National Standardized Dental Claim Utilization Review Criteria

NATIONAL STANDARDIZED DENTAL CLAIM UTILIZATION REVIEW CRITERIA

Revised: 4/1/2016

The following Dental Clinical Policies, Dental Coverage Guidelines, and dental criteria are designed to provide guidance for the adjudication of claims or prior authorization requests by the clinical dental consultant. The consultant should use these guidelines in conjunction with clinical judgment and any unique circumstances that accompany a request for coverage. Specific plan coverage, exclusions or limitations may supersede these criteria. For reference, criteria approved by the Clinical Policy and Technology Committee are provided. These represent clinical guidelines that are evidence-based. Please Note: Links to the specific Dental Clinical Policies and Dental Coverage Guidelines are embedded in this document. Additionally, for notices of new and updated Dental Clinical Policies and Coverage Guidelines or for a full listing of Dental Clinical Policies and Coverage Guidelines, refer to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines.

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE DIAGNOSTIC Clinical Oral Evaluations Documentation in member record that includes all services performed for the code submitted D0120-D0191 Pre-Diagnostic Services Documentation in member record that includes all services performed for the code submitted. D0190-screening of a patient D0191-assessment of a patient Diagnostic Imaging Documentation in the member record. Diagnostic, clear, readable Criteria for codes D0364-D0368, D0380-D0386, D0391-D0395: images, dated with member name. Image capture with interpretation- Cone beam computed tomography (CBCT) is unproven and not medically D0210-D0371 necessary for routine dental applications. There is insufficient evidence that CBCT is beneficial for use in routine dental Image Capture only- applications. CBCT should not replace traditional dental x-rays as a preliminary D0380-D0386 diagnostic tool, or for routine dental procedures such as restorations, but be used as an adjunct when the level of detail CBCT is needed to safely render Interpretation and Report only- treatment for complex clinical conditions (e.g. oral surgery, implant placement D0391-D0395 and endodontics). These procedures may have a higher risk of complications without the level of detail CBCT imaging provides. CBCT imaging used for these reasons should be read and interpreted by an appropriately trained professional.

In addition, radiation exposure associated with CBCT needs to be weighed against possible benefits, which have not been supported in the published literature. Limited definitive conclusions regarding the clinical role of CBCT can be reached due to the lack of well-designed studies that systematically evaluate diagnostic accuracy and the impact of CBCT on clinical decision making and 1

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE patient health outcomes. Additional studies are needed to verify that CBCT provides added diagnostic value beyond two-dimensional imaging such as panoramic radiography and conventional computed tomography and to determine whether CBCT improves treatment decision making and health outcomes.

Refer to clinical policy: Imaging Services: Cone Beam Computed Tomography (DCP.002.01)

Tests and Examinations Provider narrative including clinical reason/diagnosis for test and type of D0415-D0470 test performed.

D0601-D0603-caries risk assessment

Oral Pathology Laboratory D0472-D0502

D0999-Unspecified diagnostic procedure by report PREVENTIVE Dental Prophylaxis Services performed must be documented in the member record. D1110-D1120 Topical Fluoride Treatment Age and medical necessity. An adult is generally defined as twelve years For hypersensitivity and to prevent root caries and recurrent decay around D1206-D1208 or older. existing restorations.

Often for patients who have undergone head/neck radiation therapy.

Other Preventive Services Documentation/narrative in member record that service was performed D1310-D1330 and materials supplied to member. Sealants Sealant: Tooth numbers. Provider responsible for three years for repair or Preventive Resin Restoration: D1351-D1352 replacement. No decay or restorations- the occlusal surface must be intact.

Sealant cannot be done on the same tooth as a preventive resin.

Space Maintenance Radiographs of the involved arch.

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE D1510-D1555 For primary dentition only. Should be submitted for primary tooth that has been extracted.

All adjustments for 6 months are included.

No benefit if permanent tooth is ready to erupt.

If bilateral teeth are missing, benefit given for bilateral space maintainer, even if two unilateral space maintainers are requested.

RESTORATIVE Direct Restorations: Documentation Inclusive components: Tooth number and surface. Local anesthesia; tooth prep; liners/bases; restorative material; Amalgam Restorations Caries removal documented in member record. polishing/sealing; adjustments; tooth etching. D2140-D2161 Criteria: Resin-Based Composite Primary teeth should not be ready to exfoliate and requests are subject to Restorations-Direct review based on the age of the patient and the tooth number. D2330-D2394

Gold Foil Restorations D2410-D2340

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Indirect Restorations: Documentation Criteria for codes D2510-D2664, D2710-D2799 Pre-operative x-rays. If endodontic therapy has been performed, a Inlay/Onlay Restorations periapical radiographic image clearly showing the apex of the completed Indications for Coverage D2510-D2664 (Inlay/onlays) treatment is required; otherwise, bitewing x-rays may be sufficient at Five-year longevity should be evident, periodontium must be healthy or have the discretion of the reviewer. documentation the member has periodontal disease under control for a period Crowns-Single Restorations Only of at least 6 months, and no evidence of endodontic pathology or potential D2710-D2799 A narrative or photograph may provide additional information, endodontic issues on the radiographic image. Coverage includes local especially for replacement of existing crowns. anesthetic, impressions, tooth preparation, temporary restoration, fitting, cementation, adjustment and any liners or bases. “Cracked tooth syndrome” requires adequate documentation of extent of fracture, location and how it was diagnosed. Tooth must be Crowns symptomatic. Crowns are indicated for the following:  Extensive caries on three or more surfaces or 50% loss of clinical crown Restorations for members under age 15 require statement of medical  Large, >50% of the tooth, defective restoration that can be seen on the necessity. radiographic image  Fracture of cusps Inclusive  Endodontically treated teeth, unless minimal access opening on anterior Local anesthesia; tooth preparation; temporary crown; fitting; tooth cementation; post-op adjustments, impressions; bases.  Documentation that a direct restoration is not possible  Crown/root ratio must be favorable  Documentation/narrative that the failing existing crown can only be resolved with a new crown if not visible on radiographic image  50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery  Anterior teeth: at least 50% involvement of incisal portion  Bicuspids and molars: 3 or more surfaces and one or more cusps involved  Anterior teeth: at least 50% involvement of incisal portion  Bicuspids and molars: 3 or more surfaces and one or more cusps involved  Symptomatic “cracked tooth syndrome” (not enamel “craze lines”)  Full coverage restoration of a primary tooth without a permanent successor

Crowns are not indicated for the following:  If a lesser means of restoration is acceptable  If root resorption is present  Solely for cosmetic/aesthetic reasons (peg teeth, diastema closure, discoloration)  For alteration of vertical dimension  For purposes of preventing future fracture, or to eliminate enamel craze lines (Cracked tooth syndrome must be diagnosed with documented diagnostic tests and supported by a narrative. Tooth must be symptomatic).  To treat non-pathologic wear/abrasion, or abfraction lesions in the absence 4 of decay  For molars exhibiting bone loss with a class III furcation involvement

