor.
D7948	LE FORTE II or LE FORTE III NO BONE GRAFT	none	Once per area	Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes.	Sectioning of upper jaw; includes all procedures and follow-up care. Conforms to CDT descriptor.
D7949	LE FORTE II OR LE FORTE III W/BONE GRAFT	none	Once per area	Diagnostic images, approved orthodontic treatment plan if for orthognathic surgery (under age 21), operative notes.	Sectioning of upper jaw; includes all procedures and follow-up care. Conforms to CDT descriptor.
D7950	MAXILLA OR MANDIBLE GRAFT	none	AMN	Full mouth radiographic images, approved restorative/prosthetic treatment plan.	Preprosthetic surgery to increase ridge height of Maxilla or Mandible; repair of trauma or post-cancer surgery. Conforms to CDT descriptor.
D7951	SINUS AUGMENTATION W/ BONE OR BONE SUBSTS. LATERAL APPROACH	none	Once per area; total limit is two procedures	Full mouth radiographic images, approved restorative/prosthetic treatment plan.	Unilateral. Conforms to CDT descriptor.
D7952	SINUS AUGMENTATION VERTICAL APPROACH	none	Once per area	Full mouth radiographic images, approved restorative/prosthetic treatment plan.	Unilateral Conforms to CDT descriptor.
D7955	REPAIR MAXILLOFACIAL SOFT/HARD TISSUE DEFECTS	none	AMN	Diagnostic imaging of area, dental records.	For facial reconstruction, trauma or congenital defects not a preprosthetic procedure. Conforms to CDT descriptor.
D7961	BUCCAL/LABIAL FRENECTOMY (FRENULECTOM Y)	none	AMN	DMN. Narrative describing importance to success of prosthetic or orthodontic	Aberrant muscle attachments which hinder oral function, development or treatment. Separate procedure.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				treatment. Intraoral image when available.	Conforms to CDT descriptor.
D7962	LINGUAL FRENECTOMY (FRENULECTOM Y)	none	AMN	PA required. If referred by PCP, narrative of medical necessity required when requested for purposes of lactation or speech.	Aberrant muscle attachments which hinder oral function, development or treatment. Separate procedure. Conforms to CDT descriptor.
				Narrative describing
				importance to success
				of prosthetic or
				orthodontic treatment.
				Intraoral image when
				available.
D7963	FRENULOPLASTY	none	AMN	Dental records, intraoral image.	Aberrant muscle attachments which hinder oral function, development or treatment. Conforms to CDT descriptor.
D7970	EXCISION HYPERPLASTIC TISSUE	none	AMN; per arch	Dental records, intraoral image.	Pre prosthetic surgery Conforms to CDT descriptor.
D7971	EXCISION PERCORONAL GINGIVA	none	AMN for permanent teeth	Dental records, intraoral image; with other oral surgical procedure.	To remove tissue surrounding partially erupted teeth; not as periodontal therapy. Conforms to CDT descriptor.
D7972	SURGICAL REDUCTION FIBROUS TUBEROSITY	none	Once per area limit two per DOS	Dental records, intraoral image.	Pre prosthetic surgery Conforms to CDT descriptor.
D7979	NON-SURGICAL SIALOLITHOTOMY	none	AMN	BR, dental records.	Medical history, clinical presentation of glandular obstruction. Conforms to CDT descriptor.
D7980	SURGICAL SIALOLITHOTOMY	none	AMN	Dental records.	Salivary gland/duct stone present. Conforms to CDT descriptor.
D7981	EXCISION OF SALIVARY GLAND	none	Once per gland	BR; dental records.	Pathology due to tumor, infection or blockage. Conforms to CDT descriptor.
D7982	SIALODOCHO- PLASTY	none	AMN	Dental records	Salivary gland duct defect. Conforms to CDT descriptor.
D7983	CLOSURE OF SALIVARY FISTULA	none	AMN	Dental records	Repair of pathological opening into oral cavity. Conforms to CDT descriptor.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D7990	EMERGENCY TRACHEOTOMY	none	AMN	Dental records; may be paid under medical benefit.	Blocked airway; respiratory distress Conforms to CDT descriptor.
D7991	CORONOIDEC- TOMY	none	Once per side	Dental records, diagnostic radiograph/image of area.	Pathology resulting in need for removal of coronoid process. Conforms to CDT descriptor.