 Periodontally compromised teeth, even with successful endodontics, unless the patient has undergone previous periodontal therapy/surgery and progress notes/periodontal notes indicate the tooth is stable  Fracture of porcelain not involving the margin or a functional ridge is not PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Other Restorative Services Documentation Criteria for codes: D2929, D2930, D2931, D2932, D2933, D2934 (D2910-D2999) Tooth number Prefabricated Crowns are indicated for the following:  For the restoration of teeth with more than two surfaces affected with Porcelain/Ceramic Crown carious lesions, or where extensive one or two surface lesions are present. D2929  For one and two surface carious lesions in documented high caries risk children. Risk factors must be thoroughly documented by the provider in Stainless Steel Crown the dental record, and include: D2930, D2931, D2932, D2933, o Mother or primary caregiver has active caries; D2934 o White spot lesions or enamel defects; o Visible caries or previous restorations; o Poor oral hygiene; o Sub-optimal systemic fluoride intake; o Frequent exposure to cavity-producing foods and drinks; o Patients with special health care needs; o Low socioeconomic status; o Xerostomia; o More than one interproximal lesion; o Other factors identified by professional literature;  Cervical decalcification, and/or developmental defects (hypoplasia, hypocalcification, enamel hypoplasia, Amelogenesis imperfecta, Dentinogenesis imperfecta etc.).  Interproximal caries extending beyond line angles.  Following pulpotomy or pulpectomy.  For restoring a primary tooth that is to be used as an abutment for a space maintainer.  For the intermediate restoration of fractured teeth.  Restoration and protection of teeth exhibiting extensive tooth surface loss due to attrition, abrasion or erosion.  In patients with impaired oral hygiene in which the breakdown of intra- coronal restorations is likely.  When the tooth cannot be effectively isolated for amalgam or composite restorations.

Prefabricated Crowns are not indicated for the following:  A primary molar that is close to exfoliation, with more than half the roots resorbed.  Excessive tooth crown loss resulting in the inability for mechanical retention.  Loss of space due to tipping of neighboring teeth into carious defect interfering with the ability to attain proper fit.  As a definitive restoration on a permanent tooth.  For low and moderate caries risk patients, when a more conservative restoration is indicated. 5  Solely for cosmetic purposes.  As a prophylactic measure for teeth with no evidence of pathology.

Refer to clinical policy: Prefabricated Crowns (DCP012.01)

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Protective restoration Documentation Criteria D2940 Recorded in member chart. Direct placement of a restorative material to protect tooth and/or tissue form. Used to relieve pain, promote healing, or prevent further deterioration.

Covered as a separate procedure only if no other service other than radiographic images and exam were performed on the same tooth on the same day.

Not to be used for endodontic access closure, or as a base or liner under a restoration

Core buildup Documentation Criteria D2950 Bitewing unless tooth has had root canal therapy, then a periapical Evidence of extensive caries or at least three surfaces of the tooth have severe should be submitted. breakdown. NOTE: (out of numerical order to keep code by crown procedures) Must be necessary for retention of the crown.

Not covered when procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation.

Vertical height of clinical crown must be adequate to support a prosthetic crown.

Evidence of radiographic decay around an existing restoration and removal of the filling is clinically indicated.

Not benefited with post/core. Pin retention per tooth Documentation in member record One per lifetime per tooth D2951 Post and Core Post-op endodontic radiographic image required showing adequate root Criteria D2952, D2953, D2954, D2957 canal treatment. Only for retention or reinforcement when inadequate tooth structure remains for retention or to resist masticatory forces.

An anterior tooth with minimal access opening may not require a post/core.

There must be sufficient tooth structure to support a crown.

No periodontal disease and at least 50% bony support. No benefit for post preparation.

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Labial Veneer Documentation Criteria D2960-2962 Radiographic image and narrative of medical necessity. May be benefited if the destruction is such that a crown is not recommended Intraoral photo helpful. but a direct restoration will not suffice.

Not covered when strictly cosmetic.

Coping Documentation Criteria D2975 Bitewing or periapical if tooth has had root canal therapy Only if insufficient natural tooth structure remains to retain the crown or alignment is a problem.

Repairs necessitated by Documentation restorative material failure Narrative required, radiographic images if indicated D2980-D2999

ENDODONTICS Endodontic therapy Documentation Criteria for codes D3110-D3240, D3310-D3333, D3346-D3348, D3351-D3357 D3230, D3240, D3310, D3320, Pre and post-operative radiographic image and provider narrative if D3330, D3331, D3332, D3333, pathology is not evident on the film. Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01) D3346, D3347, D3348

Endodontic codes: General documentation requirements Criteria for codes D3110-D3240, D3310-D3333, D3346-D3348, D3351-D3357 D3110-D3240 Pre and post endodontic periapical radiographic images showing apex of D3310-D3333 tooth. Indications for Coverage – Vital Pulp Therapy D3346-D3348 For retreatment, surgical endodontics, cracked tooth syndrome and Direct Pulp Cap D3351-D3357 other procedures: pre- and post-op images, taken within one year and Direct pulp capping is indicated for the following: narrative if the reason for treatment is not evident on films.  Tooth has a vital pulp or been diagnosed with reversible pulpitis  All caries has been removed  Mechanical exposure of a clinically vital and asymptomatic pulp occurs Diagnosis  Bleeding is controlled at the exposure site Diagnostic tests used to determine a diagnosis of irreversible pulpitis or  Exposure permits the capping material to make direct contact with the vital periapical pathology must be documented in the record. pulp tissue  Exposure occurs when the tooth is under dental dam isolation  Adequate seal of the coronal restoration can be maintained  Patient has been fully informed that endodontic treatment may be indicated in the future

Direct Pulp capping is not indicated for the following:  A carious exposure in primary teeth

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Indirect Pulp Cap Indirect pulp capping is indicated for the following:  Tooth has a vital pulp or been diagnosed with reversible pulpitis  Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation  No history of subjective pretreatment symptoms  Pretreatment radiographs should not show periradicular pathosis

Coverage Limitations and Exclusions for Direct and Indirect Pulp Cap  Limited to once every 36 months  Not to be billed on same day as any definitive restoration  Not to be billed when a liner or a base is placed  Not to be billed as a liner or base when the likelihood of pulpal exposure is absent

Therapeutic Pulpotomy Therapeutic pulpotomy is indicated for the following:  Exposed vital pulps or irreversible pulpitis of primary teeth  Any bleeding was controlled within several minutes  As an emergency procedure in permanent teeth until root canal treatment can be accomplished  As an interim procedure for permanent teeth with immature root formation to allow continued root development  In primary teeth, where there is a reasonable period of retention expected (approximately one year)

Therapeutic pulpotomy is not indicated for the following:  Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor  As the first stage of complete root canal therapy  Removal of pulp apical to the dentinocemental junction  For primary teeth that are near exfoliation or less than 50% of the tooth root remains

Coverage Limitations and Exclusions for Therapeutic Pulpotomy  Not to be billed on same day as root canal therapy

Partial Pulpectomy for Apexogenesis A partial pulpotomy for Apexogenesis is indicated for the following:  In a young permanent tooth for a carious pulp exposure  When the pulpal bleeding is controlled within several minutes  A vital tooth, with a diagnosis of normal pulp or reversible pulpitis 8

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE

Coverage Limitations and Exclusions for Partial Pulpectomy for Apexogenesis  Not to be billed on same day as any definitive restoration  Not to be billed on same day as a surgical endodontic procedure

Apexification/Recalcification Apexification/recalcification is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs. When closure or repair is complete, nonsurgical root canal treatment should be completed:  Incomplete apical closure in a permanent tooth root  External root resorption or when the possibility of external root resorption exists.  Necrotic pulp, irreversible pulpitis or periapical lesion  For prevention or arrest of resorption  Perforations or root fractures that do not communicate with oral cavity

Apexification/recalcification is not indicated for the following:  Tooth with a completely closed apex  If patient compliance or long term follow up may be questionable

Pulpal Regeneration Pulpal regeneration is indicated for the following and involves two or more separate appointments:  Permanent tooth with immature apex  Necrotic pulp  Pulp space not needed for post/core or final restoration  When tooth is not restorable

Pulpal regeneration is not indicated for the following:  Primary teeth  The pulp space would be needed for final restoration

Indications for Coverage – Non Vital Pulp Therapy Pulpal Debridement (Pulpectomy) Pulpal Debridement (Pulpectomy) is indicated for the following:  For a restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified  For the relief of acute pain prior to complete root canal therapy  For a primary tooth, where there is a reasonable period of retention expected (approximately one year)

Pulpal Debridement (Pulpectomy) is not indicated for the following: 9

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE  Complete root canal therapy of an infected or necrotic tooth  For primary teeth that are near exfoliation or less than 50% of the tooth root remains

Coverage Limitations and Exclusions for Pulpal Debridement (Pulpectomy)  Not to be billed on same day as any definitive restoration  Not to be billed on same day as a surgical or non- surgical endodontic procedure

Pulpal Therapy (resorbable filling) – Primary Teeth Pulpal Therapy for primary teeth is indicated for the following and includes all appointments need to complete treatment, as well as intra-operative radiographs:  For a restorable primary tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified  The prognosis for keeping the tooth is up to one year and the tooth root lies in at least 25% bone

Pulpal Therapy is not indicated for the following:  For primary teeth that are near exfoliation or less than 50% of the tooth root remains  For permanent teeth

Coverage Limitations and Exclusions for Pulpal Therapy – Primary Teeth  Indicated to age 15

Endodontic Therapy Endodontic Therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs:  For a restorable mature, completely developed permanent or primary tooth with irreversible pulpitis, necrotic pulp or frank vital pulpal exposure  For teeth with radiographic periapical pathology  For primary teeth without a permanent successor  Trauma  When needed for prosthetic rehabilitation

Endodontic Therapy is not indicated for the following:  Teeth with a poor long term prognosis  Teeth that are considered non-restorable  Teeth with inadequate bone support or advanced or untreated periodontal disease  Teeth with incompletely formed root apices

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Coverage Limitations and Exclusions for Endodontic Therapy  Not for third molars, unless necessary as bridge abutment with a good prognosis, or if tooth will be in functional occlusion  Not covered solely for cosmetic/aesthetic reasons

Treatment of root canal obstruction; non-surgical access Treatment of a root canal obstruction is indicated for the following and includes all appointments needed to complete treatment, including intra-operative radiographs:  When there is an obstruction of the root canal system, (biological, iatrogenic ledges or post removal) and endodontic retreatment is needed  Removal of obstruction is complex and/or requires significant time

Treatment of a root canal obstruction is not indicated for the following:  When there is no obstruction evident

Coverage Limitations and Exclusions for Treatment of root canal obstruction  Limited to once per tooth per lifetime  Not billable if tooth has a history of incomplete endodontic therapy or internal root repair of perforation defects

Incomplete endodontic therapy: inoperable, unrestorable or fractured tooth Incomplete endodontic therapy is indicated for the following and includes all appointments needed to complete treatment including intra-operative radiographs:  During endodontic treatment of a tooth, it becomes apparent that the procedure cannot be successfully completed  The tooth will not be able to be restored, or the tooth fractures, necessitating discontinuation of treatment

Coverage Limitations and Exclusions for Incomplete endodontic therapy  Limited to once per tooth per lifetime

Internal root repair of perforation defects Internal root repair of perforation defects is indicated for the following and includes all appointments needed to complete treatment including intra- operative radiographs:  There is a root perforation caused by pathology such as resorption or decay  A communication between the pulp space and external root surface as a result of internal root resorption.

Internal root repair of perforation defects is not indicated for the following: Teeth that are considered non-restorable 11

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Teeth with inadequate bone support or advanced untreated periodontal disease

Coverage Limitations and Exclusions for Internal root repair of perforation defects  Limited to once per tooth per lifetime  Not billable for iatrogenic root perforation

Retreatment of previous root canal therapy Retreatment of previous root canal therapy is indicated for the following and includes all appointments needed to complete treatment, including intra- operative radiographs:  Canal fill appears to extend to a point shorter than 2millimeters from the apex, or extends significantly beyond the apex  Fill appears to be incomplete  Tooth is sensitive to pressure and percussion or other subjective symptoms  The existing endodontics is poor  Placement of a post has the potential to compromise the existing obturation or apical seal of the canal system  The canal is accessible and allows for retreatment with a non-surgical procedure

Coverage Limitations and Exclusions for Retreatment of previous root canal therapy  Original treatment must be at least 8 weeks prior to the retreatment date  Not benefited within 12 months of original treatment if by same dentist

Refer to coverage guideline: Non-Surgical Endodontics (DCG009.01)

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Surgical Endodontics Documentation Pre and postoperative radiograph image. Provider narrative may be Criteria for codes D3410-D3950, D3999 D3410-D3950, D3999 requested if pathology is not visible. Apicoectomy Date of last root canal treatment if needed. Apicoectomy is indicated for the following:  Failed retreatment of endodontic therapy  When the apex of tooth cannot be accessed due to calcification or other anomaly  Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected  Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist  When individual patient considerations make prolonged non-surgical treatment not practical  A marked over extension of obturating materials interfering with healing

Apicoectomy is not indicated for the following:  Unusual bony or root configurations resulting in lack of surgical access  The possible involvement of neurovascular structures  Teeth that are considered non-restorable  Teeth with inadequate bone support or advanced or untreated periodontal disease  When non-surgical endodontic treatment has not been attempted or was not indicated

Periradicular Surgery without Apicoectomy (includes surgery and periradicular curettage) Periradicular surgery without apicoectomy is indicated for the following:  Failed retreatment of endodontic therapy  When the apex of tooth cannot be accessed due to calcification or other anomaly  When a biopsy of periradicular tissue is necessary  Where visualization of the periradicular tissues and tooth root is required when perforation or root fracture is suspected  Diagnosis of accessory canals or small fractures when post endodontic therapy symptoms persist  When individual patient considerations make prolonged non-surgical treatment not practical  A marked overextension of obturating materials interfering with healing