D7993	SURGICAL	none	AMN	BR; dental records.	To aid in retention of an
	PLACEMENT OF			May be paid under	auricular, nasal or orbital
	CRANIOFACIAL IMPLANT - EXTRAORAL			medical benefit; indicate that these services are provided by physicians or OMFS and	prosthesis. Conforms to CDT descriptor.
				include if provider uses
				CPT or CDT codes.
D7994	SURGICAL	none	AMN	BR; dental records.	To provide support and
	PLACEMENT –			May be paid under	attachment of a maxillary
	ZYGOMATIC IMPLANT			medical benefit; indicate that these services are provided by	dental prosthesis. Conforms to CDT descriptor.
				physicians or OMFS and
				include if provider uses
				CPT or CDT codes.
D7995	SYNTHETIC GRAFT FACIAL BONES	none	AMN	BR; for congenital defects and/or trauma; includes allogenic material.	Loss of bone or bone defect. Conforms to CDT descriptor.
D7996	IMPLANT MANDIBLE AUGMENTATION	none	AMN	BR, dental records.	Loss of mandibular bone width or height, Excludes alveolar ridge Conforms to CDT descriptor.
D7997	APPLIANCE REMOVAL	none	Not to provider originally treating fracture(s)	Panoramic image, narrative, dental records.	Fracture of jaw(s); includes removal of arch bar; appliance non-functional, treatment complete. Conforms to CDT descriptor.
D7999	UNSPECIFIED ORAL SURGERY PROCEDURE	none		BR. DMN; diagnosis, clinical presentation of provided service.	Service not described by CDT code.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D8010	LIMITED ORTHO TX PRIMARY DENTITION	From age 4 up to age 9	Orthodontic treatment (D8010-D8080) Based on DMN.	Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required.	To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate.
D8020	LIMITED ORTHO TX TRANSITIONAL DENTITION	From age 6 up to age 15	Orthodontic treatment (D8010-D8080) Based on DMN.	Narrative of clinical dings; treatment plan; estimated treatment time; diagnostic photos, x-rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required.	To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate.
D8030	LIMITED ORTHO TX ADOLESCENT DENTITION	From age 8 up to age 21	Orthodontic treatment (D8010-D8080) Based on DMN.	Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required.	To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO Provider Manual. Paid as case rate.
D8040	LIMITED ORTHO TX ADULT DENTITION	From age 8 up to age 21	Orthodontic treatment (D8010-D8080) Based on DMN.	Narrative of clinical findings; treatment plan; estimated treatment time; diagnostic photos, x- rays or digital films, study models; PCD attestation of completed dental	To treat any stage of dentition. When part of a comprehensive case, indicate objective and submit complete treatment plan. Reimbursement includes placement and removal of appliance(s) by same provider. Refer to MCO

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				treatment. If re-banding or replacement of appliance is requested supporting explanation and complete treatment plan is required.	Provider Manual. Paid as case rate.
D8050	INTERCEP ORTHO TX PRIMARY DENTITION	From age 4 up to age 9	Orthodontic treatment (D8010-D8080) Based on DMN.	Classification of malocclusion, diagnostic radiographic images and photographs, diagnostic study or digital study models, cephalometric image, attestation from PCD re: preventive and dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis.	May include localized tooth movement to include redirecting tooth eruption, correcting dental cross bite or recovery of space. When part of a comprehensive case, submit complete treatment plan.
D8060	INTERCEP ORTHO TX TRANSITIONAL DENTITION	From age 6 up to age 21	Orthodontic treatment (D8010-D8080) Based on DMN.	Classification of malocclusion, diagnostic radiographic images and photographs, diagnostic study or digital study models, cephalometric image, attestation from PCD re: preventive and dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis.	May include localized tooth movement to include redirecting tooth eruption, correcting dental cross bite or recovery of space. When part of a comprehensive case, submit complete treatment plan. Localized tooth movement to redirect tooth movement, redirect tooth eruption regain space or correct cross bite. For treatment of anterior ectopic eruption when it does not meet criteria for anterior cross bite.