Periradicular surgery without apicoectomy is not indicated for the following:  Unusual bony or root configurations resulting in lack of surgical access  The possible involvement of neurovascular structures 13  Teeth that are considered non-restorable  Teeth with inadequate bone support or advanced or untreated periodontal

disease  When non-surgical endodontic treatment has not been attempted or was not indicated

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE PERIODONTICS

Surgical Periodontics – Resective Documentation/Other for codes D4210, D4211, D4212, D4230, D4231, Criteria for codes D4210-D4261, D4274 Procedures D4240, D4241, D4245, D4249, D4261 D4210 Gingivectomy/Gingivoplasty D4211 Full radiographic images (panoramic with bitewings or full periapical Gingivectomy/Gingivoplasty is indicated for the following: D4212 series with bitewings) taken within 24 months. The reviewer will  Elimination of suprabony pockets, exceeding 3mm, if the pocket wall is D4230 determine what type of radiographic images are appropriate, given that fibrous and firm and there is an adequate zone of keratinized tissue; D4231 the practical reality is that many offices take only panoramic and  Elimination of gingival enlargements/overgrowth due to medications, D4240 bitewing films. medical conditions or tooth position; D4241  Elimination of suprabony periodontal abscesses; D4245 Tooth numbers or site designations.  For exposure of soft tissue impacted teeth to aid in eruption; D4249  To reestablish gingival contour following an episode of acute necrotizing D4261 Periodontal charting performed within 12 months, including six point ulcerative gingivitis; D4274 probing, furcation, mucogingival relationship, bleeding, case type, oral  To allow restorative access, including root surface caries. hygiene status. Gingivectomy/Gingivoplasty is not indicated for the following: Documentation for code D4274  When bone surgery is required for infrabony defects, or for the purpose of examining bone shape and morphology; Pre-surgical radiograph images.  Situations in which the bottom of the pocket is apical to the mucogingival junction;  Areas where aesthetics are a concern (particularly in the anterior maxilla);

 In areas with a shallow palatal vault or prominent external oblique ridge;

 Severely edematous or inflamed tissue;

 Patients with poor plaque control or non-compliance with non-surgical

procedures; Grafts:  Patients with an uncontrolled underlying medical condition;  One soft tissue graft per two contiguous teeth.  Solely for cosmetic/aesthetic purposes.  Bone graft and guided tissue regeneration: only one or the other

allowed. Anatomical Crown Exposure  Evidence of mobility, bruxism and/or hyperocclusion may Anatomical Crown exposure is indicated for the following: contraindicate grafting  In an otherwise periodontally healthy area to facilitate the restoration of

subgingival caries;

 In an otherwise periodontally healthy area to allow proper contour of restoration;  In an otherwise periodontally healthy area to allow management of a fractured tooth in which the fracture extends subgingivally.

Anatomical Crown exposure is not indicated for the following:  Solely for cosmetic/aesthetic purposes;  Patients with an uncontrolled underlying medical condition.

Gingival Flap Procedure 14

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Gingival flap procedure is indicated for the following (includes root planing):  The presence of moderate to deep probing depths;  Loss of attachment;  The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful;  The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods.

Gingival flap procedure is not indicated for the following:  Solely for cosmetic/aesthetic purposes;  Patients with an uncontrolled underlying medical condition;  Patients who have been non-compliant with previous periodontal therapies.

Apically Positioned Flap Procedure Apically Positioned Flap Procedure is indicated for the following:  The presence of moderate to deep probing depths;  Loss of attachment;  The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful;  The diagnosis of a cracked tooth, fractured root or external root resorption when this cannot be accomplished by non-invasive methods;  To preserve keratinized tissue in conjunction with osseous surgery.

Apically Positioned Flap Procedure is not indicated for the following:  Solely for cosmetic/aesthetic purposes;  Patients with an uncontrolled underlying medical condition;  Patients who have been non-compliant with previous periodontal therapies.

Clinical Crown Lengthening-Hard Tissue Clinical Crown Lengthening-Hard Tissue is indicated for the following:  In an otherwise periodontally healthy area to allow a restorative procedure on a tooth with little to no crown exposure.

Clinical Crown Lengthening-Hard Tissue is not indicated for the following:  As treatment for periodontal disease;  Solely for cosmetic/aesthetic purposes;  Patients with an uncontrolled underlying medical condition.

Osseous Surgery Osseous surgery is indicated for the following: 15

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE  Patients with a diagnosis of moderate to advanced periodontal disease;  For cases of refractory periodontal disease;  When less invasive therapy (i.e. non-surgical periodontal therapy, flap procedures) has failed to eliminate disease.

Osseous surgery is not indicated for the following:  Patients with a diagnosis of mild periodontal disease;  For teeth with a hopeless prognosis (more than 80% bone loss and Class 3 or higher mobility);  Patients with an uncontrolled underlying medical condition;  Patients who have been non-compliant with previous periodontal therapies.

Distal or Proximal Wedge (when not performed in conjunction with surgical procedures in the same anatomical area)  Distal or Proximal Wedge procedure is indicated for the following:  The presence of moderate to deep probing depths (greater than 5mm) on a surface adjacent to an edentulous/terminal tooth area;  The need for increased access to root surface and/or alveolar bone when previous non-surgical attempts have been unsuccessful on a surface adjacent to an edentulous/terminal tooth area;  The diagnosis of a cracked tooth, fractured root or external root resorption on a surface adjacent to an edentulous/terminal tooth area, when this cannot be accomplished by non-invasive methods.

Distal or Proximal Wedge procedure is not indicated for the following:  Solely for cosmetic/aesthetic purposes;  Patients with an uncontrolled underlying medical condition;  Patients who have been non-compliant with previous periodontal therapies;  In areas in which there are teeth with proximal contact.

Refer to clinical policy: Surgical Periodontics – Resective Procedures (DCP013.01)

Surgical Periodontics – Documentation Criteria for codes D4263-D4268, D4999 Regenerative Procedures Full radiographic images (panoramic image) with bitewings or full Bone Replacement Grafts D4263 periapical series with bitewings) taken within 24 months. The reviewer Bone Replacement Grafts are indicated for the following: D4264 will determine what type of radiographic images are appropriate, given  Infrabony/Intrabony vertical defects; D4265 that the practical reality is that many offices take only panoramic and  Class II furcation involvements. D4266 bitewing films. 16

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE D4267 Bone Replacement Grafts are not indicated for the following: D4268 Tooth numbers or site designations.  Class I furcation involvement; D4999  Class III or higher furcation involvement; Periodontal charting performed within 12 months, including six point  Non-vertical defects; probing, furcation, mucogingival relationship, bleeding, case type, oral  Patients with an uncontrolled underlying medical condition; Codes D4265, D4266, D4267 and hygiene status.  Patients who have been non-compliant with previous periodontal D4999 are each addressed in the therapies; Regenerative, Mucogingival and  Patients with poor oral hygiene; Resective Surgical Periodontics  Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or clinical policies. higher mobility).

Biologic Materials to Aid in Soft and Osseous Tissue Regeneration Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated for the following:  Intrabony/Infrabony vertical defects;  Class II furcation involvements.

Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are not indicated for the following:  Class I and Class III or higher furcation involvement;  Non-vertical defects;  Patients with an uncontrolled underlying medical condition;  Patients who have been non-compliant with previous periodontal therapies;  Patients with poor oral hygiene;  Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility).

Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier (includes membrane removal) Guided Tissue Regeneration is indicated for the following:  Intrabony/infrabony vertical defects;  Class II furcation involvements.

Guided Tissue Regeneration is not indicated for the following:  Teeth with a hopeless prognosis (more than 75% bone loss and Class 3 or higher mobility);  Class I furcation involvement;  Class III or higher furcation involvement;  Horizontal bone loss;  Non-vertical defects;  Patients with an uncontrolled underlying medical condition;  Patients who have been non-compliant with previous periodontal therapies; 17

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE  Patients with poor oral hygiene;  Crater defects.

Surgical Revision Procedure (per tooth) Surgical Revision Procedure is indicated to correct an abnormal healing response that interferes with the therapeutic goals of the original regenerative surgical procedure.

Surgical Revision Procedure is not indicated solely for cosmetic/aesthetic purposes.

Refer to clinical policy: Surgical Periodontics – Regenerative Procedures (DCP014.01) Surgical Periodontics – Documentation/Other Criteria for codes D4265-D4267, D4270-D4273, D4275-D4278, D4283, D4285, Mucogingival Procedures D4999 Pedicle soft tissue graft (D4270) is not benefited at the same time with D4270 other periodontal surgery. Pedicle Soft Tissue Graft Procedure D4273 Pedicle Soft Tissue Graft Procedure is indicated for the following: D4275 Soft tissue grafts are benefitted once per two contiguous teeth  Areas with less than 2 mm of attached gingiva; D4276  Unresolved sensitivity in areas of recession; D4277  Progressive recession or chronic inflammation; D4278 Documentation (see NOTE)  For teeth with subgingival restorations where there is little or no attached D4283 gingiva to improve plaque control; D4285 Full radiographic images (panoramic with bitewings or full periapical  Ridge augmentation; series with bitewings) taken within 24 months. The reviewer will  To increase vestibular depth for the correct fit of prosthesis; Codes D4265, D4266, D4267 and determine what type of radiographic images are appropriate, given that  To widen zone of attached gingiva for prosthetic abutment teeth; D4999 are each addressed in the the practical reality is that many offices take only panoramic and  To increase vestibular depth to allow proper oral hygiene techniques; Regenerative, Mucogingival and bitewing films.  Gingival clefting. Resective Surgical Periodontics clinical policies. Tooth numbers or site designations. Pedicle Soft Tissue Graft Procedure is not indicated for the following:

 Roots covered with thin bony plates; Periodontal charting performed within 12 months, including six point  Patients with an untreated medical condition. probing, furcation, mucogingival relationship, bleeding, case type, oral

hygiene status. Autogenous Connective Tissue Graft

Autogenous connective tissue graft is indicated for the following: NOTE: No radiographs required for the following codes:  Areas with less than 2 mm of attached gingiva; D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285  Unresolved sensitivity in areas of recession;

 Progressive recession or chronic inflammation;  For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control;  Ridge augmentation;  To increase vestibular depth for the correct fit of prosthesis;  To widen zone of attached gingiva for prosthetic abutment teeth;  To increase vestibular depth to allow proper oral hygiene techniques; 18

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE  Gingival clefting.

Autogenous connective tissue graft is not indicated for the following:  Broad, shallow palatal donor site;  Excessively glandular or fatty submucosal tissue in donor site;  A donor site with roots covered with thin bony plates;  Patients with an untreated medical condition.

Non-Autogenous Connective Tissue Graft Non- autogenous connective tissue graft is indicated for the following:  Areas with less than 2 mm of attached gingiva;  Unresolved sensitivity in areas of recession;  Progressive recession or chronic inflammation;  For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control;  Ridge augmentation;  To increase vestibular depth for the correct fit of prosthesis;  To widen zone of attached gingiva for prosthetic abutment teeth;  To increase vestibular depth to allow proper oral hygiene techniques;  Gingival clefting.

Non- autogenous connective tissue graft is not indicated for the following:  When indications for connective tissue grafting are not met;  Patients with an untreated medical condition. Combined Connective and Double Pedicle Graft Combined Connective and Double Pedicle Graft is indicated for the following:  Areas with less than 2 mm of attached gingiva;  Unresolved sensitivity in areas of recession;  Progressive recession or chronic inflammation;  For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control;  Ridge augmentation;  To increase vestibular depth for the correct fit of prosthesis;  To widen zone of attached gingiva for prosthetic abutment teeth;  To increase vestibular depth to allow proper oral hygiene techniques;  Gingival clefting.

Combined Connective and Double Pedicle Graft is not indicated for the following:  Roots covered with thin bony plates;  Patients with an untreated medical condition.

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Free Soft Tissue Graft Procedure (including donor site surgery) Free Soft Tissue Graft Procedure is indicated for the following:  Unresolved sensitivity in areas of recession;  Progressive recession or chronic inflammation;  For teeth with subgingival restorations where there is little or no attached gingiva to improve plaque control;  To increase vestibular depth for the correct fit of prosthesis;  To widen zone of attached gingiva for prosthetic abutment teeth;  To increase vestibular depth to allow proper oral hygiene techniques;  Gingival clefting.

Free Soft Tissue Graft Procedure is not indicated for the following:  Broad, shallow palatal donor site;  Excessively glandular or fatty submucosal tissue in donor site;  A donor site with roots covered with thin bony plates;  Patients with an untreated medical condition.

Biologic Materials to Aid in Soft and Osseous Tissue Regeneration Biologic Materials to Aid in Soft and Osseous Tissue Regeneration are indicated for the following:  To enhance periodontal tissue regeneration and healing for mucogingival defects in conjunction with mucogingival surgeries with or without guided tissue regeneration.

Guided Tissue Regeneration – Resorbable and Non-Resorbable Barrier (includes membrane removal) Guided Tissue Regeneration is indicated for the following:  For sensitivity in areas of recession;  Progressive recession or chronic inflammation;  Areas of bone dehiscence and fenestration’  Single tooth, wide and deep localized recession;  For areas associated with failed cervical restorations.

Guided Tissue Regeneration is not indicated for the following:  Multiple adjacent tooth sites of root coverage required;  Solely for cosmetic/aesthetic purposes.