D8080	COMPREHENSIVE ORTHO TX ADOLESCENT DENTITION	From age 8 up to age 21	Orthodontic treatment (D8010-D8080) Based on DMN.	Classification of malocclusion, diagnostic radiographic images and photograph to show full view of millimeter ruler in position to show measurement, diagnostic study or digital study models, cephalometric image, completed current NJ HLD, attestation from PCD re: preventive and	Handicapping malocclusion to treat late mixed and permanent dentition. Scoring based on HLD or extenuating circumstance which meets medical necessity requirement.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
				dental treatment services provided; treatment planned extraction(s) and/or surgical interventions and medical diagnosis. Include documentation of extenuating conditions.
D8210	ORTHODONTIC REMOVEABLE APPLIANCE TX	Up to age 21	Maximum 2 per date of service	Clinical findings; treatment plan; estimated treatment time with prognosis; diagnostic photos and/or models; adjustments included to provider of placement.	Documentation of harmful habit including but not limited to thumb sucking and tongue thrust.
D8220	FIXED APPLIANCE THERAPY HABIT	Up to age 21	Once without PA	Clinical findings; treatment plan; estimated treatment time with prognosis; diagnostic photos and/or models; adjustments included to provider of placement.	Documentation of harmful habit including but not limited to thumb sucking and tongue thrust.
D8660	PREORTHODONTI C TX VISIT	Up to age 21	Once per year; service linked to provider	Clinical findings, diagnostic materials (current NJ HLD) required for interceptive and comprehensive treatment.	Evaluate with documentation of findings associated with orthodontic conditions.
D8670	PERIODIC ORTHODONTIC TX VISIT	Up to age 21	24 months of active treatment are expected to be adequate to complete most cases (up to 36 months).	12 visits included on PA for D8080; PA for additional 12 visits to include treatment notes; PCD attestation; pre-and current panoramic image and/or photos; documentation of any compliance problems; initial approval if started in different NJFC program.	Case in comprehensive treatment.
D8680	ORTHODONTIC RETENTION	Up to age 21	AMN	Documents completion of D8080 by provider initiating or treating case.	Treatment outcomes demonstrate completion or termination of orthodontic treatment.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D8681	REMOVABLE RETAINER ADJUSTMENT	Up to age 21	Once per day of service	Narrative including Member compliance; dental records. Not to provider of original placement.	Patient in retention.
D8695	REMOVE FIXED ORTHO APPLIANCE (FOR REASONS OTHER THAN CASE COMPLETION)	none	DMN, AMN	BR; Non-compliance with ortho treatment, dental records, provider attestation for request; release from treatment form from parent/member to agree to removal of appliances. Includes fee for removal and retainer(s) if provided by provider of placement.	DMN; treatment is not progressing.
D8696	REPAIR OF ORTHODONTIC APPLIANCE- MAXILLARY	Up to age 21	AMN	Clinical findings	For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance).
D8697	REPAIR OF ORTHODONTIC APPLIANCE- MANDIBULAR	Up to age 21	AMN	Clinical findings	For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance).
D8698	RE-CEMENT OR RE-BOND FIXED RETAINER- MAXILLARY	Up to age 21	AMN	Clinical findings	Patient in retention; may be included in case rate. Dislodged retainer that is undamaged.
D8699	RE-CEMENT OR RE-BOND FIXED RETAINER- MANDIBULAR	Up to age 21	AMN	Clinical findings	Patient in retention; may be included in case rate. Dislodged retainer that is undamaged.
D8701	REPAIR OF FIXED RETAINER, INCLUDES REATTACHMENT- MAXILLARY	Up to age 21	AMN	Narrative including Member compliance; dental records.	For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance).
D8702	REPAIR OF FIXED RETAINER, INCLUDES REATTACHMENT- MANDIBULAR	Up to age 21	AMN	Narrative including Member compliance; dental records.	For functional appliance and palatal expanders, not brackets (standard fixed ortho appliance).
D8703	REPLACEMENT OF LOST OR BROKEN RETAINER- MAXILLARY	Up to age 21	AMN	Narrative including Member compliance; dental records.	Replacement of lost or broken retainer based on medical necessity.