Refer to clinical policy: Surgical Periodontics – Mucogingival Procedures (DCP015.01)

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Provisional Splinting Full radiographic images (panoramic image with bitewings or full Criteria for codes D4320-D4321 D4320, D4321 periapical series with bitewings) taken within 24 months. The reviewer will determine what type of radiographic images are appropriate, given Provisional Splinting using these codes is indicated for the following: that the practical reality is that many offices take only panoramic and  Multiple teeth that have become mobile due to loss of alveolar bone loss bitewing films. and periodontium;  During surgical and healing phases of regenerative periodontal therapy. Tooth numbers or site designations. Provisional Splinting using these codes is not indicated for the following: Periodontal charting performed within 12 months, including six point  Tooth transplantation; probing, furcation, mucogingival relationship, bleeding, case type, oral  Trauma resulting in the reimplantation of completely avulsed tooth/teeth; hygiene status.  Trauma resulting in displacement or fracture of tooth/teeth.

Coverage Limitations and Exclusions for Provisional Splinting  Limited to once per 36 months per same tooth/teeth.

 Not to be billed on same day as any restoration, prostheses or implant for

same tooth/teeth.

Refer to coverage guideline: Provisional Splinting (DCG011.01) Non-Surgical Periodontal Therapy Documentation D4341, D4342, D4381, D4910 Criteria for codes D4341, D4342, D4381, D4910 Full radiographic images (panoramic image with bitewings or full periapical series with bitewings) taken within 24 months. The reviewer Scaling and Root Planing will determine what type of radiographic images are appropriate, given Scaling and Root planing is indicated for any of the following: that the practical reality is that many offices take only panoramic and  Localized or generalized mild chronic periodontal disease – characterized bitewing films. by 1-2 millimeters of clinical attachment loss (CAL).  Localized or generalized moderate chronic periodontal disease- Tooth numbers or site designations. characterized by 3-4 millimeters clinical attachment loss (CAL). In molars, furcation involvement not to exceed Class 1. Periodontal charting performed within 12 months, including six point  Localized or generalized severe periodontal disease – characterized by probing, furcation, mucogingival relationship, bleeding, case type, oral more than 5 millimeters of CAL. hygiene status.  Chronic refractory mild or moderate periodontal disease – characterized by patients who demonstrate additional attachment loss despite being longitudally monitored with periodontal maintenance.  Periodontal abscess characterized by localized swelling and/or increased probing depth and loss of periodontal attachment.

Scaling and root planing is not indicated for the following:  In the absence of diagnosed periodontal disease.  For the removal of heavy deposits of calculus and plaque.  Gingivitis defined as inflammation of the gingival tissue without loss of attachment (bone and tissue).  As a sole treatment for chronic periodontitis with advanced loss of support demonstrated by pockets greater than 6 millimeters with CAL greater than 4 millimeters, and radiographic bone loss. Mobility may or may not be 21

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE present.  As a sole treatment for refractory chronic, aggressive or advanced periodontal diseases.

Localized Delivery of Antimicrobial Agents Localized Delivery of Antimicrobial Agents is indicated as an adjunct to scaling and root planing in cases of refractory disease and/or residual probing depths greater than or equal to 5 millimeters with inflammation that are still present following conventional therapies.

Localized Delivery of Antimicrobial Agents is unproven and not indicated in the absence of periodontal scaling and root planing (SRP) procedure.

Periodontal Maintenance Periodontal Maintenance is indicated for the following:  To maintain the results of non-surgical periodontal scaling and root planing therapy and prevent recurrent disease.  As an extension of active periodontal therapy at selected intervals.

Periodontal Maintenance is not indicated for the following:  No history of scaling and root planing (SRP) or surgical procedures.  Gingivitis- defined as inflammation of the gingival tissue without loss of attachment (bone and tissue).

Gingival Irrigation Per Quadrant Gingival Irrigation per quadrant is unproven. There is limited evidence to support the efficacy of a single episode or multiple in office irrigation appointments. The available studies show the greatest problem with irrigation as an adjunctive therapy is that the antimicrobials are quickly eliminated.

Refer to clinical policy: Non-Surgical Periodontal Therapy (DCP.004.01) Full mouth debridement Full radiographic images (panoramic image with bitewings or full D4355 periapical series with bitewings) taken within 24 months. The reviewer Criteria for codes D4355 will determine what type of radiographic images are appropriate, given that the practical reality is that many offices take only panoramic and Indications for Coverage bitewing films. Full Mouth Debridement is a covered dental service and indicated when the following criteria have been met: Tooth numbers or site designations.  Heavy calculus is present on teeth and usually visible on radiographs.  Due to the amount of calculus, plaque and debris, a comprehensive Periodontal charting performed within 12 months, including six point examination and diagnosis is not possible. probing, furcation, mucogingival relationship, bleeding, case type, oral hygiene status. Coverage Limitations and Exclusions  Limited to once every 36 months.  Not to be billed on same day as any exam code or non-surgical periodontal therapy code. 22

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE  Not to be billed within 12 months of prophylaxis or periodontal maintenance.  Not to be used as a therapeutic or preventive procedure such as scaling and root planing or prophylaxis.

Refer to coverage guideline: Full Mouth Debridement (DCG.001.01)

Unscheduled Dressing Change D4920 Gingival Irrigation- per quadrant D4921 REMOVABLE PROSTHETICS D5110-5899 General documentation requirements

Full mouth radiographic images.

Tooth numbers for missing teeth to be replaced, and other missing teeth.

Date of extractions if indicated.

Age of existing prosthesis.

Immediate denture: X-rays showing at least one tooth present and severe periodontal disease or caries. Complete dentures Criteria D5110-D5140 Gross caries &/or advanced periodontal disease

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Partial dentures Criteria D5211-D5281

 Distribution and condition of abutments  Periodontal and endodontic status: disease/pathology must be treated before partial dentures will be approved.  Crown/root ratio must be favorable  Abutment teeth free of decay and have at least 50% bone support  Replacement not allowed if current denture may be made serviceable  Good five-year prognosis

No replacement for loss, or damage.

Adjustments, relines, rebases, Criteria repairs D5410-D5761 Relines, rebases inclusive in the first six months after placement. Exception: immediate denture-- one reline or rebase covered in first six months.

Repairs and adjustments inclusive in first 12 months.

Extensive repair of marginally functional dentures may not be covered. More than three repairs for same problem may not be benefited.

Provider must pay for more frequent relines (one per 12 months is covered) if necessitated by a problem with the denture fabrication.

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Interim partial dentures Documentation Criteria D5820-D5821  Distribution and condition of abutments Radiographic images if indicated.  Periodontal and endodontic status: disease/pathology must be treated before partial dentures will be approved.  Crown/root ratio must be favorable  Abutment teeth free of decay and have at least 50% bone support  Replacement not allowed if current denture may be made serviceable  Good five-year prognosis

No replacement for loss, or damage.

Criteria Interim complete denture considered final denture if in place > one year. Overdenture Documentation Criteria D5863, D5864, D5865, D5866 Radiographic images if indicated. Follows full and partial denture criteria

MAXILLOFACIAL PROSTHETICS Maxillofacial Prosthetics Documentation D5900-D5999 Narrative Radiographic images if indicated

IMPLANTS D6010-D6013, D6040-D6050, Documentation Criteria for codes D6010-D6013, D6040-D6050, D6104, D6199 D6104, D6199  Single implant: periapical acceptable; request full mouth images or A dental implant is an artificial tooth root that is placed into the jaw to hold a panoramic image if needed. replacement tooth or bridge. Adequate bone in the jaw is needed to support the  More than one implant: full mouth images or panoramic image implant, and recipients should have healthy gum tissues that are free of required. periodontal disease. For most plans, implants are not covered, but for those  Bone graft at time of implant placement: periapical pre-op plans that do have coverage, the following identify guidelines for implant radiograph, request full mouth images or panoramic image if placement: needed.  The implant site must be osseointegrated prior to loading.  Implant must have adequate crown/root ratio.  Must not have more than two threads above the alveolar crest.  Implant must not be closer than 1-1.5mm to adjacent roots.  Same day implant placement at time of extraction considered acceptable. 25

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE  No direct loading of abutment and/or fixed prosthesis on date of implant placement.  Periodontal health of existing dentition must be favorable.  Long term prognosis must be favorable.  Site is free of acute infection.

Factors to consider in treatment planning for implants:  Location of tooth/teeth;  Bone quality/quantity;  Periodontal status;  Restorability;  Patient cost;  Patient age (implants not appropriate for patients under age 15);  Patients undergoing strong chemotherapy;  Myocardial infarction: within 6 months of an attack;  Anticoagulant therapy;  Severe neuropsychiatric disease, mental disability, and narcotic drug addicts ;  Severe blood diseases;  Systemic Risk Factors: o Smoking o Diabetes o Hypertension o Decreased estrogen levels in postmenopausal women o Use of IV bisphosphonates

Refer to coverage guideline: Implant Placement (DCG.007.01) D6101-D6103 Documentation Review for medical necessity Pre-op periapical; request full mouth images or panoramic image if needed.

Interim abutment Documentation/Criteria D6051  Post of radiograph to confirm interim abutment.  Includes placement and removal.  Healing cap is not an interim abutment.  Loading of interim abutment on the same day as implant placement is acceptable for anterior teeth to allow for an esthetic temporary crown/bridge.

FIXED PROSTHETICS 26

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE D6205- D6999 Documentation Criteria

Radiographic images: full periapical set with bitewings. Panoramic with Inclusive components (where applicable) bitewings and PA of area (not preferable/panoramic needs to be high quality) of involved teeth, as well as contralateral and opposing sites. Tooth preparation, temps, bases, impressions, local anesthesia, all adjustment and occlusal correction. Pontic must be at least 2/3 the size of the tooth being replaced. Abutment considerations Repair: Reviewer may request narrative if needed. Double abutments are usually not a benefit for most plans. If double abutments Replacement: Reviewer may request narrative if needed. are indicated, alternate treatment should be considered.

Should be at least 50% bony support with no ligament or apical pathology and with favorable crown/root ratio.

Molars that have class III furcation problems or teeth that are significantly periodontally compromised are not covered unless teeth have been documented to have had periodontal evaluation by a specialist stating the teeth are stable and can withstand the stress of a bridge.

Span of bridge and angulation of abutments should be considered in terms of suitable number of abutments. Excessive number of abutments relative to the number of teeth being replaced should be reviewed for dental necessity and possible alternate benefit.

Dental services and treatments for restoring tooth structure loss from abnormal or excessive wear or attrition, abrasion, abfraction, bruxism, and /or erosion, except when due to normal masticatory function may not covered.

Endodontic considerations

Endodontic fill is dense, within 2mm of apex and not significantly beyond (as evidenced on post-op film). No new PAP on the radiographic image.

Other clinical considerations

Teeth are reviewed for crowns if bridge denied as indicated by plan.

Diastema closure is not covered if this is the primary purpose for the restoration.

Not generally covered to replace long-standing missing teeth in a stable occlusion. Example: teeth missing two (2) years or longer, not currently replaced, and where adjacent and opposing teeth are in full or partial occlusion 27

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE or contact.

Cantilever:  Not more than one pontic and sufficient abutments for support  If dentition shows signs of excessive stress (wear facets), a cantilever may not be appropriate  If three or more abutments are needed, consider alternate benefit  Resin-bonded attachments are not appropriate

Resin bonded retainer

 No large fillings or untreated periodontal condition.  Consider span and number of pontics due to high failure rate as number of pontics increase.  Can combine standard full coverage with bonded attachment.

D6950 Precision attachment

 Only covered if abutment is tipped so as to prohibit seating of bridge

D6980B Bridge repair

 Must involve a functional bridge with good long-term prognosis.

 Procedure necessitated by restorative material failure

Full mouth reconstruction

Full Mouth Reconstruction (FMR): FMR encompasses the re-establishment of the occlusal profile whereby all or most teeth are restored via laboratory fabricated crowns, onlays and/or fixed bridges. Treatment plans are generally extensive and delivered in phases over an extended period of time. FMR associated with a change in vertical dimension of occlusion, treatment of Temporomandibular Disorder, or cosmetic dentistry, is generally not covered. FMR may be covered to restore teeth damaged by significant decay, fracture or lack of structural integrity, as well as to replace large defective restorations—by application of the same criteria used for the consideration of indirect restorations.

Periodontal splinting where teeth do not require crowns:

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Not covered by most plans. Remaining teeth and periodontal condition warrant splinting. Prognosis determined by review of progress notes, charting and x-rays. Not for sole purpose of maintaining or stabilizing occlusion.

Replacement

Narrative supporting open margins fractured solder joint, caries and existence of other missing teeth (for possible alternate benefit). Abutments must be periodontally stable with good five-year prognosis. Anterior bridge: not due to gingival recession or worn facings. Only if existing bridge cannot be made functional. Not covered for porcelain fracture if margins are intact and functional area not involved.

Alternate benefit

 Consider for posterior if two or more missing teeth in arch; three or more teeth missing in one quadrant.  Consider for anterior when member has bilaterally missing anterior teeth, advanced periodontal disease and missing teeth in the posterior on the same arch.  Must be appropriate to the clinical situation (may not be appropriate for a patient who has undergone extensive perio therapy)  Consider abutment teeth for full coverage  If inadequate periodontal support for bridge  If a tooth was recently extracted and can be added to an existing rpd  A bridge on the opposite side has poor prognosis

Other

Congenitally Missing Teeth:

Not covered if pre-existing condition exclusion in plan; otherwise considered the same as any other missing tooth. Covered if retained deciduous teeth have been functioning as permanent teeth and are then extracted.

ORAL SURGERY D7111-D7999 Documentation Alternate benefit permitted if submitted code is not supported by documentation. Dated and labeled radiographic images including panoramic image or 29

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE periapicals usually taken within one year and appropriate to document the case.

Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation.

Narrative:  If reason for extraction is not apparent  For bicuspid with no apparent pathology, to determine if orthodontic extractions  D7241, full bony impaction with complications  D7260, oroantral closure  D7270, reimplantation (copy of accident report helpful)  D7340, 7350, vestibuloplasty  D7953, bone graft for ridge preservation  D7970, excision of hyperplastic tissue

Cyst removal (D7450, 7451, 7460, 7461): Documentation of special services; size greater than 1.25mm and/or unrelated to tooth removal; operative notes and pathology report.