D8704	REPLACEMENT OF LOST OR BROKEN RETAINER- MANDIBULAR	Up to age 21	AMN	Narrative including Member compliance; dental records	Replacement of lost or broken retainer based on medical necessity.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D8999	UNSPECIFIED ORTHODONTIC PROCEDURE	Up to age 21		BR. DMN; diagnosis, clinical presentation of provided service.	Service not described by CDT code.
D9110	TREATMENT DENTAL PAIN MINOR PROCEDURE	none	Once per date of service; per tooth or per site	DMN	Emergency, limited treatment for pain.
D9210	DENTAL ANESTHESIA W/O SURGERY	none	Twice per year per provider with PA; not with dental procedure	Narrative, radiographs and/or photos not with D9211, D9212.	For diagnostic purposes only
D9211	REGIONAL BLOCK ANESTHESIA	none	Twice per year per provider with PA; not with dental procedure	Narrative, radiographs and/or photos not with D9210, D9212.	For diagnostic purposes only
D9212	TRIGEMINAL BLOCK ANESTHESIA	none	Twice per year per provider with PA; not with dental procedure	Narrative, radiographs and/or photos not with D9210, D9211.	For diagnostic purposes only
D9222	DEEP SEDATION GENERAL ANESTHESIA 1st 15 MINUTES	none	AMN	Dental records, radiographs, anesthesia record; Not with D9230	In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety.
D9223	DEEP SEDATION GENERAL ANESTHESIA EACH SUBSEQUENT 15 MINUTES	none	AMN	Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239, D9248.	In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety.
D9230	ANALGESIA (NITROUS OXIDE)	none	AMN	Dental records, clinical presentation; One unit per DOS; not with D9222, D9223, D9239, D9243.	Situational anxiety during dental treatment.
D9239	IV MODERATE SEDATION, 1st 15 MINUTES	none	AMN	Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239, D9248.	In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety.
D9243	IV MODERATE SEDATION EACH SUBSEQUENT 15 MINUTES	none	AMN	Dental records, radiographs, anesthesia record; Maximum 7 units per DOS. Not with D9230, D9243, D9239, D9248.	In conjunction with removal of impacted teeth; multiple extractions, complex OMFS procedure; SHCN for dental services; situational anxiety.

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D9248	NON-IV CONSCIOUS SEDATION	none	Four times per RY	Dental records, clinical presentation; not with D9222, D9223, D9239, D9243; may be billed with D9230.	Situational anxiety during dental treatment.
D9310	CONSULTATION	none	AMN	Dental records, clinical presentation; not with D9420. Only to be billed with diagnostic services on same DOS.	DMN; Used for: consultation by specialist with referral from general dentist or physician; or, general dentist consultation with referral from physician; or orthodontic evaluation when treatment is not imminent Cannot be used for 2nd opinion between general dentists. (For non-specialty dental second opinions D0140, D0160 may be used as appropriate).
D9311	CONSULT W/MEDICAL HEALTH CARE PROFFESSIONAL	none	Two per RY	Medical history, clinical presentation; to licensed clinicians only.	Presence of appropriate medical diagnosis Conforms to CDT descriptor
D9410	DENTAL HOUSE CALL	none	Once per LTC facility per DOS; billed on one claim	Limited to visits at a LTC facility, institution, or homebound; in addition to services rendered	Patient in LTC facility, institution or home bound.
D9420	HOSPITAL/ASC CALL	none	AMN	Hospital call requiring dental evaluation Once per date of service; only when services rendered outside of office/clinic; not with D9310. Scheduled visit in the OR of a hospital or ASC when medical necessity or age of patient requires this place of service	Patient meets criteria for receiving dental services in a hospital OR or ASC; patient confined to hospital. (Refer to DMAHS Newsletter Vol. 22, No. 18).
D9430	OFFICE VISIT DURING HOURS OBSERVATION	none	No other services on same DOS; not for suture removal	Post OMFS surgical case evaluation; no other services performed.	Recently received OMFS procedure from same provider/group.
D9610	THERAPEUTIC PARENTERAL DRUG SINGLE ADMIN	none	AMN	Narrative, dental records; not with D9222, D9223, D9239, D9243.	Not for sedatives, anesthetic or reversal agents. Appropriate diagnosis; Conforms to CDT descriptor
D9612	THERAPUTIC PARENTERAL DRUGS 2 OR > ADMIN	none	AMN	Narrative, dental records; not with D9222, D9223, D9239, D9243.	Not for sedatives, anesthetic or reversal agents. Appropriate diagnosis; Conforms to CDT descriptor

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D9630	DRUGS/MEDS DISPENSED FOR HOME USE	none	AMN	BR. To include name of product, strength and dosage administered.	Oral antibiotics, analgesics, topical fluoride; not for written prescriptions.