Treatment notes if radiographic information not conclusive.

Extractions Criteria D7111-D7250  Inappropriate removal of teeth to construct full dentures is excluded. Patient preference in the absence of clinical indications, is not sufficient  Must be pathology involved (non-restorable caries, untreatable periodontal disease, untreatable endodontic disease)  Exception to above may be made based on underlying medical condition  Extraction of bicuspids may be ortho-related and fall under that benefit Bone graft with extraction is not a benefit unless a significant residual defect is present

Inclusive components

Sutures, local anesthesia, normal post-op care

Third molar removal

Classification is based on anatomic position of the tooth, not the technique 30

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE required for its removal. Classification is based on ADA CDT descriptor for the code submitted. See codes for specific guidelines.

Extraction includes removal of soft tissue including but not limited to granulomatous, follicular or minor cystic tissue associated with the tooth.

No bone graft is allowed unless a significant residual defect remains and is radiographically documented post op.

ERUPTED THIRD MOLAR – one that is so positioned that the entire clinical crown in visible

PARTIALLY ERUPTED THIRD MOLAR – one that is so positioned that only a portion of the clinical crown is visible

UNERUPTED/IMPACTED THIRD MOLAR – one that has not penetrated through bone and/or soft tissue and entered the oral cavity.

D7111 Coronal Remnants

If near exfoliation (expected within 6 months) and presents with infection.

Extraction of erupted tooth or exposed root D7140

Criteria

Includes minor smoothing of socket and closure.

Exposed Tooth:  Bone loss >50% with active or recurrent disease involving vertical defects, furcations, 2+ mobility or other periodontal condition outside the scope of the plan  Severe or rampant decay that does not lend itself to restoration with a good prognosis  Non-restorable fracture  Remaining teeth distributed in such a way to not be suitable abutments for partial denture Exposed Root:  The tooth is severely decayed or fractured with no hope of restoration

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE  The tooth is a retained, exposed root  The tooth is not encased in bone and removal does not require a flap procedure with bone removal

Surgical Extraction of Erupted Documentation Criteria for codes D7210, D7250 Teeth and Retained Roots D7210, D7250 Dated and labeled radiographic images including panoramic image or Surgical Extraction of an Erupted Tooth periapicals usually taken within one year and appropriate to document Surgical extraction of an erupted tooth is indicated for any of the following: the case.  No clinical crown is visible in the mouth;  There is insufficient remaining clinical crown to allow a non-surgical Panoramic, periapicals, or tomography for third molar extractions are extraction; indicated by the clinical presentation.  The fracture of a tooth or roots during a non-surgical extraction procedure;  Erupted teeth with unusual root morphology (dilacerations, cementosis); Treatment notes if radiographic information not conclusive.  Erupted teeth with developmental abnormalities that would make non- surgical extraction unsafe or cause harm;  When fused to an adjacent tooth;  In the presence of periapical lesions;  For maxillary posterior teeth whose roots extend into the maxillary sinus;  When severe crowding or ectopic position of the tooth is present;  When tooth has been crowned or been treated endodontically;  Other conditions as deemed necessary by a licensed dentist.

Surgical extraction is not proven or indicated for the following:  When a conservative non-surgical procedure is possible;  When the Indications for Coverage criteria above are not met.

Surgical Removal of Residual Tooth Roots 32

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Surgical removal of residual tooth roots is indicated for the following:  When tooth roots, or fragments of tooth roots remain in the bone following a previous incomplete tooth extraction;  Extreme tooth decay resulting in the destruction of the dentition to the extent that only root tips remain.

Refer to coverage guideline: Surgical Extraction of Erupted Teeth and Retained Roots (DCG.005.01)

PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Surgical Extraction of Impacted Documentation Criteria for codes D7220, D7230, D7240-D7241, D7251 Teeth D7220 Dated and labeled radiographic images including panoramic image or The prophylactic extraction of impacted third molars that are asymptomatic and D7230 periapicals usually taken within one year and appropriate to document disease free remains highly controversial. In the absence of strong clinical D7240 the case. evidence to support or refute prophylactic extractions of asymptomatic and D7241 disease free third molars, the following coverage rationale has been adopted. D7251 Panoramic, periapicals, or tomography for third molar extractions are indicated by the clinical presentation. Surgical extraction of soft tissue impacted teeth Surgical extraction of soft tissue impacted teeth is indicated for the following: Narrative:  Extraction of premolars, third molars and other teeth as deemed necessary  If reason for extraction is not apparent for the facilitation of orthodontic treatment when this service is benefitted;  For bicuspid with no apparent pathology, to determine if  For a tooth/teeth in the line of a jaw fracture or complicating fracture orthodontic extractions management;  D7241, full bony impaction with complications  As part of comprehensive treatment in orthognathic surgery;  Moderate to severe or acute pain, or recurrent episodes that do not Cyst removal (D7450, 7451, 7460, 7461): Documentation of special respond to conservative treatment (i.e. pain medication or antibiotics); services; size greater than 1.25mm and/or unrelated to tooth removal;  Non restorable caries; operative notes and pathology report.  Management of, or limiting the progression of periodontal disease;  In the case of acute/chronic infection (abscess, cellulitis, pericoronitis); Treatment notes if radiographic information not conclusive.  Pulpal exposure;  Non restorable pulpal or periapical lesion;  Internal resorption;  As a prophylactic procedure for an underlying medical or surgical condition (e.g. organ transplants, alloplastic implants, chemotherapy, radiation therapy prior to intravenous bisphosphonate therapy for cancer );  Tumor resection;  Ectopic position;  For purposes of prosthetic rehabilitation (partial dentures and complete dentures).

Surgical extraction of soft tissue impacted teeth is not indicated for the following:  For prophylactic reasons other than an underlying medical condition;  When a more conservative procedure can be performed;  For pain or discomfort related to normal tooth eruption.

Surgical extraction of partially bony impacted teeth Surgical extraction of partially bony impacted teeth is indicated for the following:  Extraction of premolars, third molars and other teeth as deemed necessary for the facilitation of orthodontic treatment when this service is benefitted;  Tooth/teeth in the line of a jaw fracture or complicating fracture management; 34  As part of comprehensive treatment in orthognathic surgery;  Moderate to severe or acute pain, or recurrent episodes that do not

respond to conservative treatment (i.e. pain medication or antibiotics);  Non restorable caries;  Management of, or limiting the progression of periodontal disease;  In the case of acute/chronic infection (abscess, cellulitis, pericoronitis); PROCEDURE DOCUMENTATION CLAIM UR CRITERIA / DENTAL CLINICAL POLICY / DENTAL COVERAGE GUIDELINE Oroantral fistula closure Documentation Criteria D7260 Dated and labeled radiographic images including panoramic or Benefitted if the condition cannot be treated by approximating the soft tissue periapicals usually taken within one year and appropriate to document and suturing and requires excision of fistulous tract with closure by the case as applicable. advancement flap.