D9910	APPLICATION DESENSITIZING MEDICAMENT	Age 16 and older	Once per 12 months	Per visit; narrative, dental records.	For root/tooth sensitivity, sensitive dentin.
D9911	APPLICATION DESENSITIZING RESIN	Age 16 and older	Once per 12 months	Per tooth; narrative, dental records; not with D9910.	Application of adhesive resin to sensitive dentin for root/tooth sensitivity.
D9920	BEHAVIOR MANAGEMENT	none	AMN	Clinical presentation and documentation of medical necessity; One unit = 15 minutes; 2 units per DOS allowed. Not on same DOS as: D9222, D9223, D9239, D9243, D9248 or D9420.	DMN to include inability to cooperate with dental treatment due to behavioral health condition, intellectual, developmental or other disability, members with SHCN, children and individuals with situational anxiety.
D9930	TREATMENT OF COMPLICATIONS POST SURGICAL	none	AMN	Narrative, dental records.	Recent complex surgical procedure by same provider or group.
D9943	OCCLUSAL GUARD ADJUSTMENT	none	AMN	Narrative, dental records. Paid to provider who did not place occlusal guard.	DMN Sore/high spots, areas of roughness.
D9944	OCCLUSAL GUARD-HARD APPLIANCE, FULL ARCH	Age 18 and older	Once per 24 months	Narrative, dental records.	For bruxism or other occlusal factors; not for TMJ; includes all adjustments; paid as case rate. Does not include athletic mouth guards (D9941) which are presently not covered services.
D9945	OCCLUSAL GUARD-SOFT APPLIANCE, FULL ARCH	Age 18 and older	Once per 24 months	Narrative, dental records; FMX demonstrate occlusal wear.	For bruxism or other occlusal factors; not for TMJ; includes all adjustments; paid as case rate. Does not include athletic mouth guards (D9941) which are presently not covered services.
D9951	LIMITED OCCLUSAL ADJUSTMENT	none	AMN	Per visit; narrative, dental records. For permanent teeth; not same DOS with a restorative, endodontic or prosthetic service	Occlusal equilibration to create more harmonious tooth contact. Conforms to CDT descriptor

CDT	SHORT - DESCRIPTION	AGE LIMITS	FREQUENCY LIMITS	DOCUMENTATION/ REQUIREMENTS	CLINICAL CRITERIA
D9952	COMPLETE OCCLUSAL ADJUSTMENT	none	Once	Narrative, dental records. Diagnostic casts should be	In conjunction with extensive restorative treatment, periodontics, orthognathic surgery dysfunctional occlusion or past jaw trauma. Not in conjunction with orthodontics. Conforms to CDT descriptor
				available upon request.
				For permanent teeth;
				not same DOS with a
				restorative, endodontic
				or prosthetic service;
				may require several
				appointments; includes
				all visits.
D9971	ODONTOPLASTY	none	Once per	Narrative, dental	Enamel projections irregular
	1-2 TEETH		location	records. For permanent	tooth morphology.
				teeth; completed in one
				visit; not same DOS with
				a restorative,
				endodontic or
				prosthetic procedure.
D9974	INTERNAL BLEACHING PER TOOTH	none	Once per permanent tooth	Narrative, radiographs and/or photos.	Discolored anterior tooth, previous endodontics
D9999	UNSPECIFIED ADJUNCTIVE PROCEDURE	none		BR. DMN; diagnosis, clinical presentation of provided service.	For service not described by CDT code. Code may be used by MCO (in addition to dental services) when dental services are provided in the OR of a hospital or in an ASC. When the code is used for this service, the clinical criteria for D9420 must be met. Medical necessity or age of patient requires in-patient or out-patient dental services be rendered at a hospital or ASC (Refer to DMAHS Newsletter Vol. 22, No. 18).
END GRID

Clinical Criteria Grid - Horizon NJ Health

Clinical Criteria Grid